Panel Stresses Public Health Risks : Study Finds System Now Lacks Ability to Offer Safeguards

The nation’s public health system is in “disarray” and major public health responsibilities--from fighting critical epidemics such as AIDS to keeping drinking water safe--”have become so fragmented that deliberate action . . . is often difficult, if not impossible,” according to a report released Wednesday by the Institute of Medicine.

“We Americans are taking our public health system for granted,” said Dr. Richard D. Remington, professor of preventive medicine and environmental health at the University of Iowa, who served as chairman of the study panel. “Our guard is now down.”

Erratic Delivery of Care

The institute, a part of the prestigious National Academy of Sciences, attributed the poor condition of the public health system to an inadequate understanding by public health agencies and by citizens of what services should be provided. It also cited erratic delivery of care “that often leaves the poor without services,” a tremendous diversity of services from one state to another and within states and tension between public health experts and politicians.

Further, the study said, the public expects public health agencies to provide direct health care to the estimated 30 million or more Americans who have little or no health insurance, without giving them the resources to do so.

“The result is a public health system in disarray--a system in which neither the public health providers nor the citizens receiving the benefits have a clear vision of what the responsibilities for public health institutions at the federal, state and local levels should be,” Remington said at a press conference.

Chartered by Academy

The National Academy of Sciences is a congressionally chartered, private organization that advises the federal government on matters of science and technology. The Institute of Medicine was chartered by the Academy in 1970 to enlist members of the medical and other professions to study various aspects of public health policy.

The two-year study found substantial differences in the ways states delegated public health responsibilities. In one state, for example, the health department was a major provider of prenatal care for poor women, while in other states “women who could not pay, got no care,” Remington said. Some state health departments maintained traditional responsibilities for monitoring drinking water safety, while others assigned this task to a separate environmental department “where health issues receive less attention,” Remington said.

In many states, mental health activities are carried out by separate mental health departments, while in others, the public health department assumes responsibility, he said.

Uneven Capabilities

Some state health departments are “active and well-equipped,” while others perform fewer functions and “get by on meager resources,” the study said.

The report--although critical of the system--was praised immediately by members of the public health community.

“I think the effort to diagnose some of the problems faced by the public health endeavor in this country were well done, and I think most of them are right on,” said Dr. William H. McBeath, executive director of the American Public Health Assn., which represents an estimated 50,000 members, more than half of whom work in state, local and federal public health agencies. “Most of the problems they identified are very real ones--and most of the people who work in public health would agree.”

Dr. Thomas Vernon, president of the Assn. of State and Territorial Health Officials, said that the report “provides the impetus for public health to achieve matters that have been on the back burners” and “strengthens our hand in public health practice generally.”

Two Examples Cited

Committee members cited the AIDS epidemic and the disposal of toxic substances as examples of where the tug of war between health experts and politicians adversely influenced the decision-making process.

“Public health has had great difficulty accommodating itself to these political dynamics,” the report said. Public health decision making is “driven by crises, hot issues, and the concerns of organized interest groups,” the study said. “Decisions are made largely on the basis of competition, bargaining and influence, rather than comprehensive analysis.”

Recommendation for States

The committee recommended that each state have a department of health that incorporates all health-related functions, including Medicaid, mental health programs and areas of environmental protection requiring health expertise.

Further, the study urged that the states guarantee a minimum set of essential health services for all citizens, particularly the uninsured and underinsured.

“No citizen from any community, no matter how small or remote, should be without identifiable and realistic access to the benefits of public health protection,” Remington said.