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The Public Health System |
PROLOGUE
The Public Health System
PROLOGUE: The nation’s commitment to public health has grown by fits and starts, according to most accounts, lurching forward when an immediate danger looms and lapsing into neglect when it fades. Since the World Trade Center and Pentagon attacks and the attempt to start an anthrax epidemic through the mail in late 2001, some impressive strides have been taken to upgrade the public health infrastructure. For example, more than 90 percent of the U.S. population will be served by a local health department with high-speed Internet access by the end of 2002, compared with 21 percent five years ago, Ed Baker and Jeffrey Koplan report. Those accustomed to assuming that government always moves slowly may be surprised to learn of additional initiatives by the Centers for Disease Control and Prevention (CDC) and other public agencies to improve communication, disease surveillance, workforce training, and laboratory capacity.
The danger, many observers agree, is that recent progress will give way to another loss of momentum. Higher aspirations for public health have already been through two boom-and-bust cycles since World War II, according to a historical survey by Elizabeth Fee and Theodore Brown. The war effort engendered ambitious plans for the U.S. Public Health Service in the mid-1940s, when Surgeon General Thomas Parran declared that "it is a duty of governments...to guarantee healthful living conditions and...freedom from preventable disease." But such expansive views of the public sector’s role were branded as socialistic and abandoned during the McCarthy era. In the 1960s and 1970s expanded health and environmental programs made headway under the banner of the Great Society and the War on Poverty. But the pendulum swung again in the 1980s as initiatives favoring privatization brought a 25 percent reduction to the budget of the U.S. Department of Health and Human Services. Now the threat of bioterrorism and the emergence (or reemergence) of infectious diseases have begun to refocus the nation’s attention on the critical role of a vigorous, effective public health sector.
Public health advocates have been candid about treating current alarm about the threat of bioterrorism as an opportunity. While the money is flowing, the system’s champions want Congress to recognize that investments in bioterrorism preparedness can also repair a frayed and underfunded system of disease surveillance and health promotion. In a response to Baker and Koplan, though, Nicole Lurie suggests that efforts should focus on restructuring the public health infrastructure and attacking the lack of coordination and communication between the public health and the general medical sector, rather than simply increasing funding for an irrational agglomeration of unsynchronized half-measures. Higher investment alone cannot be counted on to meet the nation’s public health needs in the future, Lurie argues. It’s not going to be that easy.
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