P A R T TW H R E E I L S O N , Providers of Health Services Q U A S H E 1 9 9 7 B U 141 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 6 Public Health: Joint Public-Private Responsibility in an Era of New Threats Paul R. Torrens CHAPTER TOPICS W I L S O N , LEARNING OBJECTIVES Levels of Prevention Upon completing this chapter, the reader should be able to Q U The Structure of Organized Public Health A Efforts in the United States S The Role of the Private Sector in Health Promotion and Disease Prevention H Public Health in an Era of Terrorism and E Emerging Diseases Historical Evolution of Health Promotion and Disease Prevention in the United States 1. Understand the role of public health services in protecting the health of populations. 2. Differentiate the various levels of prevention. 3. Appreciate the history of public health in the United States. 4. Understand the roles and duties of each level of government in providing public health services. 1 9 9 7 B U 5. Appreciate the increasingly important role of the private sector in public health. 6. View public health services as a collective requirement of all participants in the health care system. Lester Breslow contributed to previous editions of this chapter. 142 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 6 Public Health: Joint Public-Private Responsibility in an Era of New Threats In the past, if one were discussing the organization of health services in the United States, that discussion would most likely not include a great deal of detail with regard to health promotion or disease prevention. It would probably not cover in very great detail the organization of governmental public health services either. Health services in the past meant curative and treatment services for the most part, and health promotion or disease prevention services were considered only peripherally, if at all. This is not to suggest that the providers of health care services in the past were uninterested in keeping their patients healthy over a longW period of time. Rather, it is meant to suggest thatIthe model of health care in the past was focused around acute treatment of short-term illnesses (withL some notable exceptions). Public health was the job for govS ernmental agencies and was seen as something O quite distinct and very rarely overlapping with curative and treatment services. N In recent years, fortunately, a new paradigm , for health promotion and disease prevention has emerged that is based on a public-private partnership to protect and preserve the health of the Q American public. The newer challenges of terrorism U and emerging diseases have further enhanced the urgency of this relationship. This chapterA examwill ine this new paradigm of health promotion and S disease prevention and will provide the modern health care practitioner with a better framework for H understanding and dealing with the major health E problems of the public. 1 9 LEVELS OF PREVENTION 9 To understand the new framework 7 health for promotion and disease prevention, it is important B rst to provide background information about the levels of prevention, as included in theU terms primary, secondary, and tertiary prevention. Without a clear understanding of the levels of prevention, it would be difcult to understand the relative 143 roles of the public and the private sectors with regard to the enhancement of the health of the public. Primary prevention means averting the occurrence of disease. It includes those measures that are applied or brought into effect before disease is present. These may include general attempts to promote better health by efforts to educate the public, to establish standards of appropriate sanitation, to apply specic methods of protection such as immunizations, to remove occupational hazards, and to protect from known carcinogens. Primary prevention focuses on the promotion of healthy lifestyles and specic protections from known hazards. Secondary prevention means halting the progression of disease from its early, unrecognized stage to a more severe one and preventing the complication or sequelae of disease. It focuses on early diagnosis and/or prompt treatment of a health problem that would otherwise have serious impacts on the health of individuals. This means identifying the presence of a problem before it breaks the clinical horizon and before it becomes symptomatic in most cases, although it also includes attempts to discover disease early while it is still effectively treatable. In the case of coronary artery disease, for example, secondary prevention would focus on identifying individuals at high risk for disease people, for example, who have a strong family history of heart disease, a history of heavy smoking, a lack of exercise, or a blood lipid prole that is abnormal. These early screening efforts can lead to more specic and focused tests and examinations that might further establish the early diagnosis of potential disease while it can still be constructively handled. Tertiary prevention involves the prevention (or at least, the limitation) of the effects of disease once it has been identied. This level of prevention operates on the premise that simply because disease is present does not mean that its course should be allowed to run unhindered. In the case of coronary artery disease, for example, tertiary prevention would include efforts at cardiac rehabilitation and Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 144 exercise programs, control of stress, maintenance of optimum weight and diet, and possibly adherence to a medical regimen that might reduce the future risk of further worsening of the disease. In the new paradigm of public/private partnership in health promotion and disease prevention, there is a role for both the public and the private sectors at each level of prevention. Sometimes the roles are quite different and separate; other times the roles are similar, and perhaps overlapping, requiring some collaboration and coordination. The important message, however, is that there are sevW eral different levels on which health promotion and disease prevention can focus and a wide varietyIof interventions that can be sponsored by both public L and private sectors. S O N HISTORICAL EVOLUTION OF HEALTH PROMOTION AND , DISEASE PREVENTION IN THE UNITED STATES Q U To understand the present circumstances in the United States with regard to health promotion A and disease prevention, it is important to review S the history of public health activities in the United States. Much of our tradition and organizational H framework for public health activities in the United E States today is the product of the thinking and actions of previous generations (Brockington, 1956; Rosen, 1993). Therefore, it is important to know 1 these developments and to understand how they affect our current thinking. 9 In the eighteenth century in the United States, 9 public health activities were, for the most part, limited to individual cities and were focused 7 on protection of the public in those cities from disB eases introduced by travelers arriving from elseU where. Early public health efforts in the United States in the eighteenth century focused on inspection of ships arriving in harbors along the eastern sea coast and included laws for the isolation and PART THREE Providers of Health Services quarantine of persons suspected to be carrying diseases that might be spread to the general population. In some of these cases, local governments established institutions (pest houses) to voluntarily (or involuntarily) contain suspected disease carriers until they either became noninfectious or, more likely, expired from their illness. During this period, the focus of public health activity in the United States was carried out by local governments and was limited to preventing the introduction of disease into the populations of port cities. The nineteenth century marked a great advance in public health and was described by C.E.A. Winslow as \"the great sanitary awakening\" (Winslow, 1923). In this period, problems of sanitation were identied as a cause of disease, and public health efforts were focused on the improvement of social and environmental conditions. Housing, water supply, and sewage disposal were all the focus of organized public health activities, with the intent of reducing the disease burden on the public by improving the physical environment. As in the eighteenth century, these activities in the nineteenth century were generally carried out by cities and local governments, with the thrust of organized public health services being carried out on a local level, not necessarily on a state or national one. In Massachusetts, Lemuel Shattuck published a landmark report in 1850 (Report of the Sanitary Commission of Massachusetts) that, for the rst time, collected vital statistics on the population of Massachusetts, pointing out the variable threats to health throughout the state as a result of variable sanitary conditions (Shattuck, 1850). His report recommended, among other things, new census schedules, regular surveys of local health conditions, supervision of water supplies and waste disposal, and special studies on specic diseases such as tuberculosis and alcoholism. Probably most important was the recommendation of the establishment of a State Board of Health to enforce sanitary regulations. Massachusetts did set up such a State Board of Health in 1869, becoming the rst state in the United States to do so. Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 6 Public Health: Joint Public-Private Responsibility in an Era of New Threats From the late nineteenth century to the early twentieth century, many of the sanitary threats to public health were brought under control, and emphasis shifted to the prevention of acute illnesses by use of increasingly available immunizations and vaccinations. This shift of emphasis from sanitary and environmental threats toward individual bacteriological threats to health signaled a major change in the role of health departments. In previous years, organized public health services focused more on problems that were sanitary and environmental in nature and did not necessarily involve individual W people; the efforts were more engineering in nature than they were directly clinical. After theIturn of the century, public health activities began to turn more directly toward the prevention of diseaseL individin ual people. Organized public health activities S moved away from structural protections of food, O water, sewage, and housing toward more personal and individual protection through immunization N of children. Organized public health activities re, mained largely local government activities, but there now began to be increasing state government activity in public health as well. Q As the twentieth century began to progress, fedU eral government activities grew with regard to specic health problems related to children. The United A States Children's Bureau was formed in 1912, and S the rst White House conference on child health was held in 1919. The Sheppard-Towner Act of H 1922 established the federal Board of Maternity E and Infant Hygiene; this act provided administrative funds to the Children's Bureau and also provided funds to the states to establish programs in 1 maternal and child health. It also established a pattern of federal-state relationship that was to 9 become standard in later years, with the federal 9 government requiring individual states to develop a plan for providing services, to designate a state 7 agency to administer the program, and to report on B operations and expenditures of the program to U the federal government. States that did not wish to comply with these regulations were deemed ineligible to receive federal funding, thereby setting the model of the federal practice for establishing 145 guidelines for public health programs and providing funds to the state to implement programs meeting these guidelines. The Social Security Act of 1935 further expanded the federal government's leadership role in setting national directions for public health; it also further solidied the federal-state partnership with regard to the delivery of public health services in the United States. Under the terms of the Social Security Act of 1935, grants were provided to the states for aiding state and local health departments to provide maternal and child health services as well as the expansion of the work of state and local governments. This marked the rst major effort of the federal government to see that a nationwide system of state and local government public health organizations were put into place. By the time that Joseph Moutin issued his landmark report on local public health services in 1946, almost 80 percent of the total United States population had some access to organized local public health services. These services may not have always been of great depth, but at least a national framework of organized local public health services had been established (Moutin, Hankela, & Druzin, 1947). The period of the New Deal in the 1930s also had a profound effect on the development of governmental public health services, but this effect was unfortunately somewhat negative with regard to the leadership of state and federal government activities. During these times, there was considerable pressure to expand the delivery of personal health services, both curative and preventive, more broadly to the public at large, and there was even some consideration by Franklin Roosevelt's administration of a mandatory, universal health insurance program that would cover the entire population. Because the role of the federal government in so many other areas was aggressively expanding, it was believed that perhaps there might be a similar expansion of governmental role with regard to the direct provision of health services. Unfortunately, the political backlash against the expansion of the role of the federal government in the direct provision of health servicesled primarily Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 146 by the American Medical Associationwas successful in forcing public health ofcials to assume a more cautious attitude toward the role of government assistance. It became quite clear that there was no strong political support for the expansion of governmental health services, at least in the curative area, and many public health ofcials limited their activities to those programs and functions that were of a more traditional nature (i.e., sanitation, immunization, early detection, and connement of communicable diseases) rather than risk the wrath of organized medicine. This did not mean that the organized public health efforts W of local, state, and federal government were reduced I in volume, but it did mean that the governments L were much more cautious in expanding the scope of their services, being careful to keep them within S the connes of prevention and not venturing into O treatment. Indeed, it should be pointed out that the feeling N in the United States was so conservative with re, gard to the federal government's role in health care that a cabinet-level department focusing on the health of the United States' people was not estabQ lished until 1953, almost 180 years after the estabU lishment of the republic! Various public health activities had been initiated by the federal governA ment over the years, but it was not deemed necessary, or possibly, politically feasible, to haveS a federal \"department of health,\" as health was seen H as a personal matter involving private physicians E and their patients. It should be pointed out that this same type of thinking governed our nation's thoughts with regard to education and social wel1 fare: these also were seen as local matters in which the federal government should not be involved,9 at least not directly. The creation in 1953 of a federal 9 Department of Health, Education, and Welfare (HEW) provided a national focus for developing 7 and implementing federal government policy with B regard to these three important areas. U In the period of 1953 to the present, there has been a great expansion of governmental activity focused on the public's health, much of it in the traditional public health areas, but much more in PART THREE Providers of Health Services programs and functions related to the provision of personal health services. The passage of the Medicare and Medicaid programs in the mid-1960s is generally not seen as an expansion of the federal government's traditional public health role, but in retrospect, the passage of these nancing mechanisms for the expansion of personal health services probably has had as major an impact as any of the previous, more traditional public health activities. One further important development in public health thinking and theory was the passage of the federal Health Planning and Resource Development Act of 1974 (PL 93-641). Under this law, the federal government provided the funds to individual states for the establishment of a State Health Planning and Development Agency whose purpose was to plan and control the future development of health servicesprimarily hospitalsin the United States. The thinking behind the passage of this law was that there needed to be a coordinated planning effort to ensure that the proper type and volume of health services were available in equitable fashion throughout the United States, and that this could be carried out only by some type of publicly mandated planning effort to coordinate and regulate the development of these services. Although this national health planning effort was really a public health effort in the broadest sense, it was never fully connected to the already existing public health structures in the country and was never fully accepted as a legitimate public health activity by many formal public health professionals. The implementation of the Health Planning and Resource Development Act of 1974 was complicated and lled with signicant controversy throughout the country; the law has since been allowed to lapse on both federal and state levels, and there is presently no direct attempt, by either federal or state governments, to plan the distribution of personal health services. Lessons from History What can be learned from this review of the evolution of organized public health efforts in the United Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 6 Public Health: Joint Public-Private Responsibility in an Era of New Threats States? What important political, social, and cultural trends can be identied that will tell us more about the current and future status of public health in the United States? There are several major points to emphasize. First, it should be pointed out that organized public health activities in the United States began in local, seaport communities and only gradually expanded to state and federal government agencies. Indeed, the Constitution of the United States reserves to the states all functions (such as health) not specically earmarked to the federal governW ment. For most of our country's history, public health was an activity that was primarily carried I out by a local or state governmental agency, and L it was only after World War II that it was perceived as necessary or appropriate to have a federal S cabinet-level Department of Health, Education, O and Welfare. In many ways, this development would suggest N that our country views public health activities (and , perhaps health activities in general) as a local and state matter; federal government involvement developed mostly after World War I, and mostly because Q of the abundance of federal tax revenues to be reU distributed to states and local governments. The continuing efforts to reduce the size and scope of A the federal government and to return basic funcS tions (and funds) to local and state governments in recent years may be seen as a continuation of this H general idea. Organized public health activities in E United the States began with the quarantine and isolation of potential disease carriers, moved on to the im1 provement of sanitation in the environment, then went on to focus on immunization of children 9 and control of individuals with contagious infec9 tious disease. Almost all these activities focused on acute infectious diseases, regardless of their 7 origins. This has given rise to an unofcial and B generally unspoken agreement that the primary U mission of organized public health efforts in the United States should be toward the prevention and control of acute illness rather than chronic disease. 147 Organized public health efforts in the United States have focused on outbreaks of illnesses such as diphtheria and polio because of the suddenness and the severity of any outbreaks of these illnesses. In reality, however, the much more serious and major public health problems of the United States are no longer acute infectious diseases but rather are chronic long-term degenerative conditions such as heart disease, cancer, and stroke. Organized public health efforts throughout the United States have a well-recognized role in protecting the public from outbreaks of infections, but they spend considerably less time and energy on problems of a much more serious and long-term nature, such as cancer, alcoholism, and mental illness. By default, organized public health agencies in the United States have accepted an acute illness prevention role as being appropriate, but they have not accepted a chronic disease prevention role to the same degree of intensity. Because of the unfortunate political controversies of the 1930s around a possible national health insurance program, it would have to be admitted that there has been a relatively guarded relationship between the private medical sector and organized public health agencies throughout the country. As long as the organized public health agencies kept to the more traditional public health roles of sanitation, immunization, and infectious disease control, their activities were generally supported by the private sector. However, whenever the public health sector became more active in the provision of general health services or in the governance or planning of facilities and personnel in the private sector, considerable opposition arose. As a result of this opposition, organized public health agencies have been rather cautious about expanding their efforts beyond the boundaries of what were perceived as \"traditional\" public health activities. This is probably most marked and most obvious in reviewing organized public health's unwillingness or inability to assert any major role in the planning or regulation of the provision of health services in the United States. Although a broad denition of public health would certainly include Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART THREE Providers of Health Services 148 the necessity of ensuring that the public has adequate access to personal health services, this planning or regulatory role has not been one that public health agencies have been willing to assume, or been allowed to assume by other forces in society. As a result, the health care system of the United States is a relatively unplanned and poorly coordinated system compared to most other major industrialized countries throughout the world. In these countries, it is assumed that public health must protect the interest of the public in obtaining access to appropriate health services of high quality, but that has W not been an accepted role for organized public health in the United States until now. I THE STRUCTURE OF ORGANIZED PUBLIC HEALTH EFFORTS IN THE UNITED STATES L S O N , The United States utilizes a very intricate combinaQ tion of local, state, and federal government public health agencies to accomplish the public sector's U responsibilities to the American public (ScutcheldA & Keck, 2002). Compared to other countries of the S world, the United States has one of the most complex sets of relationships between different levelsH of government of any country in the world, a set of E relationships that reects the unique social and political values of the people of the United States. To understand how public sector activities in health 1 promotion and disease prevention accomplish their objectives, it is important to understand each of the 9 three elements in the public sectorthe local, state, 9 and federal government effortsand then, after understanding how each segment works, understand 7 the relationships between and among them. B In its important 1988 review of public health U in the United States, The Future of Public Health, the Institute of Medicine stated that the mission of public health was to assure conditions in which people can be healthy; it further stated that the governmental role in public health was made up of three functions: assessment, policy development, and assurance (Institute of Medicine, 1988). Looked at in another way, these functions could be described as identication of the major public health problems, mobilization of necessary effort and resources, and assurance that vital conditions are in place so that crucial services are received. With regard to assessment, this heading includes all of the activities involved in community diagnosis, such as surveillance, identifying needs, analyzing the causes of problems, collecting and interpreting data, case nding, monitoring and forecasting trends, research, and evaluation of outcomes. Assessment was seen by the Institute of Medicine committee as inherently a public function because policy formation, in order to be legitimate, is expected to take in all relevant information and to be based on neutral and objective factors. Moreover, public decisions take place in the context of limited resources so that a function of government is to provide a central mechanism by means of which competing proposals can be evaluated with only the best interest of society in mind. A fully developed assessment function is absolutely essential for an ideal public health system: without it, a society's real problems cannot be accurately measured, nor can alternative solutions be objectively evaluated (Fallon & Zgodzinski, 2005). Policy development is the process by which a society makes decisions about public health problems, chooses goals and the proper means to reach them, handles conicting views about what should be done, and allocates resources. The Institute of Medicine asserted that government provides overall guidance in this process, as it alone has the power to give answers that are binding on the entire society. In order to maintain its credibility in this policy development role, the governmental public health agency must pay attention to the quality of the policy development process itself and must raise crucial questions that no one else can raise. To carry out this function effectively, the governmental public health agency must be equipped for its policy role with technical knowledge and professional Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 6 Public Health: Joint Public-Private Responsibility in an Era of New Threats expertise; this knowledge base of public health can therefore temper the excesses of partisan politics and make for fair social decisions. The assurance function of governmental public health agencies makes sure that necessary services are provided to reach agreed-upon goals, either by encouraging private sector action, by requiring it, or by providing services directly. The assurance function in public health involves the implementation of legislative mandates as well as the maintenance of statutory responsibilities. It includes regulation of services and products provided in both the pubW lic and private sectors, as well as maintenance of accountability to the people by setting objectives and I reporting on progress. Carrying out the assurance function requires the exercise of socialL authority; therefore, this is not a responsibility that can be S delegated to the private sector. Members of society O expect the government to make certain that they enjoy at least adequate safety and security. N In reviewing the activities of the various govern, mental levels with regard to public health functions, it will be clear that some levels carry out more of one function than another. For example, Q the federal government level of public health in U the United States has more of an assessment and policy development function than it does an assurA ance function, whereas state and local government S public health activities have more of an assurance and assessment function than they do of policy H development. E Federal Government Public Health Activities 1 The federal government's role in public 9 health was relatively limited until the passage in 1913 of the 9 Sixteenth Amendment to the United States Constitution, which authorized a national income tax. 7 Prior to that time, the federal government's role in B much of public life in the United States was relatively limited, particularly with regardU public to health because the government had neither statutory nor regulatory authority, nor did it have nancial resources available to carry out its will. After 149 the passage of a national income tax in 1913, the resources of the federal government in the United States became so overwhelming that federal government authority in all aspects of life, including public health, became the dominant aspect of governmental activity in the United States. Although local and state governments actually have more formal and ofcial responsibilities placed upon them to carry out public health functions than does the federal government, the federal government has by far the greater nancial resources and power to make possible implementation of laws and regulations throughout the country. The federal government, therefore, has the predominant role in public health activities in the United States, not necessarily because of its explicitly assigned public health functions under the United States Constitution, but rather because it has more nancial power and authority available to it because of the national income tax. The federal government's activities in public health in the United States are carried out through the Department of Health and Human Services, a cabinet-level department in the federal government. Although the exact internal organization of the Department of Health and Human Services varies somewhat from Congress to Congress and president to president, there is one descriptive characteristic that seems to remain: The Department of Health and Human Services is composed of a series of relatively separate superagencies that have comparatively little interaction with each other and that relate to quite different specialized constituencies, both public and professional. The Department of Health and Human Services is not a carefully designed and well-integrated organization that was intentionally put together to accomplish very specic functions of the whole organization; rather, it is an historical collection of powerful, individual, specialized agencies that at various times in their history were added into an already-existing federation of superagencies. As a result, the Department of Health and Human Services cannot be seen as functioning as a single, well-coordinated organization with a clear operating agenda that governs all Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 150 of its parts; rather, the agendas of the individual separate superagencies, taken together, make up the policy of the department itself. The federal Department of Health and Human Services can most easily be understood as having two major subdivisions, one related to health activities and the other related to human services activities. On the human services side of the department would be organizations such as the Administration on Aging; the Administration for Children, Youth, and Families; and the Social Security Administration (the agency that administers the Social SecuW rity program). On the health services side of the department would be health-related organizations I such as the Centers for Disease Control and PreL vention; the Food and Drug Administration; the Health Resources and Services Administration; the S National Institutes of Health; the Alcohol/Drug O Abuse/Mental Health Administration; and the Centers for Medicare and Medicaid Services. ApproxiN mately two-thirds of the total budget of the entire , Department of Health and Human Services is devoted to human services activities (and the vast bulk of that is specically devoted to the Social Q Security Administration), while approximately oneU third of the total Department of Health and Human Services budget goes to health-related acA tivities (and the vast majority of that goes to the S Medicare and Medicaid programs). The major activities of the federal DepartmentH of Health and Human Services with regard to public E health can be described through its eight primary functions: (1) documenting the health status and health situation in the United States through the 1 gathering and analysis of statistical data; (2) sponsoring research in both basic and applied sciences; 9 (3) formulating national objectives and policy; 9 (4) setting standards for performance of services and protection of the public; (5) providing nancial 7 assistance to state and local governments to carry B out predetermined programs; (6) ensuring that U personnel, facilities, and other technical resources are available to carry out national policies and goals through support for training, construction, and program development; (7) ensuring public ac- PART THREE Providers of Health Services cess to health care services by the provision of special health insurance programs; and (8) providing limited direct services to certain subgroups of the population. The major portion of the federal government's health activities are conducted through contracts and grants to states, localities, and private providers and organizations. The federal government acts through nancing intergovernmental and interorganizational contracts to encourage various public health initiatives, convening participants around an issue, coordinating activities, and developing state and local provider coalitions. In return for federal funds, states, localities, and private organizations must follow the federal standards and policies set in the contract. In most of its activities, the federal government takes an oversight, policysetting, and technical assistance role, rather than a direct-provider role. Most contracts to states and localities were initially offered as categorical grants, focusing on particular health issues or populations (such as research training grants for education, nutrition information programs, substance abuse and mental health programs, and family planning programs). In the early 1980s, the federal government grouped numerous categorical grants to states into four major block grants: one in preventive health, one in maternal and child health, one in primary care, and one in alcohol/drug abuse/mental health. The more traditional public health functions of the Department of Health and Human Services have generally been channeled through the Health Resources and Services Administration and the Centers for Disease Control and Prevention, but these are by no means the only channels by which federal public health nances and resources are channeled to state and local governments. It should be noted that one of the federal government's major health activities, the provision of a large volume of direct patient care through the Veterans Administration, has no formal or organizational connection with the Department of Health and Human Services. The Veterans Administration and its extensive network of hospitals and clinics Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 6 Public Health: Joint Public-Private Responsibility in an Era of New Threats throughout the United States does not operate under the authority or jurisdiction of the Department of Health and Human Services at all. State Government Public Health Activities States are the principal governmental entity responsible for protecting the public's health in the United States. In the Tenth Amendment to the United States Constitution, states are designated as the repository of all government powers not specically W granted to the federal government. States carry out most of their responsibilities through their I police powerthe power to enact and enforce laws L to protect and promote the health and safety of the people. S There are 55 state health agencies in the United States (the 50 states plus the District of O Columbia, Guam, Puerto Rico, American Samoa, and the N Virgin Islands). It is probably safe to say that each , state agency is somewhat different from all the rest, as there is wide variation in the exact way in which state health agencies are organized. In general, each Q state agency is directed by a health commissioner or a secretary of health. Each agency U has a also state health ofcer (required to be a licensed physiA cian) who is the top public health medical authorS ity in the state; in many states, the state health ofcer is the director of the state agency, but in H some states, the state health ofcer works for a nonE physician director who is the administrator of a larger agency or department. In approximately half the states, there is also some type of state Board of Health or similar appointive body that 1 charged is with the responsibility for approving policy in the 9 public health area and for reviewing the use of pub9 lic funds. Approximately half the states do not have Boards of Health and operate their public health 7 agencies as administrative units of state governB ment without any outside appointive oversight. U Earlier we described the federal Department of Health and Human Services as a somewhat loose collection of superagencies, each of which operated in a semiautonomous fashion from all the rest. 151 State public health agencies, on the other hand, are relatively compact in the organization of their public health services and function as a single operational unit that is usually fairly well integrated within itself. The variation among state public health agencies, however, is that the public health function may be gathered together with a wide variety of other health-related agencies under some type of superagency or department. In some states, the traditional public health functions, usually gathered together in a single operational unit, are housed in a superagency that also contains organizations that deal with environmental issues, mental health services, services for retarded or disabled individuals, as well as the state Medicaid program. There is no uniform arrangement for these statelevel superagencies; thus, the public health unit may stand alone as an organizational unit or may be associated with up to four or ve other healthrelated units in a superagency. Regardless of the organizational arrangement, there are certain functions and activities that seem to be common throughout the 55 state public health agencies in the United States. These include the following general functions: (1) collect and analyze health statistics to determine the health status and general health situation of the public; (2) provide general education to the public on matters of public health importance; (3) maintain state laboratories to conduct certain specialized tests that are required by state public health law; (4) establish and police public health standards for the state as a whole; (5) grant licenses to health care professionals and institutions throughout the state and monitor and inspect the performance of personnel and institutions as appropriate; and (6) establish general policy for local government public health units and provide them with nancial support as may be appropriate. In general, state public health agencies nationwide receive half of their nancial resources from state taxes, approximately one-third from federal government grants and contracts, and the remainder from special sources such as licensing fees and reimbursements. In discussing federal public Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART THREE Providers of Health Services 152 health agencies, we pointed out that the nancial resources of the federal public health activities draw on the very large national income tax for the nancing of their operations, and at the same time, the federal government agencies have relatively few mandated responsibilities that must be carried out. By contrast, state governments must depend on a less robust (as evidenced by the 2000-2003 scal era) state income tax for approximately half of their funding and, at the same time, have many more mandated services that they must provide. In general, state health departments are moderately well funded for the services that they are required W to provide but considerably underfunded in terms Iof the potential health promotion and disease prevenL tion services that they could provide. If it can be said that the federal government pubS lic health agencies focus their energies on the idenO tication of major health problems in the country and the establishment of national policies to attack N these problems, state public health departments , concentrate their energies on translating national health goals and objectives into state policy and spend a considerable bit of their time seeing that Q that policy is carried out. Many of these policies are U carried out by the state public health agencies themselves, and many of them are carried out A by local public health agencies under the direction and S supervision of state health departments. Local Government Public Health Activities H E Local health departments are the front line of public health services in the United States. It is here1 in the local government agencies that the actual daily 9 work of public health takes place, and it is here that 9 the policies and strategies decided upon by federal and state public health agencies must be carried 7 out. It is here where the stress of meeting public B health challenges is greatest and where deciencies or shortfalls are most visible and obvious (LevyU & Sidel, 2005). Local health departments carry out their activities under the authority delegated by either their state or their local jurisdictions. Depending upon the interests and the resources of the local government, the local government public health function may either be very broad and energetic or very narrow and restricted. Some local health departments serve a single city or county, while others cover a group of counties. In about one-third of the states, the local health units are actually district ofces of state health agencies, and in another one-third, the local health agencies are responsible to both local governments and the state public health agency. The organization of the local public health agency is generally relatively simple, with the local public health agency responding directly to the local elected authorityeither a mayor, county administrator, or board of supervisors. In its operations, however, the local public health authority must depend on state or federal funds for approximately half of its operating budget, so the leaders of the local public health agencies must continuously maintain a dual reporting function, one to their local government and the other to the state and/or federal government that provides them with the bulk of their operating revenues. A special committee of the American Public Health Association, chaired by Haven Emerson in 1945, dened the six basic functions of a local health department as follows (Emerson, 1945): 1. Vital statisticsrecording, tabulating, interpreting, and publishing of essential facts of births, deaths, and reportable diseases 2. Communicable disease controltuberculosis, venereal disease, measles, hepatitis, and AIDS 3. Sanitationsupervision of milk, water, and eating places 4. Laboratory services 5. Maternal and child health services, including supervision of the health of children in schools 6. Health education of the public For the most part, local public health departments continue to carry out the vital statistics, communicable disease control, environmental sanitation, and Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 6 Public Health: Joint Public-Private Responsibility in an Era of New Threats maternal and child health functions even up to the present time. They also, for the most part, maintain active public health education programs, although these efforts have become increasingly endangered by budgetary deciencies. For the most part, laboratory services are no longer provided by local public health departments but are now provided by state health departments. And for the most part, the local public health department's functions are very immediate and in direct contact with the public: recording births and deaths, trying to maintain control or contact of individual people with serious W communicable diseases, inspecting restaurants and other public gathering places to identify sanitary I problems, and making sure that newborn infants L receive their immunizations for infectious diseases and that children in school have someS degree of health supervision. If the federal government's O functions can be described as distant, nationwide, impersonal, and related to policy, the local governN ment's public health function can be described as , immediate, individual, pragmatic, and personal. The basic operating unit of local government public health only serves to enhance this sense of Q immediate contact with the public because it is usuU ally represented by the local health center or local public health ofce; this is usually situated in areas A of the greatest public health problems and at locaS tions that provide the easiest access to the most susceptible segments of the population. H Unfortunately, the disconnection between manE dated required services and nancial resources becomes most apparent at the local public health level. In the United States, local governments are 1 usually the least well nanced of the three levels of government, and it is no different for local public 9 health agencies. 9 7 Integrating Public B Health Services U From this description, it can be seen that the public portion of our nation's health promotion and disease prevention activities depends on an intricate collaboration and cooperation between three levels of governmental agencies: federal, state, and local. 153 It involves elaborate transfer of nancial resources from the federal government (where the resources are most abundant) to state governments (where resources are less abundant but still sufcient) and through to local public health agencies (where resources are scarcest and responsibilities most intense). The public portion of our nation's health promotion and disease prevention activities is, for the most part, focused rst on the protection of the public from potential threats to health and only secondarily on the active promotion of healthier lifestyles (Novick & Mays, 2001). Although the public health professionals in governmental health agencies know very well that the greatest long-term impact on the health of our nation's people probably depends on changes in styles of living, those same public health professionals very often nd themselves limited in their ability to engage in activities that are directly focused on lifestyle change. Federal, state, and local government public health agencies can create policies and goals to encourage individual personal lifestyle change, but for the most part, the actual implementation of those changes probably rests with the private sector, with the providers of medical care. Governmental public health agencies can go only so far with the resources available to them in creating an atmosphere for major lifestyle change and improvement and, therefore, must depend upon their private-sector colleagues to carry the effort more directly into the homes of individual people. Nevertheless, governmental public health agencies have played a vital role in the protection of the public, in setting strategies and goals for the improvement of the health status of the public, and in motivating the public to move to an even higher level of healthful living. For that next level of health promotion and disease prevention, however, the full involvement and participation of the private sector is necessary. The importance of the private-sector clinical role was originally stressed in the United States Preventive Services Task Force Report in 1989 and was reinforced by the United States Public Health Service's major reports, Healthy People 2000 and Healthy People 2010, which set national health promotion Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 154 and disease prevention objectives for the country (U.S. Department of Health and Human Services, 2000; U.S. Preventive Services Task Force, 1989; U.S. Public Health Service, 1990). THE ROLE OF THE PRIVATE SECTOR IN HEALTH PROMOTION AND DISEASE PREVENTION W It is comparatively easy to discuss the role of governI mental public health agencies: usually they have L been in existence for some time, have clearly dened roles, and have well-documented track records exS tending over many years. When one approaches O the role of the private sector in health promotion and disease prevention, however, discussion beN comes more difcult and more diffuse, if no less im, portant. Indeed, in the minds of many individuals, the role of the private sector, particularly the physician in private practice, is increasingly central in Q creating the major lifestyle changes that are viewed U as being so important to the prevention of disease over the long term. A Many deaths in the United States are attriS butable to lifestyle and personal actions on the part of individuals, such as tobacco use, improper H diet and activity patterns, overuse of alcohol and E rearms, unsafe sexual behavior, and vehicular accidents while under the inuence of alcohol. Most of these causes of death are only partially 1 amenable to change by broad social or legislative actions, and only individual behavior change will 9 really affect many of them. The physician in medical 9 practice is in a key position to inuence behavior change because research has shown that individ7 uals are more likely to follow improved health B habits if they are encouraged to do so by their U usual medical practitioner. The central role of the practicing physician in encouraging and enhancing improved personal life habits has long been acknowledged and must be central to any future PART THREE Providers of Health Services national plan of health promotion and disease prevention. There are two major barriers to the individual physician's assuming the central role in health promotion and disease prevention: (1) the individual physician's willingness and ability to perform these health promotion and disease prevention activities, and (2) the ability of the population to access the services of a private physician. With regard to the physician's interest in, and ability to perform, health promotion and disease prevention activities, it has long been noted that physicians are generally more interested and more competent in matters related to curative and treatment activities than they are in matters related to health promotion and disease prevention. This may be a reection of their early medical training, which may have lacked emphasis on health promotion and disease prevention, or it may be related to the physician's natural human tendency to see curative treatment as \"doing something\" while seeing health promotion and disease prevention as \"not doing something.\" Physicians are by nature activists and are more naturally drawn to the interventions where they are likely to see results in a relatively short period of time as opposed to events where the consequences of their actions will be known only, if at all, many years later. It should also be pointed out that in the previous era of fee-for-service medicine, physicians were only reimbursed for treatment activities and were usually not reimbursed, either by insurance companies or by individuals paying their own bills, for prevention services. The former methods of payment for medical services encouraged increased active treatment of illness but did not encourage its active prevention. It is only natural, therefore, that physicians in the past should have responded to obvious incentives by spending more of their time and energies on treatment and less on prevention. Probably a greater barrier to enhancing the role of the private physician in health promotion and disease prevention is the limited access that a significant portion of our population has to medical care. A signicant portion of the United States Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 6 Public Health: Joint Public-Private Responsibility in an Era of New Threats population is uninsured or has very limited insurance, with relatively large nancial burdens still resting with the individual patient who is unlikely to visit a physician on a regular basis. If individual people in the United States discover that their insurance plans do not cover health promotion and disease prevention and that they must pay for such tests themselves, they are less likely to use such tests and procedures and to visit a physician on a regular basis to obtain the counseling and encouragement that might be possible there. It would seem natural to suggest, therefore, that W if our nation wishes to involve the private sector in extensive health promotion and disease prevenI tion activities that reach our entire population, it must be arranged in some fashion forL entire the population to have health insurance coverage that S ensures adequate access to medical care (Levy & Sidel, 2005). Without universal healthO insurance coverage of some kind, it is an illusion to talk N about a nationwide health promotion and disease , prevention effort, as a signicant percentage of the population (and, perhaps, those at highest risk) cannot access the one place where the most inuQ ential health promotion and disease prevention U counseling might take placethe ofce of a private medical practitioner. Universal health insurA ance coverage, therefore, is central to any nationS wide effort of health promotion and disease prevention. H Merely having universal health insurance coverE age, however, is not enough if that health insurance coverage does not include nancing for health promotion and disease prevention tests, procedures, 1 and counseling. Many of the health insurance plans issued at the present time do not include9 reimbursement for health promotion and disease prevention, 9 and as a result, individuals who may actually have health insurance coverage of a general nature are not 7 covered for health promotion and disease prevenB tion services. Therefore, it is essential that the deU sign of future health insurance packages include nancing for these services. Without such nancing, individuals may be actively discouraged from seeking health promotion and disease prevention 155 tests and procedures, as well as advice and counseling, from their primary physician. The Role of Managed Care in Health Promotion and Disease Prevention The advent of managed-care health insurance coverage around the United States may present an opportunity to accomplish some of these health promotion and disease prevention objectives, particularly if the specic managed-care plans are those of the health maintenance organization (HMO) type, which reimburse physician groups on a per capita basis. The advent of managed care of the HMO type presents opportunities for the expansion of health promotion and disease prevention in ways that have not been previously available (Breslow, 1996; Koplan & Harris, 2000). It is important to note two essential elements of the HMO type of managed-care plan: (1) the ofcial assignment of the long-term responsibility for supervising all aspects of an individual's care to a specic physician or medical group, and (2) the reimbursement of that physician or medical group on a per capita basis. Each of these specic aspects of HMO managed care is very supportive of the general long-term thrust in health promotion and disease prevention. With regard to the rst (i.e., the assignment of long-term responsibility for an individual's care to a specic physician), HMO managed-care plans require the identication of a specic primary care physician for each person covered by that type of insurance. This puts a particular physician on notice that this individual patient (or family unit) is his or her long-term responsibility. This identication of the individual physician as having an ofcial long-term and continuing responsibility for an individual or a family changes the perspective of the individual physician away from the provision of specic individual services and toward the long-term health of the individual or the family. The designation of an individual physician as a patient's primary care doctor further solidies the long-term Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 156 role of that physician in managing the entire healthrelated set of activities in the minds of both the physician and the patient. The use of per capita reimbursement to the primary care physician further reinforces the longterm nature of the relationship and particularly emphasizes the long-term role of attempting to reach maximum health outcomes, not just providing individual fee-for-service interactions. The HMO per capita reimbursement method serves as a reminder to the physician that his or her nancial rewards are dependent upon keeping the individW ual patient as healthy as possible, rather than simply providing a series of individual services to a I sick person. The dynamics in the HMO managedL care plan thereby provide more incentives for keeping people healthy. S Managed-care insurance coverage of the HMO O type also has a great advantage over the previous fee-for-service type of coverage in that it not only N assigns ofcial responsibility to an individual phy, sician or medical group, but it also holds that physician or medical group accountable for what happens to the patient. In the past, no physician or Q medical group was responsible for reporting to any U insurance plan or purchaser of health care about the long-term pattern of services and their results. A The individual physician merely provided one serS vice after another on an individual and relatively unconnected basis, and no accountability was ever H really required as to how the pattern of individual services eventually affected the overall health of E an individual patient. Under the new forms of HMO managed care, 1 not only is it possible to assign individual longterm responsibility to a specic physician or medi9 cal group, but it is also possible, and, indeed, in9 creasingly the rule, to designate specic actions that the physician or group must take during the course 7 of a particular year. It is increasingly common for B HMO managed-care plans to outline certain U specic services or practices that a physician must follow and also to require documentation of the completion of those services. PART THREE Providers of Health Services For example, many HMO managed-care plans require that physicians provide certain health promotion and disease prevention services (such as immunizations for children, provision of mammograms for women over a certain age, blood cholesterol measurements, and the like). Not only are the HMO managed-care plans able to require physicians to provide these services, but they are also able to require the physicians to report that these services have actually been completed. What this means for the encouragement of health promotion and disease prevention activities on the part of the physician should be obvious. In the future, if it is judged that a certain pattern of health promotion and disease prevention services or activities should be provided to an individual patient during the course of a particular year, that requirement can be written into the contract with the individual physician before he or she is allowed to assume long-term responsibility for the patient. Unwillingness to perform these health promotion and disease prevention actions would bar the physician from being able to contract with the HMO managed-care plan in the rst place. The contract language can also ensure that the physician agrees to provide information that will allow the plan to determine whether the services have actually been delivered to the patient as agreed upon. Many aspects of managed care are cause for concern among thoughtful observers of health care in the United States, but the enhancement of health promotion and disease prevention activities is not one of them. Indeed, one of the major positive aspects of managed care is its potential ability to install an organized, well-nanced, and welldocumented system of care that emphasizes health promotion and disease prevention. Despite whatever other concerns may exist about managed care, it is clear that the growth of managed-care health insurance coverage offers an opportunity for an entirely new era with regard to the promotion of better health and prevention of future disease in the United States. Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 6 Public Health: Joint Public-Private Responsibility in an Era of New Threats PUBLIC HEALTH IN AN ERA OF TERRORISM AND EMERGING DISEASES Public health services received tremendous new attention following September 11, 2001, from both the increased threat of terrorist attacks and the emergence of new diseases (Table 6.1) (Shadel et al., 2004). Preparation for potential terror events W has been funded in varying degrees by federal and state sources. The focus on such preparation has enI compassed a wide range of public health activities L including monitoring, planning, mobilization, coordination with other entities, and prepared reS sponse. Public health services are integral to any O response to external attack, and the expertise of N public health agencies and ofcials has been expanded through training, expansion of capabilities, , acquisition of equipment, and a more prepared workforce. Q U A Table 6.1. Illustrative Twenty-First Century S Emerging Public Health Threats H Terror Natural Disasters Disease E Active attacks on commerce Economic attacks including those on banking Interference with food, water, utilities, supplies Internet attacks Earthquakes Extreme heat Floods Hurricanes Landslides and mudslides Power outages Tornadoes Tsunamis Volcanoes Wildres Winter weather Anthrax Avian inuenza 1 Botulism Ebola hemorrhagic 9 fever 9 Hantavirus Lassa 7 fever Plague B Ricin toxin Viral encephalitis U 157 As with terror threats, in recent years the advent of emerging new disease challenges, including SARS, hemorrhagic fevers, avian u, and other potential illnesses, has led to increased surveillance and preparation. The potential impact of these threats could be huge in the United States and internationally, such that public health agencies are expected to be prepared to respond, and indeed, to anticipate potential threats (Merson, Black, & Mills, 2005). Combined with possible terrorist use of infectious agents such as anthrax, reliance on public health agencies may be greater than funding and stafng would suggest is realistic. Finally, of course, natural disasters also pose tremendous challenges for public health agencies. Hurricanes, earthquakes, fires, and floods have all demonstrated their impact on human populations nationally and internationally. The prospective preparation for these events has clearly been grossly inadequate. Most local public health agencie