The Future of Public Health: The Institute of Medicine’s 1988 Report BAILUS WALKER, JR. CPOPTFOR years to come, the public health community almost assuredly will measure its progress against what has become known familiarly as the “IOM Report” (1). Certainly for much of the past century, public health’s benchmark has been several of the report's predeces- Scepaes sors, including the 1850 Shattuck Report of the Sani- tary Commission of Massachusetts (2). While it is important to implement quickly as much of the IOM Report as possible, the report should be reviewed in its proper perspective. In this paper, I summarize the report and offer comments not only from the perspective of a member of the committee that developed the document, but also from the viewpoint of a public health practitioner whose assign- ments have included two state public health portfolios: first as the Michi- gan State Director of Public Health, and later as Commissioner of Public Health for the Commonwealth of Massachusetts and Chairman of the Massachusetts Public Health Council. THE REPORT The long-awaited report, formally titled The Future of Public Health, became public in late 1988, Itis the product of a two-year study by an Institute of Medicine committee under the chairmanship of Richard Rem- ington, Professor of Preventive Medicine at the University of Iowa. The committee was formed to address a growing perception among Institute of Medicine membership and many others concerned with the health of the public that this nation has lost sight of its goals and has allowed the system of public health services to fall into disarray. There may be at least two ways of evaluating this 217-page document. One is to describe it as a farsighted and forward-looking proposal for improving the public health service system. Another point of view is that the document represents a terrible indictment of the current status of 1920 JOURNAL OF PUBLIC HEALTH POLICY » SPRING 1989 public health services in this country. Both of these points may well be warranted. The public health community is naturally prone to point to its great achievements, and indeed this nation’s well-developed system for per- sonal medical services rests in large part on the significant accomplish- ments of public health programs. It is the advances in public health made during this century which have permitted communities to make commit- ments to direct medical care. While we proudly point to this long list of significant achievements in public health, we have hesitated to publicize those areas that have been neglected or programs nd services that have not reached their maximum potential. The IOM report conveys an urgent message to the American people: publichealth activities are vital functions that are introuble, They have become inappropriately politicized, and are characterized by lack of clarity and agreement about the mission of public health, the role of government, and the specific means necessary to accomplish publichealth objectives. The report points also to flaws in the system for educating public health practitioners. In its inquiry the committee found many present barriers to effective problem solving in public health including: — inadequate capacity to carry out essential public health functions of assessment, policy development, and assurance of services; — disjointed decision-making without necessary scientific data bases; ~ lack of effective leadership; and — poor public image of public health, inhibiting necessary support. Some of that “necessary support” must come from the medical profes- sion. But on this issue the committee observes: “A particular problem for public health professional leadership is lack of supportive relationship with the medical care profession. There are numerous examples of prac- ticing physicians being supportive of public health activities but confron- tation and suspicion too often characterize the relationship from both sides. The director of one state medical association perceived the state health department’s failing to seek medical advice as distrustful of private physicians.” Evaluating the policymaking process, and personnel that converts in- puts from the environment into public health policies that then produce outputs, the committee noted that the development of public health policy and the provisions for public health services have been marked byWALKER * THE IOM’S 1988 REPORT 2 vaguely-worded statutes, confusion about health agency mission, uncer- tainty in program administration, and lack of consistent judgment by policymakers and program administrators. ‘The story reveals flaws in decision-making that have led many people to believe that the public health service system is not working asit should. The effects of flip-flops in decision-making were prolonged uncertainty and some loss of the public health system’s credibility plus the absence of services that firmly address community-wide health needs. Over time, the public expects governmental agencies and institutions to help make sense of complexity and confusion, to clarify choices and resolve differ- ences. But in this case at least, agencies were often not up to the task before them. HEALTH CARE In the committee's interviews, public health workers expressed concerns when their agencies served as providers of last resort for medical care of the indigent or as the administrator of Medicaid or other financing pro- grams. Those concerned saw these functions as detracting from essential public health activities such as disease surveillance and control. Others saw the public health role in the care of the indigent as essential —at least until other means are developed by society ro meet these needs. In many of the site visits, the committee was told of the overwhelming unmet needs of medical care of the indigent. This situation caused tension in that public health agencies were attempting to provide personal medical care without at the same time depriving other public health services of an appropriate share of limited health resources. Because the dollar flow to medical services is large and because reimbursement through federally- matched sources of funding such as Medicaid is available, care for the indigent looms large in the state budget-serting process as compared to other public health functions. In this connection, the identification of public health with care of the indigent in the minds of decision-makers and of the general public some- times clouds the perception of the importance of public health services to the population. ENVIRONMENTAL HEALTH Over and against concerns in those areas, the committee found that one of the effects of increased public attention and the perception of unre- sponsiveness of public health agencies was a separation of many environ-22 JOURNAL OF PUBLIC HEALTH POLICY - SPRING 1989 mental health concerns from public health services. The split was sym- bolized at the Federal level by the creation of the Environmental Protec- ‘tion Agency to carry out programs concerned with air and water quality, solid waste management, noise control, ionizing radiation monitoring and pesticide regulation. Following the federal lead, states separated from public health departments responsibilities for the identification and modification of important environmental factors that increase the risk of illness and premature death. As a result, many observers believe the health implications of environmental hazards have not received the depth of analysis or level of support they deserve. In some cases, for example, uninformed analysis of environmental health risks may have exacerbated public fears of those risks unnecessarily. MENTAL HEALTH Issues of mental health made up another element of the committee’s inquiry. The committee found a tremendous amount of persuasive evi- dence that, despite the expansion of the range of mental health services, the relationship between public health and mental health remains under- developed. Organizational, historical, professional and interest group barriers to more productive interactions persist even though mental health and public health have moved closer together conceptually. Mechanic and Aiken (3) corroborate these observations, They write: “Community tolerance for the mentally ill has diminished in the absence of decent services. The public mental health sector must be revitalized if we are to avoid recreation of public asylums. Building an effective public system will take dedicated professional commitment, a focused planning and organizational structure, and a new way of consolidating public financing,” HOW DID THIS ARISE? How could these and many other problems cited by the committee have arisen within the public health service system? In my view, there are several interrelated reasons. Historically, much of the public health service system was associated with communicable disease control. The decline in some infectious dis- eases and the disappearance of others as a result of immunization, anti- biotics, improvements in water quality, in food sanitation, and in housing standards led to the erroneous assumption that public health problems were solved and that the residuals of communicable disease could beWALKER + THE [OM’S 1988 REPORT 23 managed by the private health sector. Indeed, a prominent health scientist-administrator (4) reported in the early 1970sthat in any commu- nity there are many nongovernmental forces and resources which can and do contribute significantly and critically to the solution of public health and social problems including those related to health. Many of them can do this successfully and efficiently, and even more so than the public health agencies. This report, and several other proclamations and developments, prompted a shift of resources away from services to prevent disease in the total population to medical diagnosis and treatment of particular individuals or groups. Italso facilitated the fractionation of public health programs among a number of agencies (5). As David Rogers (5) concludes, the forward march of American society climinated or reassigned to other groups many of the problems that formerly occupied the public health community’s time—problems that kept public health prominently in the public view. Similarly, as he further notes, “although developing, organizing or operating better programs for the delivery of more broadly available and less costly personal health services became the health ‘crises’ of our times, those in the public health professions have not been in an effective position to improve our collec- tive performance or assumed a leadership role in revising flawed health policies and programs.” This has been distressing, for itis the public health professionals who have studied the success and failure of other systems and have thought more deeply about these areas. One source of the problem is that tradi- tional compartmentalization of disciplines and professionals can work against the kind of collegial chinking needed to solve complex health problems. At the same time, political and other policymakers show a marked tendency toward unidimensional solutions which are perhaps even less likely to prove satisfactory in the end. From the standpoint of state and local governments, the IOM report is long overdue and its implementation is vital not only to the public health community but also to every person in the nation. The state and local public health system envisioned by the report would bring to a focus the assessment, policy development, and assurance functions necessary for a comprehensive approach to disease prevention and health promo- tion, The impact and stimulus of such a system would be felt throughout the nation, This is because after all the federal health policies have been developed,24 JOURNAL OF PUBLIC HEALTH POLICY « SPRING 1989 dollars appropriated, and technical assistance provided, itis the state and local health agencies that deliver services. They bring the work of the public health system to its operational level—direct services to people in their communities. This i likely to be even more so in the future because the recent burst of state activism—in education, in welfare reform, in health care, and in liability insurance—is considered not to be just a response to the Reagan Administration policies (6). “To some extent, this rejuvenation is an outgrowth of earlier federal policies that stimulated the states to expand their institutional and political capacity to provide needed services,” writes Timothy Conlan (6), a long-time analyst of intergovernmental issues, He notes that there is no question that stare and local governments are now less dependent on federal assistance. In a process some have called “de facto New Federalism,” federal aid as a percentage of state and local outlay has declined by 32 percent since 1978. Direct federal aid to localities has been especially hard hit. With the elimination of general revenue sharing and the restructuring of block grants, many localities which once received direct federal funding now receive none. In this context, the process of thoughtfully establishing and maintain- ing priorities and the allocation of resources for public health services would be greatly enhanced if the major programs were brought under ‘one managerial roof. Then at least trade-offs could be made within a coherent policy, and more intelligent planning for long-term oppor- tunities could be pursued, including the more effective application of the health and related sciences. ORGANIZATION ‘Thus the committee presents a strong citation of the need for each state to have a department of health that groups all primarily health-related functions under professional direction—separate from income mainte- nance. The committee states: “Responsibilities for this department should include disease prevention and health promotion; Medicaid and other indigent health care services; mental health and substance abuse; environmental responsibilities that clearly require health sciences exper- tise; health planning, and regulation of health facilities and professions.” I is the committee’s belief that diffusion of primarily health-related func- tions among different agencies and the organizational linkage of health with a particular set of related activities—income maintenance for low- income populations—has gone too far in many states.WALKER + THE IOM’S 1988 REPORT 2s But some community groups and social services analysts generally react strongly to the suggestion that many of the health and health-related activities in state and local governments be collected into a single agency. ‘They maintain that because there is no monopoly on foresight, we need to offer multiple sources of support for community health and welfare services. Creative approaches are more likely to survive, it is argued, when all proposals for public health supports do not have to pass through ‘one central channel. While a variety of organizational steps might be followed, there is ample evidence that a unified organization that puts primarily-related functions under competent health-oriented leadership is one of the most direct approaches. If state and local health officials respond to this need, they will take more interest in mental health, addictive diseases, school health, violence and delinquency, occupational health, water resources issues, and air pollution—indoor and ambient. HEALTH COUNCIL Another level of organization addressed by the committee is a state health council that reports regularly to the state’s residents and makes health policy recommendations to the governor and the legislature. These policy-makers and others who must provide health resources need, and will continue to need, advice on public health problems for which money and personnel are to be allocated. Such advice cannot come solely from those whose primary responsibilities lie within the public health service system. But this isnot an argument for restoring the “golden age” of state boards of health dominated by the medical profession. Indeed, public health agencies can no longer operate behind the cloak of privileged professional information, in isolation from the economic, social and political community. They must continue to bring consumers and others into the public health policy-making process. The council envisioned by the committee would not be a group to control health matters. Rather, it would provide a positive framework within which community values, professional knowledge, and health, social and economic data can be blended to evaluate major issues of enduring importance and to reach wise policy judgments that will assure effective and efficient comprehensive health services. Participants in the debates about the organization of public health agencies often make the implicit assumption that there is an “ideal” type of public health organization which health departments across the coun-26 JOURNAL OF PUBLIC HEALTH POLICY - SPRING 1989 try ought to adopt. A close look at the evidence available casts doubt on the validity of this assumption. It is therefore likely that none of the debaters will ever be declared the winner. Each of the debaters has based his or her conclusions on very different perspectives concerning what public health agencies and public health professionals should be doing. Furthermore, quite different assumptions have been made about the nature of state and local governments. The different perspectives and assumptions are clearly not applicable to all public health agencies, For this reason, the arguments used in the debate lack general applicability. CAPACITY BUILDING Changes in patterns of illness, in the demography of the population, and in the organization of private medical care have outstripped the capacity of the public health service system, the committee argues. Given the potential for major outbreaks of disease and environmental disasters, the nation’s public health services could be caught between growing req ments for technical, political, managerial and fiscal skills and a dimin- ishing supply of public health practitioners capable of planning and implementing needed services. Moreover, the framework for illness, its treatment, and, more important, its prevention, is undergoing fundamen- tal change because of changes in community values, lifestyle, household structure and the paradigms of health, Such developments are adding to the health service demand, necessitating additional and more highly- skilled personnel and a stronger health service capacity. ‘The weight of evidence is that social forces such as the interplay be- tween values, science, technology and social structure, and a host of micro and macro issues affecting community health, will demand even more managerial and programmatic skills within the system. Prudent health resource planners should anticipate thar the public health services’ requirements for skilled service providers are unlikely to diminish in the years ahead. It is more likely, given the present course, that the need for such people will grow commensurately with the complexity of the service demand. These factors and several other forces are combining to increase the demand for early correction of deficits in the capacity of public health agencies to provide comprehensive services. First is the widely discussed “aging” of the US. population on the one hand, and, on the other, the growth of the population share of nonwhite citizens. Each of these trendsWALKER - THE 10M’S 1988 REPORT 27 has ramifications for public health policy and for the structure and scope of services provided by public authorities. For example, the aging of the population implies increased attention to community-based geriatric ser- vices. The growth of the nonwhite share of the population is bound up with certain familiar pathologies of disenfranchisement—teenage prep- nancy, substance abuse, as well as more recent challenges to the health service system such as that of devising, supporting and delivering appro- priate services t0 illegal aliens (7). Each of these trends also lends added weight in the public health system to large segments of communities with new or greater health service needs, or with needs that have so far not been met. For these populations, public health services must give considerable attention to the means of promoting a high quality of function and minimizing dependency, which in itself is a momentous challenge to the health professions. It, too, requires a variety of skills and competencies. Then there is the new and relatively complex process of risk assessment as it relates to the prevention and control of environmentally-provoked disease and dysfunction. It draws extensively on a strong scientific basis for linking environmental exposure to chronic health effects and for the development of risk management options. The latter requires evaluation of public health, economics, and the social and political consequences of public action to reduce environmental health risks. Finally, the public health service system will continue to confront sur- prising consequences of new social arrangements, and political and economic changes in direction, some of which are perverse in relation to the goals of health programs. This requires sound data systems, the capacity to monitor and maintain mechanisms for corrective feedback. Even the framing of health policy issues, the examination of alternatives, the mode of reaching policy determinations and defining the scope of services, are implicitly, if not overtly, influenced by the competencies within the public health service system. The committee saw these as formidable challenges and it recognized that unless more resources are invested in improving the capacity of the system, public health services may well be shunted further to a lower level of priority in the general system of state and municipal services. IMPLEMENTATION It is reasonable to suggest that there is little need for concern that the28 JOURNAL OF PUBLIC HEALTH POLICY « SPRING 1989 IOM report will be implemented too fast. Experience would indicare a contrary concern. Here are excerpts from a not-too-recent but well- publicized report: “We recommend that measures be taken to prevent, as far as practica- ble, the smoke nuisance.” Noting thar “The tendency of our people seems to be toward social concentration . . .,” this report continues: “We recommend that in laying out new towns and villages, and in extending those already laid out, ample provisions be made for a supply in purity and abundance of light, air, water, for drainage, for paving and for cleanliness.” This report contains additional recommendations relative to housing, schools, occupational health, adulterated food and drugs. The report also recommends “that persons be specially educated in sanitary science.” Many students of public health will recognize these as selected excerpts from the 1850 Shattuck Report of the Sanitary Commission of Massa- chusetts (2). Is our progress so fast as to be cause for concern? But we have learned from a long list of public health experiences that issues must have a broad impact to become a societal issue and gain a high priority on the national agenda. The Shattuck report was dormant for nearly a quarter of a century because it lacked momentum. Similarly, environmental health issues were premature in the 1950s and 1960s. They became important—had broad impact and momentum—in the 19708. The IOM report comes in a period of profound change which could well place it high on the national agenda. For example, several governors in their state-of-the-state address this year expressed concerns about further investment in medical diagnosis and treatment and in related health care costs, Other state executives expressed frustrations with ef- forts to provide quality medical care for a much broader segment of the population—an effort that has been less satisfying socially and politically. Moreover, they called attention to the new progressive era at the state and local levels that may foreshadow a new national agenda. A renewed federalism, many governors said, is producing innovative solutions to vexing problems and allowing states to test these remedies on a small scale and discard what doesn’t work and build what does. The forces pushing increased activity at the state and local levels are unlikely to be muted by alterations in the political landscape. As the budget deficit limits the federal role, states will be forced to bear a growing share of the costWALKER * THE 1OM’S 1988 REPORT 29 of health care and they are apt to want to shift the focus from curative care to preventive services, and to structure more effective systems for accomplishing this goal. Most states require that their budget be balanced each year. Asa result, state policy and decision-makers are not hampered by the difficulties of deficit financing. Starting each year with a balanced budget, states are free to think, create, and reshape programs and services and are not shackled from the beginning. There is also a current surge of support for environmental health as a public health function due in part to the state of many beaches in the summer of 1988 and to scientific reports that pollution is altering the climate and increasing the risk of environmentally-provoked diseases. These were not the first developments to elevate public awareness about environmental health. Earlier concerns about the lack of progress in research and development of advanced sewage treatment and recycling plants, and problems of agricultural toxic waste, underscored the need for more coherent attention and increased governmental investment in environmental health. Indeed, a majority of Americans, 65 percent, agree that environmental quality is so important that requirements and standards to protect public health cannot be too high and that environmental improvements must be made regardless of cost, according to a New York Times/CBS poll conducted in late 1988. This wide support provides the momentum necessary for making improvements in environmental health policy and programs within a disease-prevention context as recommended by the IOM report. Perhaps, then, there is no better time to begin major reforms in the public health system than in the next few years as the public is becoming increasingly sensitized to the importance of community-wide health ser- vices in reducing the incidence of disease of environmental and occupa- tional origins, and those that might be called new “societal diseases” — some physical, some psychological, some both. This is not a task for the public health profession and government alone. The private sector (business and industry) must give more consid- eration to its obligation to ensure a financially stable and effectively directed public health service system. While the private sector invests resources in health research, it must also recognize its responsibility to ensure that research results are effectively translated into services to im- prove community health profiles. The private sector can also exercise its considerable political clout in bringing about constructive changes in30 JOURNAL OF PUBLIC HEALTH POLICY - SPRING 1989 public health policies and in the organizational structure and scope of health services necessary to overcome the deficiencies identified by the committee. A broad range of channels already exists through which a coordinated private-public effort can be pursued. The strength, effective- ness and stability of the public health service system should be a matter of high business-industry priority as the nation’s economy becomes an increasingly globalized economy which calls for a highly-skilled and healthy labor force. But in the final analysis, the test of the public health system is whether it effectively serves the people—by their measurements, not those of the public health profession. The pride of the public health system must be that it has the capacity to respond effectively to the health service needs of all people—rich, poor, and powerless. In short, the system must be ready to say that the public health community’s overriding concern is with preventing disease, dysfunction and premature death through or- ganized community efforts. CONCLUSION The United States has the capacity to fashion a public health service system that should function effectively well into the next century, But putting that system into place will require considerable forethought and national discussion; it will also require a recognition that the present system has many deficiencies. The IOM report provides the documenta- tion for accomplishing both. REFERENCES 1, Institute of Medicine. The Future of Public Health. Washington, D.C.: Na~ tional Academy Press, 1988. 2. Report of the Sanitary Commission of Massachusetts, 1850, Cambridge, Mass.: Harvard University, 1948. 3. Mechanic, D. and Aiken, L. H. “Improving the Care of Patients With Chronic Mental Illness,” New Eng. J. Med. 317 (1987): 1634-38 4 Hanlon, J. J. “Is There a Future for Local Health Departments?,” Public Health Reports 10 (1973): 898-91. 5. Rogers, D. “A Private Sector View of Public Health Today,” Am. J. Pub. Health 64 (1974): 529-33.WALKER + THE IOM’S 1988 REPORT 3r 6. Conlan, T. “Federalism After Reagan,” The Brookings Review 6 (1988): in Medical Education: The Challenge of Diversity,” Journal of Medical Education 62 (1987): 86-94. ABSTRACT A long list of enduring and emerging public health issues have raised questions about the capacity of the public health service system to address these concerns. A two-year Institute of Medicine study revealed a system in disarray. Its inap- propriately politicized, and public health responsibilities have become so frag- mented that deliberate action is often difficult. The Institute of Medicine’s com- mittee emphasized that these issues are complex and affect our society broadly. Ie called for comprehensive action to bring about necessary changes including a clear delineation of the mission of the public health service system and improve- ‘ment in technical, political, managerial and programmatic skills of public health practitioners.