TURNOCK READING ROOM

Public health practice: back to the future

Turnock BJ---Division of Community Health Sciences, University of Illinois at Chicago School of Public Health

Leadership in Public Health 1998;4(3):25-27

Has the practice of public health changed over time? Should it change in response to emerging public health problems? Or is public health practice timeless and constant in its approach and methods, so that what's really needed is the expansion of its army of practitioners and continuous improvement of its processes?

For many public health professionals, these questions have been already asked and answered in view of the avalanche of articles and reports citing the need to reinvent, reengineer and retool public health practice. Fully a decade ago, the Institute of Medicine’s landmark report on The Future of Public Health, initiated a national dialog on public health practice. Its conclusion that the American public health system was in disarray has gone largely unchallenged, as have its restatement of public health’s purpose and its delineation of the three major components (core functions) of the public health mission. Since 1988, we have witnessed an unprecedented series of initiatives aimed at reinventing government at all levels, reinventing public health, reengineering public health in Illinois, and a host of similar themes.

One important take home message from these developments has been that public health practitioners must acquire new skills in order to remain relevant. The conventional wisdom from these sources argues that public health practice has already undergone considerable change (such as the steady advancement of managed care) and faces even more to come in the near future.

But in one perspective---perhaps a traditional and even conservative one---public health practice is timeless and constant; it neither has nor should change. This view stems partly from the longstanding view that public health practice and medical practice differ in important respects. Public health practice calls upon age-old methods to identify and address new problems while medical practice seeks new and better methods to address age-old problems. Public health practice relies on data and information to assess problems and risks thereby informing the establishment of community and societal priorities. Or as one astute observer remarked nearly 50 years ago, the history of public health is one of redefining the unacceptable. While science and social values may have changed over time, the methods of blending these powerful forces to identify and address unacceptable health states and their causative factors have not. Indeed, the Pew Commission's various reports suggest that public health concepts and skills are needed by virtually all health professionals now and in the future.

Public health’s three core functions have defied simple definition partly because they reflect collective, as opposed to individual, decisions and actions. The assessment function determines what should be done, a decision based on values. Policy development determines what will be done, a decision based on resources and priorities. The assurance function determines the most effective means to accomplish agreed upon ends, an evidence-based decision. These functions---the framework for public health practice---have persisted over many centuries. They were evident in the work of Jenner, Snow and Chadwick in centuries past; they are evident in the application of public health methods to chronic diseases; and they are equally evident in the modern social problems with health effects that plague American society today.

Much of the debate as to whether public health practice has changed over time stems from the assumption that public health practice occurs only in the public sector. This assumption virtually equates public health practice with public health agency activities. As the range of activities offered by these agencies expanded from community-wide prevention to clinical preventive services and primary medical care, many observers incorrectly viewed these developments as changes in public health practice rather than a shift in the balance of public health and medical practice in public sector agencies.

At its core, public health practice primarily encompasses activities and interventions that seek to promote, maintain and protect health through community-wide primary prevention strategies. While some of these interventions involve clinical preventive services (immunizations are an obvious example) many more do not. In recent decades, however, additional interventions have been carried out by public health agencies. These include both secondary and tertiary prevention strategies. Mass screening, targeted case-finding, and primary care for the medically indigent illustrate these new activities. The failure of the private health care system in the U.S. to cover many clinical preventive services and to provide access for all Americans largely explains why these activities fell to our public health agencies. At the same time, many community-based and voluntary sector organizations, and even many private sector interests, increased their involvement in public health practice in terms of participating in assessment (what should be done) policy development (what will be done), and assurance (how to do things best) activities.

With the even more recent advancement of managed care strategies within the health care delivery system, the settings for public health practice will likely experience even greater changes in the future. An increased emphasis on health and healthy populations, the use of data for performance monitoring, and demands for greater accountability all suggest that public health principles and concepts will be more frequently practiced in the private health care system than ever before. Indeed, only one in four current graduates from schools of public health will take positions within public health agencies. Increasingly they are working, and practicing public health, in the private sector.

While these developments may not suggest that public health practice itself is changing, they may pose other important challenges for the public health community. Some might see these changes as further erosion of the public health infrastructure cited by the IOM in its 1988 report. But neither the IOM nor anyone else has ever demonstrated that public health practice is best carried out or should solely be carried out by public sector agencies. The parallel development of medical practice and public health practice sub-systems in the U.S. is after all a peculiarly American creation and not a model that has been widely emulated by other developed nations. Most developed countries with more favorable health status indicators have found better ways to integrate public health practice into their social systems. Still its is likely that only government (especially state and local government) can carry out key aspects of public health (enforcement of laws and ordinances, quality assurance and oversight of health services in the community). It is equally unlikely that anyone other than government can live up to the charge provided by the IOM to see to it that the public health mission is being addressed in each community.

The challenges facing the practice of public health are many. They certainly include the many persistent, emerging, re-emerging, newly assigned health problems and issues that have become unacceptable realities. But these challenges also include continuously improving public health’s various processes, as well as the need for its further extension into other societal institutions, including our health system. The trick is in expanding the circle of public health practice while maintaining the integrity of its core.