Strengthening New York's Public Health System for the 21st Century
REPORT OF THE PUBLIC HEALTH INFRASTRUCTURE WORK GROUP TO THE PUBLIC HEALTH COUNCIL
VIII. CONTEXT FOR MAJOR FINDINGS
It should be noted at the outset that several broad issues and themes provide a context for a contemporary understanding of public health in the U. S. in general and in New York in particular. To the degree that they also inform and influence New York State's public health system, they provide a foundation for an assessment of its infrastructure needs. Their impact came into particular focus and offered important background for the Work Group as it reviewed data and held many discussions with its public health colleagues at the county level.
Public Health's commitment to prevention is at the heart of its mission. To do this it utilizes a comprehensive set of coordinated resources aimed at preserving and promoting the health of the whole population rather than focusing on the health of individual patients. This role can be undervalued however due to the fact that successful prevention is invisible. As Work Group Chairperson and Public Health Council member Joan Ellison, RN, MPH, observes, "… public health has all too often been the silent medical partner in the community." When one case of measles occurs, it makes the headlines. The fact that a measles case was preceded by public health immunizations that prevented measles from occurring in 3000 still healthy children is overlooked. When disease outbreaks are prevented and good population health prevails, public health's contribution to this state of good health can go unnoticed.
Public health efforts are focused at the local level where community partners cooperate in prevention programs as a matter of practical necessity. Attending to the population's health through prevention means performing functions that impact multiple areas of local interest. These targets can be populations defined by geography such as a town or by a physical setting such as a day care facility. They can also include populations defined by age, risk profile, family history or lifestyle. The environmental context in which public health delivers its preventive services thus spans a broad landscape from the home where lead paint screening may occur, to the school where immunizations are carried out, to the restaurant where food preparation is inspected to the nursing home where patient care standards are overseen. Informing much of the work of public health prevention today is an ecological model of health that argues that a population's health must be considered in the context of its total environment. Thus public health looks for relationships and determinants of health among social, economic, biological and behavioral factors.
The threat of global terrorism is transforming the way in which public health is practiced. Nowhere is this more dramatically experienced than at the level of local health departments. One minute a local health department is being asked to develop plans and protocols to respond to threats and emergencies anticipated from bioterrorism, the next minute it must develop smallpox plans and work with newly published Centers for Disease Control and Prevention (CDC) guidelines. In the midst of this, an epidemic of SARS redirects public health's focus yet again. The "routine" responsibilities of monitoring disease, providing immunizations, combating malnutrition and obesity, protecting the water supply, and other traditional public health activities still must be met in spite of competing demands.
The challenges to population health have accelerated and carry greater urgency. One result is a public health leadership that is more conspicuous from the local to the international stage. The convergence of people and place in time, the transfer of information instantly around the globe and an interested media mean that a community's attention is captured early in the cycle of a disease outbreak or a public emergency. The movement of people across the globe can complicate local health care delivery with a startling juxtaposition of old and new diseases. Infectious diseases previously thought eradicated have reappeared together with the introduction of new ones that are affecting unprepared populations. The global connection can have local consequences. In short, the public health system is learning to live at a higher state of alertness.
A vast public and private financial network underwrites medical care in this country. Governments invest in both personal medical care systems (Medicaid and Medicare for instance) as well as public health care systems to protect their citizens (CDC, NIH). In the personal health care system, the medical model identifies individual patients as the focus of care. In the public health care system, the population is the focus of care. This personal medical care system is financed at a rate almost 20 times that of the public health system and historically has had mechanisms in place to allow for inflation and other cost-related adjustments. The national public health care system on the whole, however, is organized through disease specific grants, and lacks the opportunity for real-time funding increases even when demands on it change. Recent assessments have indicated that "state and especially federal level investments in governmental public health infrastructure… have been uneven and unsystematic."32 In the main, public health funding at every level of government is not indexed to proportionate rising costs in the public sector associated with an acknowledged rising set of needs. This is worrisome at a time when public health is more and more on the front lines protecting the public from emerging new threats.
Investment in the public health system is cost effective. The 2003 SARS outbreak demonstrated how successful disease prevention can be. Public health leaders responded swiftly across most of the globe. At home, their protections assured that the virus did not overwhelm the US population or its medical system. Arguably, by preventing the potential human and economic consequences of SARS on the scale that occurred in China, both lives and dollars were saved in this country. An analysis of the potential costs to treat such an epidemic, when they are tallied from the losses that might be sustained by individuals, families, health care workers, medical institutions, businesses and other institutions of productive life, would make a sound case for investing in prevention. The same can be said for prevention efforts associated with West Nile Virus or other modern day contagion. The economic benefits are compelling to say nothing of the obvious human benefits.
The public is a critical partner in protecting the population's health, just as individuals are partners in maintaining personal health. This relationship is emphasized at times of crisis, but like individuals, the public may be a reluctant or uninitiated participant. Typically, the public enjoys the benefits of public health without necessarily possessing a great appreciation for the efforts advanced to produce such benefits. To assure effective community engagement, the public health system, especially governmental public health agencies and their leaders, must strengthen the system's capacity to communicate with the public about its role in promoting community health. It must also engage the public in the design, implementation and evaluation of critical public health programs, not just "inform" them when the programs are launched.
New times demand bold, new actions. Together with community partners, public health leaders must find innovative methods to engage and mobilize all of its public constituencies. Again to quote from the IOM publication "… communities … are the points of convergence for the interests of employers, business and academia…( etc.)… they are physical and cultural settings…" where it can be assumed the interests of the individual must be balanced against the needs of the whole.33 In reaching out to the public however, it needs to be remembered that it is a public with a transformed demographic. The population is older and more racially and culturally diverse. These changes demand communication strategies that are customized and culturally sensitive. At the same time, the public has a heightened sense of its own self-interest in the face of the many new threats that now traverse the globe. It may be more willing to listen and act. The public health system must strengthen its resolve and invite citizens to join community efforts in the practice of good health.
32 The Future of the Public's Health in the 21st Century, Institute of Medicine, National Academy Press, 2003.
33 Ibid. p. 181.