Strengthening New York's Public Health System for the 21st Century
REPORT OF THE PUBLIC HEALTH INFRASTRUCTURE WORK GROUP TO THE PUBLIC HEALTH COUNCIL
V. THE NATIONAL PUBLIC HEALTH CONTEXT
Emerging trends currently impact the nation's health. Many of these phenomena intersect and inter-relate:
- Globalization has created more movement between and among individuals and nations;
- New infectious diseases and the reoccurrence of old pathogens have emerged;
- sometimes with antibiotic resistance;
- Changing demographics have increased numbers of immigrant and elderly persons;
- The character of many diseases has shifted from acute to chronic; and
- Technological and scientific advances have occurred in communication and biomedicine, both curative and preventive.
These developments are social, geopolitical and economic as well as medical. While some hold great promise for the future, they also pose significant current challenges for America's and New York's health. All carry a cost and the potential for unintended consequences. The emergence of AIDS, West Nile Virus and most recently SARS provides examples of the impact global travel, in-migrations and encroachment of people into natural environments can have on populations previously sheltered from one another.8
Other national health trends appear to be related. An increasingly elderly population accounts in part for the statistical shift away from acute disease toward chronic disease. By the year 2010, the percentage of the US population over the age of 65 is projected to be 13.3%; by the year 2025, it will represent 18.5% (US Census Bureau, 1996a). With chronic disease more prevalent among the elderly, an aging population carries obvious implications for the need for health and public health services. A racially and culturally diverse population with lower levels of education and employment introduces further complexity to the mix. Persons who face greater risks associated with socioeconomic status may be more likely to experience compromised access to medical care. To quote from the Institute of Medicine's (IOM) publication, The Future of the Public's Health in the 21st Century, "...socioeconomic status may influence health status: access, resource distribution, psychosocial conditions, physical/toxic environments, and personal behaviors...."9
Along with age and socioeconomic status, the American lifestyle with its reliance on fast foods, inactivity, work-family demands, and alcohol and tobacco use is also implicated in the rising incidence of chronic disease. One apparent consequence of lifestyle is obesity, a disease that is increasing at such an alarming rate that it has been described as an epidemic. The prevalence of obesity has grown by nearly 20% over the past 30 years. Today, 61% of adults are either overweight or obese. More critical for the future, 15% of children and teens ages 6 to 19 are deemed to be overweight, and over 10% of young children ages 2-5 are overweight.10 The obesity epidemic has lead to increases in other chronic diseases such as heart disease, arthritis and Type II diabetes. These diseases are chronic and occur more commonly among a growing number of persons who are overweight, under active and aging in the US population.
Overall health care spending in the US is substantial with approximately 13% of the nation's GDP directed toward health related expenditures. This amounted to $1.3 trillion in 2000.11 At the same time, it is important to note that nearly 95% of health care spending in the US is applied to direct curative medical care and biomedical research.12 Put differently, spending is directed more at personal health care than at population-based interventions to improve health. The Medicaid budget in 2002 was a portion of this expenditure at $142 billion serving 11.2% of the population (OMB, 2001b).13 In the same fiscal year, the Department of Health and Human Services (DHHS) was granted a discretionary budget for public health service agencies of $41 billion of which $23.2 billion was designated for the National Institutes of Health. As reported by the IOM however, "...very little of this (DHHS) discretionary money (went) directly to the states for government agency public health infrastructure."14
While the primary constitutional responsibility for public health rests with the states, the federal government exercises significant authority overseeing and influencing:
- Policy making;
- Law enactment;
- Protections through agencies such as the Food and Drug Administration (FDA) and Centers for Medicare & Medicaid Services (CMS);
- Financing of entitlement programs like Medicare (Title XVIII) and Medicaid (Title XIX);
- Collection and distribution of health data through organizations such as the National Center for Health Statistics at the Centers for Disease Control and Prevention (CDC);
- Capacity of the hospital industry (Hill-Burton) or other health system interventions through the Department of Health and Human Services (DHHS); and
- Direct services such as the Indian Health Service.15
Working with other federal agencies, with the Congress of the United States, as well as with state and local legislatures and boards of health, the federal government has contributed to important improvements in health during the last century. These advances illustrate how government's policies and programs, when combined with community action, private enterprise and public education, can reverse dangerous trends and improve the overall well being of a nation. Key examples include:
- Providing research funding to develop new antibiotics;
- Spearheading national immunization programs;
- Requiring safer workplaces;
- Funding research to prove that early screening procedures can be cost effective and lifesaving;
- Funding research to make the connection between lifestyle and disease;
- Monitoring food and drugs;
- Reducing pollution;
- Controlling toxic waste; and
- Funding research to show the benefit of fluoridating public water.
Even automobile travel poses less risk today due to safer vehicle design and seat belt requirement. At the same time, automobiles produce fewer emissions thus reducing harm to the environment.
In an ever more interconnected world, much still remains to be done by the federal government. Actions must be informed and driven by the changing needs and problems the new century poses. Conflicts and priorities are inevitable but must be managed in the face of increasing complexity. The IOM report observes that "...health stands in the balance between economic, political, and social priorities, and is caught in the middle of necessary and important tensions between rights and responsibilities - individual freedoms and community or social needs, regulation and free enterprise."16 Governments make policy, enact laws, provide financing, collect and report data, direct or oversee services that enhance the public's health. It is also true that governments continue to face constraints in fulfilling their mission. Some obstacles derive from a legacy of governmental initiatives undertaken piecemeal during the last century. Of particular concern is a legal and financial framework for public health that is hindered by antiquated laws, stove piped funding that is disease based, and statutory mandates that are not integrated, or worse still, are duplicative. To quote from the IOM report "...With more than 200 categorical public health programs in DHHS and a variety of health related programs in other federal agencies, the alignment of policies and strategies is challenging."17 Strengthening public health infrastructure to make it more effective will depend upon these inefficiencies and limitations being adequately addressed.
8 The Future of the Public's Health in the 21st Century, Institute of Medicine 2003, p. 33.
9 Ibid. p. 59.
10 National Health and Nutrition Examination Survey, CDC, 1999.
11 The Future of the Public's Health in the 21st Century, Institute of Medicine 2003. p. 20.
12 McGinnis MJ, Williams-Russo P, Knickman JR. Health Affairs 21( 2): 78-93.
13 The Future of the Public's Health in the 21st Century, Institute of Medicine 2003. p. 219.
14 Ibid. p. 115.
15 Ibid, p. 106.
16 Ibid. p. 23.
17 Ibid. p. 117.