The future of public health: a local health department view

This is an examination of factors responsible for the "disarray" in public health activities as described in the Institute of Medicine report on The Future of Public Health. It approaches the problem primarily from the viewpoint of the local health agency. Three contributing factors are discussed: disproportionate national expenditures for medical care as compared to public health funding; structural flaws in organization leading to functional difficulties; and medical profession opposition to an expanded role for local health departments. The problem of inadequately sized local governmental jurisdictions which are unable to supply sufficient resources for their health departments is discussed, and the complexities of remedial mergers across political boundaries are explored. Suggestions for improving the functions of local health departments include the provision of medical care services, not as a last resort as the Institute of Medicine report suggests, but as equal and perhaps superior competitors in the marketplace; increased state financial and technical support; and a proposed new federal program, The Health Objectives 2000 Act, S.2056, which will make specific provision to greatly strengthen health departments, facilitate the incorporation of missing skills and expertise in local health units, and enhance their capabilities to function as front-line agencies which are essential for achieving effective public health action.     

Partnering for preparedness: the project public health ready experience

Effective partnerships between local and state public health agencies and schools of public health have tremendous potential to improve the health of communities nationwide. This article highlights successful collaboration between local public health agencies (LPHA), state health departments, and Academic Centers for Public Health Preparedness (ACPHP) in schools of public health developed through participation in Project Public Health Ready, a program to recognize LPHA emergency preparedness. The project's pilot phase illustrated that LPHAs, state health departments, and ACPHP can effectively work together to improve individual public health worker competency and organizational response capacity in local public health agencies nationwide.     

Addressing community concerns about asthma and air toxics

People with asthma who live near or downwind from a source of toxic emissions commonly express concerns about the possible impact of hazardous air pollution on their health, especially when these emissions are visible or odorous. Citizens frequently turn to their local and state health departments for answers, but health departments face many challenges in addressing these concerns. These challenges include a lack of asthma statistics at the local level, limited exposure information, and a paucity of scientific knowledge about the contributions of hazardous air pollutants to asthma induction or exacerbation. Health agencies are creatively developing methods to address these challenges while working toward improving asthma surveillance data at the state and local levels. Recent community health investigations suggest that hazardous air pollutants that are occupational asthmagens or associated with odors may deserve more attention. In seeking to address community concerns about hazardous air pollution and asthma, community health investigations may also help to fill gaps in our scientific knowledge and identify areas for further research or environmental intervention. The solutions to community problems associated with environmental contamination and asthma, however, require sustained, coordinated efforts by public and private groups and citizens. Public health agencies can make a unique contribution to this effort, but additional resources and support will be required to develop information systems and epidemiologic capacity at the state and local levels.     

Improving America's health care system by investing in information technology

Large-scale investment in health care information technology (IT) infrastructure will not take place without leadership by the federal government. But how the federal government supports the financing of health care IT is critical. Health care IT development has multiple aspects, but it is fundamentally a problem of community infrastructure development. A policy approach that has had consistent success in financing our country's essential physical infrastructure in transportation and environmental protection will be well suited to fostering health care IT infrastructure as well. We propose the creation of a health care IT revolving loan fund program to invest public dollars in health care IT infrastructure projects through community-level nonprofit lending agencies.     

The unique authority of state and local health departments to address obesity

The United States has 51 state health departments and thousands of local health agencies. Their size, structure, and authority differ, but they all possess unique abilities to address obesity. Because they are responsible for public health, they can take various steps themselves and can coordinate efforts with other agencies to further health in all policy domains. I describe the value of health agencies' rule-making authority and clarify this process through 2 case studies involving menu-labeling regulations. I detail rule-making procedures and examine the legal and practical limitations on agency activity. Health departments have many options to effect change in the incidence of obesity but need the support of other government entities and officials.     

Integrating research, surveillance, and practice in environmental public health tracking

The Centers for Disease Control and Prevention in the U.S. Department of Health and Human Services is working with selected state and local health departments, academic centers, and others to develop an environmental public health tracking initiative to improve geographic and temporal surveillance of environmental hazards, exposures, and related health outcomes. The objective is to support policy strategies and interventions for disease prevention by communities and environmental health agencies at the federal, state, and local levels. The first 3 years of the initiative focused on supporting states and cities in developing capacity, information technology infrastructure, and pilot projects to demonstrate electronic linkage of environmental hazard or exposure data and disease data. The next phase requires implementation across states. This transition could provide opportunities to further integrate research, surveillance, and practice through attention to four areas. The first is to develop a shared and transparent knowledge base that draws on environmental health research and substantiates decisions about what to track and the interpretation of results. The second is to identify and address information needs of policy and stakeholder audiences in environmental health. The third is to adopt mechanisms for coordination, decision making, and governance that can incorporate and support the major entities involved. The fourth is to promote disease prevention by systematically identifying and addressing population-level environmental determinants of health and disease.     

Peer Reviewed: The Role of State Health Departments in Supporting Community-based Obesity Prevention

Background

Recent national attention to obesity prevention has highlighted the importance of community-based initiatives. State health departments are in a unique position to offer resources and support for local obesity prevention efforts.

Community Context

In North Carolina, one-third of children are overweight or obese. North Carolina''s Division of Public Health supports community-based obesity prevention by awarding annual grants to local health departments, providing ongoing training and technical assistance, and engaging state-level partners and resources to support local efforts.

Methods

The North Carolina Division of Public Health administered grants to 5 counties to implement the Childhood Obesity Prevention Demonstration Project; counties simultaneously carried out interventions in the community, health care organizations, worksites, schools, child care centers, and faith communities.

Outcome

The North Carolina Division of Public Health worked with 5 local health departments to implement community-wide policy and environmental changes that support healthful eating and physical activity. The state health department supported this effort by working with state partners to provide technical assistance, additional funding, and evaluation.

Interpretation

State health departments are well positioned to coordinate technical assistance and leverage additional support to increase the strength of community-based obesity prevention efforts.     

The 1990 objectives for the nation for injury prevention: a progress review

Unintentional injuries are the principal cause of preventable early death. Beyond terms of human suffering and death, injuries place enormous burdens on this country's economic and health care resources. Demographic, sociological, environmental, and behavioral factors that influence our society contribute to the complexity and scope of the injury problem. Progress in injury prevention will be achieved only through the combined efforts of individuals, organizations, and government at every level of our society. The Federal Government is an important contributor to this process through its role of leading, catalyzing, and providing strategic support. Within the Department of Health and Human Services, numerous agencies have major injury prevention components with a broad range of responsibilities, including the direct delivery of services, establishment of safety standards, sponsorship of education and information efforts, building of the capacity of other sectors, basic and applied research, and surveillance. The Centers for Disease Control, as the lead agency, assists State and local health departments in their injury prevention efforts and coordinates activities undertaken jointly by Federal agencies, State and local governments, and private-sector organizations. To meet the 1990 Objectives for the Nation with respect to injury prevention, both the public health and private-sector providers must recognize the injury problem of the 1980s. Without the support and involvement of the public health and provider communities and of the private sector, injuries and their costs will continue at their present alarming rates. The opportunity is great for promoting health, preventing injuries, and reducing associated costs to society. Making the best of this opportunity is our challenge during this decade.     

Strengthening the public health system.

Although the American public health system has made major contributions to life expectancy for residents of this country over the past century, the system now faces more complex health problems that require comprehensive approaches and increased capacity, particularly in local and State public health agencies. To strengthen the public health system, concerted action is needed to meet these five critical needs: First, the knowledge base of public health workers needs to be supplemented through on-the-job training and continuing education programs. To this end, self-study courses will be expanded, and a network of regional training centers will be established throughout the country. Second, communities need dynamic leadership from public health officials and their agencies. To enhance leadership skills and expand the leadership role of public health agencies, focused personal leadership development activities, including a Public Health Leadership Institute, and national conferences will provide a vision of the future role of public health agencies. Third, local and State public health agencies need access to data on the current health status of the people in their communities and guidance from the nation's public health experts. To improve access to information resources, state-of-the-art technologies will be deployed to create integrated information and communication systems linking all components of the public health system. Fourth, local and State agencies need disease prevention and health promotion plans that target problems and develop strategies and the capacity to address them.(ABSTRACT TRUNCATED AT 250 WORDS)     

Meeting the needs of people with AIDS: local initiatives and Federal support

The Health Resources and Services Administration (HRSA), one of the seven agencies of the Public Health Service, is working to meet some of the resource and patient service needs engendered by the epidemic of acquired immune deficiency syndrome (AIDS). Those actions derived from, and support the continuation, expansion, and replication of, initiatives at the community and State levels. HRSA is carrying out many of the recommendations of the Intragovernmental Task Force on AIDS Health Care Delivery by enhancing the AIDS training of health care personnel in prevention, diagnosis, and care and by counseling and encouraging the expansion of facilities outside hospitals to care for AIDS patients. The agency, through its pediatric AIDS demonstration projects, is working on models for the care of children with HIV infections. The needs of AIDS patients are being addressed through a drug therapy reimbursement program; demonstration grants to 13 projects to promote coordinated, integrated systems of care in the community; and grants for the development of intermediate and long-term care facilities for patients. Ten regional education and training centers, funded in 1987 and 1988, will increase the supply of health care providers prepared to diagnose and treat persons with HIV infections. Programs will be conducted for several thousand providers over the next 3 years, using such modalities as televised programs and train-the-trainer courses. The centers will also offer support and referral services for providers.     

The Oregon Health Plan and public health

The Oregon Health Plan would provide all Oregonians with health insurance through a combination of Medicaid expansion, employer mandates and high-risk coverage, with services delivered largely through managed care. The role of public health in a managed care environment is an important national issue, and one which has received much attention in Oregon. "Cultural" differences between Medicaid and public health have arisen over issues such as whether eligibility assures access, whether the private medical model will provide integrated care, the potential for exploitation of vulnerable populations in a capitated system, and the loss of cost-based Medicaid reimbursement to public clinics. In 1991, legislation required that Oregon's Medicaid managed care plans enter agreements with local health departments to assure their continued participation in providing certain public health services; these agreements are now being implemented. Oregon's experience suggests that any national health system will require a continuum of community and individual health services, with an important role for public health departments.     

The New Child Health Insurance Expansions: How Will School-Based Health Centers Fit In?

ABSTRACT: In June 1998, the Making the Grade National Program Office and the National Assembly on School-Based Health Care sponsored a workshop on the relationship between the State Child Health Insurance Program (SCHIP) and school-based health centers. Workshop participants used the health centers' experience with Medicaid managed care as a window for understanding their prospects for negotiating contracts with health plans under SCHIP. Speakers representing the federal perspective, state agencies, health plans, and local school-based health centers offered their views on the challenges of developing contracts, incentives, and disincentives that health plans have to contract with school-based health centers, and what has accounted for success where relationships are moving forward. Experiences in Colorado and Connecticut were presented as case studies on these evolving issues.     

Progress in efforts to prevent the spread of HIV infection among youth.

The Human Immunodeficiency Virus (HIV) that causes AIDS will continue to threaten public health for years to come. Despite some popular misperceptions, adolescents are at risk of infection. Twenty percent of persons reported with AIDS have been ages 20 through 29. Given the long incubation period between HIV infection and AIDS, some of these young adults probably were infected while they were teenagers. Young people must develop the skills they will need to avoid HIV infection and other related health problems. In 1987, the Centers for Disease Control (CDC) launched a national program to help schools and other agencies that serve youth across the nation provide effective health education to prevent the spread of HIV. CDC supports and works closely with national health and education organizations, State and local education agencies, colleges and universities, and local health departments to establish HIV prevention policies and programs, training and demonstration centers, information development and dissemination activities. The impact of these efforts are assessed through applied surveillance and evaluation research. Through this system, CDC is attempting to institutionalize the means for continuously providing educational programs that will be effective in preventing HIV infection and other important health problems.     

Public health expenditures: developing estimates for improved policy making.

The Public Health Foundation (PHF), under contract to the U.S. Department of Health and Human Services, Public Health Service (PHS), worked with federal, state, and local public health, mental health, substance abuse, and environmental agencies in nine states to develop and successfully test a methodology for estimating investments in essential public health services. Estimates from the nine-state sample revealed the predominance of personal health expenditures in the public health system. Of total state health care dollars, only 1 percent was spent on population-based health services by participating agencies. This pilot provides a rational starting point toward a uniform methodology for highlighting public health expenditures that may be critical in revealing the effects of a changing health care environment on the nation's health. In combination with other data, results are expected to lead to a more informed policy-making process.     

The Great Lakes Center's health hazard evaluation program: promoting community environmental health through partnerships between academic and public health departments

The Great Lakes Center of Excellence in Environmental Health (GLCEEH), an innovative capacity-building component of the University of Illinois, performs health hazard evaluations in collaboration with the Illinois Department of Public Health and local health departments. GLCEEH has provided state and local health departments with faculty, industrial-hygiene expertise, and research expertise to help them investigate a variety of environmental health issues. This article describes health hazard evaluations performed with support from the National Center for Environmental Health, lessons learned, and recommendations for successful collaboration between academic and public health departments. From the academic perspective, health hazard evaluations are beneficial because they provide faculty and students with the opportunity to engage in public health practice and encounter new issues that advance the science of environmental health through research. From the perspective of a public health department, health hazard evaluations are beneficial because they address priority environmental health concerns and build the capacity of department personnel to conduct health hazard evaluations with internal resources. A collaborative health hazard evaluation program increases public health capacity by developing new approaches to environmental health problems and by sharing limited resources.     

Applying HEDIS clinical measures to community health centers: a feasibility study

Since participation in managed care is critical for community health centers' (CHCs) survival, centers must demonstrate their good performance to purchasers (e.g., state Medicaid agencies) and health plans. Such measures also can contribute to quality improvement. Ideally, the effort would use measures and methods widely recognized in the managed care industry, logically the Health Plan Employer Data and Information Set (HEDIS). This article summarizes a feasibility study of applying HEDIS clinical measures to CHCs as providers. It finds that, with concerted, well-directed efforts, it will be possible to use clinical HEDIS measures in health centers.     

Educating primary care providers about HIV disease: multidisciplinary interactive mechanisms.

As HIV-related prophylactic and therapeutic research findings continue to evolve, the Health Resources and Services Administration (HRSA) of the Public Health Service has created multidisciplinary mechanisms to disseminate new treatment options and educate primary care providers at rural and urban sites throughout our nation''s health care system. HRSA has implemented (a) the International State-of-the-Art HIV Clinical Conference Call Series, (b) the national network of AIDS Education and Training Centers, (c) the nationwide HIV Telephone Consultation Service, and (d) the Clinical Issues Subcommittee of the HRSA AIDS Advisory Committee. These collaborative and comprehensive efforts at HIV information dissemination target physicians, nurses, physician assistants, dentists, clinical pharmacists, mental health care providers, case managers, and allied health professionals. The sites where they provide care include public health clinics; county, State and Federal correctional facilities; private practice offices; community and academic hospitals; military and Veterans Administration facilities; hemophilia centers; schools of medicine, nursing, and dentistry; departments of health; chronic care facilities; visiting nurse and home care agencies; health maintenance organizations; and Indian Health Service clinics and hospitals.     

妇幼保健机构委托工作经费的管理现状及对策研究

国家妇幼保健机构大量的业务工作是在各级地方妇幼保健机构和有关部门的协作、参与下在全国组织实施的,其中部分工作需要直接委托地方妇幼保健机构和有关部门协助完成,为保证委托工作的顺利完成,并按照国家相关规定合理使用委托工作经费。     

Protecting the public from mercury exposure: success through microexchange events

Mercury is a growing environmental threat that can cause serious health problems and birth defects. Household thermometers are high-risk sources of mercury because most people lack the knowledge to properly dispose of one when it is broken. The Boston Public Health Commission's Environmental Health Office, with local and national partners, created the Boston Mercury Thermometer Exchange Program to address this hazard. Large central exchanges are successful, but multiple smaller targeted "microexchanges" can be another effective way to reach the general public and specific vulnerable subpopulations such as the elderly, the homebound disabled, or recent immigrants. By conducting exchanges in community health centers and public housing developments for the elderly and disabled, and by working through home health care providers, the program collected 4477 thermometers.     

Using the PACE EH model to mobilize communities to address local environmental health issues--a case study in Island County, Washington

The Island County Environmental Health Initiative (ICEHI) is a demonstration project in the use of the Protocol for Assessing Community Excellence in Environmental Health (PACE EH) to build capacity in the 10 essential services of environmental health. The PACE EH methodology systematically applies the 10 essential services of environmental health through the completion of 13 tasks derived from a community-based environmental health assessment process. The ICEHI has successfully engaged community members, identified environmental health issues important to the community, and led to the implementation of action plans aimed at reducing environmental health risks through use of community resources. This paper describes the methodology utilized by the ICEHI to address locally important environmental health issues so that other local and state environmental health agencies may replicate the process in their communities.