Chapter 2

The Success of Public Health Programs: Critical Factors

Learning Objectives

• Understand the major accomplishments of public health departments in the United States
• Become aware of the history and development of public health departments in this country
• Understand the value of health education programs in the prevention of disease
• Recognize the need for training and development of public health leadership

Most people have minimal awareness of the role public health departments, or agencies, play in maintaining the health and longevity of Americans. This is because these departments usually receive very little publicity unless there is a serious health problem. In fact, most Americans associate public health departments with their work to control outbreaks of disease among large numbers of people, such as in responding to the recent large outbreak of salmonellosis related to the consumption of peanut butter, or in issuing warnings about a possible pandemic of avian influenza or swine flu in the United States. It is unfortunate that our only knowledge of public health relates to emergencies, because we are then unaware of the day-to-day activities public health departments perform in order to keep people healthy. This perception of public health departments as primarily responders to health emergencies prevents health policy experts from understanding the contribution that these departments could make in solving the major health care problems in this country, which include issues of cost, access, health status, and quality of care. These departments do so many things to prevent disease that are never publicized and, therefore, are not known by the average person or policymakers. Scutchfield and Keck (2009) argue that public health departments have never received the credit they deserve for their many accomplishments, including articulating a vision of the possibilities for a healthy community.

The major problem found in our health care system today is the concentration of scarce health resources on the cure of disease rather than the prevention of disease. If we improve the health of the population through health education and health promotion, the other problems found in our health care system diminish in importance. Turnock (2009) points out that public health departments can also identify and address unacceptable realities that models of preventive health care can alleviate. Stallworth and Lennon (2003) argue that collaboration is required to improve the health of the population. The improvement of the health of a community requires all health agencies, including hospitals, to work together. This one statement summarizes the true success of public health departments: their ability to get people and communities to work together to improve the health of the population. Public health departments are the catalyst of preventive health programs.

The public health system in the United States is always working at making good health available for all individuals. It is usually seen as a very silent component of health services, demanding few resources and yet producing unbelievable value for our citizens in terms of better health for all. This system employs some of the most dedicated health professionals to be found in any part of this country's health care system. Although a large income is not usually associated with public health employment, public health work affords personnel a great sense of accomplishment. Public health employees are very special people who do extraordinary work because they like what they do. They enjoy helping people even though they receive very little recognition for their work.

The public health system should be considered one of the greatest success stories within the system of health care in our country. In fact, the public health system in the United States is responsible for most of the gains in long life Americans enjoy today. It is interesting to note that this system has actually increased its successes despite cuts in funding for many programs on an annual basis.

The public health system is more than a collection of government agencies; it is actually a thick culture of dedicated professionals whose very existence is dedicated to the effort to keep people healthy. This culture among public health employees is difficult to describe and even more difficult for others to understand. Many of those who work in public health look at their work as a calling to help others become healthier, and they feel rewarded when they accomplish even a small part of this goal. These talented and dedicated employees get a certain psychic income from being successful in helping others preserve or improve health. They claim that there is no better feeling than this.

The public health sector is usually supported with federal, state, and local funds and grants that are appropriated annually. It is a political entity, often led by political appointees who never quite understand the culture of the public health employees. These temporary administrators also do not appreciate the value of marketing what a public health department does on a daily basis. Therefore, very few people understand the value of public health, and the funding for these agencies is never enough for them to really do their job. It seems that public health departments are one of the best kept secrets in this country.

According to Novick, Morrow, and Mays (2008), the American Public Health Association made a statement in 1933 that outlined two major activities for public health agencies: controlling communicable diseases and promoting child health. This statement was signed by Haven Emerson and C.E.A. Winslow, among others. In 1945, Emerson expanded these two functions to include such additional functions as disease investigation and health education, which were not being performed by other government agencies and for which government funding was always set at a bare minimum. These official functions are all very important, but they also tend to limit the vision of what public health departments would be able to accomplish if they were given sufficient resources and better leadership and support.

According to the Centers for Disease Control and Prevention (CDC, 2006a), the life expectancy of Americans has increased by over thirty years since 1900. Much of this expanded longevity has resulted from a variety of public health programs. These programs are not a part of the health care system, but have come into being as a direct result of public health initiatives. Following are ten remarkable accomplishments of U.S. public health departments over a one-hundred-year history, from 1900 to 1999, which were achieved despite a very modest budget that was usually reduced rather than increased every year (CDC, 1999b):

• Mass vaccinations
• Increased motor-vehicle safety
• Safer workplaces
• Better control of infectious diseases
• A decline in deaths from coronary heart disease and stroke
• Safer and healthier foods
• Healthier mothers and babies
• Family planning initiatives
• Fluoridation of drinking water
• Recognition of tobacco use as a health hazard

The public health prevention initiatives that drove these admirable achievements today continue to protect the public from disease, allowing the majority of Americans to live longer, healthier lives. These prevention programs, which have been so successful in reducing communicable diseases, must now be modified and improved to deal with the epidemic of chronic diseases facing our country. The accomplishments listed above can be duplicated today, but public health departments need to employ different strategies. Unlike previous challenges the public health system has encountered, chronic diseases require a well-developed community approach, in which public health departments provide leadership and innovative ideas to educate every member of the U.S. population throughout his or her life span.

Despite the dedication of the public health workforce and previous successful public health initiatives, the public health departments in this country have not been able to achieve all of their goals. The Institute of Medicine (IOM) completed a very important study concerning public health in 1988. The resulting document, titled The Future of Public Health, looked at the mission of public health, the current state of public health, and the various barriers facing public health in this country. The report determined that there was widespread agreement on the mission of public health but that this mission was not being accomplished. In fact, the public health system in our country was not meeting its current objectives. Further, the report concluded with a very serious warning that the public health system was in total disarray. Public health, the IOM argued, was never allowed to develop into a strong sector with the resources necessary to continually improve the health of all Americans, primarily because many of the political appointees running local public health agencies allowed funding to be cut in order to keep their positions. It is very dangerous for political appointees in public health departments to question the budget decisions of the administrators who appointed them to their current position.

Definition of Public Health

As we have already stated, most people know very little about the organizations and services provided by public health departments in this country, and the valuable contributions public health professionals make year after year are largely taken for granted. We only look for guidance and answers from public health officials and the various government agencies they represent when an emergency threatens our health. Problems like E. coli in our food supply, anthrax in the mail, contaminated water, or drug-resistant tuberculosis bring public health to the forefront until the crisis subsides…and then the public health system seems to disappear until we need its help again.

In 1920 Charles-Edward A. Winslow defined public health as “the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals” (quoted in Turnock, 2009, p. 10). McKenzie, Pinger, and Kotecki (2005) define public health as a field preserving the health status of members of the population through government action to promote, protect, and preserve their health. Novick et al. (2008) argue that public health involves a structured approach to improve the health of the population. Finally, Vetter and Matthews (1999) argue that public health includes the processes of promoting health, preventing disease, and prolonging and improving the quality of life through the organized efforts of society. These are definitions that support the use of public health expertise to solve many of the current health care problems in this country.

All of these definitions point to a science dedicated to the improvement of the health of a given population. The various definitions of public health also conjure up a vision of population-based medicine rather than health care that is centered on specific individuals. These definitions further emphasize the prevention of health problems rather than efforts to cure them. The tools of public health are exactly those required to solve many of the problems present in the U.S. system of health care.

According to the IOM (2002), the public health system needs to partner with the health care delivery sector to attain their shared population health goals. Public health agencies implement a large number of prevention programs very well, but they need to change some of the activities that they have continued for years and that have only a marginal impact on health outcomes.

Despite the success of public health strategies in improving the longevity and quality of life of the majority of Americans over the last one hundred years, resources for public health departments have been reduced. Making matters worse, these public health departments have been assigned new responsibilities, while at the same time losing many of their most experienced workers to retirement. There needs to be an expansion of public health programs, such as health education efforts, which have proven their worth in the reduction of high-risk health behaviors. These programs are crucial in dealing with problems of obesity, physical inactivity, and poor diet. Although public health departments have had wonderful accomplishments, it is time to move on to even greater success stories. They need to develop and use new tools to deal with the epidemic of chronic diseases that is so different from previous epidemics of communicable diseases.

Public Health Systems

The government-funded public health agencies in the United States are separated into three systems that work together in different ways to improve the health of the population. The government-funded public health departments operate at the federal, state, or local level. The people who work for each agency are usually government employees headed by a political appointee, and they are funded primarily by tax dollars.

Public Health at the Federal Level

Exhibit 2.1 lists some federal public health agencies that are responsible for addressing a large number of population-based health concerns. Several of these federal agencies are involved in formulating national objectives and policies that in turn help establish standards for both the provision of health services and the protection of the public's health. They are also responsible for the distribution of funding to state and local health department activities, including emergency preparedness initiatives. Several of the federal public health agencies, such as the Indian Health Service, also provide population-based health services to certain subgroups of the population.

Public Health at the State Level

Every state in the United States has a public health department that is empowered to protect the health and safety of its population. State health departments are responsible for gathering and interpreting various pieces of statistical data pertaining to population health and sharing this information with a number of federal health agencies. The states also offer laboratory testing and investigation services for a variety of communicable diseases that hospitals or other laboratories do not provide. Further, these agencies grant licenses to health care professionals and most medical facilities, and monitor their performance. They also finance and implement a number of health education programs.

Public Health at the Local Level

Local health departments are usually the responsibility of cities or counties that have decided to offer public health services through funding from state and federal sources. These departments are responsible for actually performing the public health activities that are legislated by the state and federal government. Their tasks include collecting health statistics, investigating communicable diseases, providing environmental sanitation services, implementing maternal and child health programs, and disseminating health education information.

Community Health Workers

The community health worker (CHW) has become a critical player in public health activities around the world. This classification of public health occupation began to develop in the 1960s. According to the U.S. Department of Health and Human Services (HHS, 2007), this type of worker has been used in cost containment and cost-effective strategies designed to provide health care to the underserved populations throughout the world. Community health workers are formally defined as “lay members of communities who work either for pay or as volunteers in association with the local health care system in both urban and rural environments and usually share ethnicity, language, socioeconomic status and life experiences with the community members they serve. They have been identified by many titles such as community health advisors, lay health advocates, ‘promotores(as),’ outreach educators, community health representatives, peer health promoters, and peer health educators” (HHS, pp. iii–iv).

CHWs work in for-profit and nonprofit agencies, such as schools, universities, clinics, hospitals, physicians' offices, individual-family-child services, and education programs. There were approximately eighty-six thousand individuals working in this field in 2000 in the United States, with approximately 67 percent being paid and 33 percent working on a volunteer basis.

The majority of CHWs are females between the ages of thirty and fifty, and are usually Hispanic or African American. They work for very low wages or volunteer, and they serve all ethnic and racial groups. The volunteers are usually employed by faith-based organizations or as part of outreach and health education efforts designed by university researchers and local health care providers. The most frequent issues that CHWs handle are women's health and nutrition, prenatal and pregnancy care as well as children's health, immunizations, and high-risk sexual behavior. The vast majority of CHWs' work in these areas involves health education and health promotion activities. These individuals are a necessary adjunct to public health departments, especially at the local level, and are most useful in the provision of health education programs, especially for underserved populations. They also provide informal counseling, which helps individuals make basic decisions in regard to healthy or unhealthy behavioral choices.

The study conducted by HHS (2007) identified roles that CHWs may assume:

• Member of the care delivery team. In this role the CHW works with a lead provider of care, typically a physician, nurse, or social worker.
• Navigator. This role requires greater emphasis on the capabilities for assisting individuals and families in negotiating increasingly complex service systems and for helping clients build confidence when dealing with providers of care.
• Screening and health education provider. This role has been one of the more common, and has been included in many categorically funded initiatives on specific health conditions, such as asthma and diabetes.
• Outreach-enrolling-informing agent. This role involves reaching individuals and families eligible for benefits or services and persuading them to apply for help or to come to a provider of care's location.
• Organizer. In this role, a volunteer CHW becomes active in a community over a specific health issue, promoting self-directed change and community development.

It is evident that CHWs are a vital component of any form of population-based medicine a given community might use. These individuals are dedicated community members who have developed collaboration skills and are motivated to improve the health of their community.

Population-Based Medicine

The health care system in our country revolves around individual patients, with an emphasis on curing diseases or other ailments. In recent years, however, managed care insurance has been moving from a focus on payment for health care to a focus on keeping the population healthy. Practicing population-based medicine is a mass strategy of which the prevention of common diseases of the population is the primary goal (Webb, Bain, and Pirozzo, 2005). Those implementing population-based medicine recognize that many diseases originate in the behavior and circumstances of members of the population, and place emphasis on the reduction of risk factors for that population. This has always been the focus of public health departments, which have long been concerned with the prevention of illness and disease in the entire population. This strategy can only be accomplished through well-developed health education programs, along with some regulation of high-risk health behaviors.

The Association of American Medical Colleges (1998) argues that population-based medicine usually involves

• The assessment of the health needs of the entire population being served
• The implementation and evaluation of specific interventions that are designed to improve the health of that specific population
• The provision of care for individual patients while considering the culture, health status, and health needs of the specific population being served

The overall goal of this approach to medicine is to reduce specific high-risk behaviors in a given population in order to improve its health.

Problems in Our Health Care System

According to McKenzie, Pinger, and Kotecki (2005), health care delivery in the United States is the greatest challenge to public health in the twenty-first century. The health care system has become extremely large and complex, and those responsible for the system seem to be more interested in money and enormous profits than in keeping people healthy. These groups and individuals seem baffled by the need to prevent illness, as opposed to using the scarce resources to repair damages to people's health after they become ill. It is up to public health agencies to help clear up this confusion, but this will require leadership.

The American health care system is receiving over 17 percent, or more than $2 trillion, of gross domestic product (GDP) each year to keep people healthy. These expenditures for health services are expected to continue rising into the foreseeable future. Despite this massive spending, however, comparisons of various health indices suggests that the United States is not doing as well as most other industrialized countries. There is now a sense of urgency in this country surrounding the question of how to cut health care costs, give access to care to millions who are without health insurance, and at the same time keep people healthy. This cannot happen if we fail in our effort to stop the epidemic of chronic diseases and the incurable complications that usually result from them.

According to McGinnis (2006), the health care system has developed resentment toward public health over the years. On the one hand, public health departments have been seen as meddling in the practice of medicine and providing health services to individuals who should be going to their family doctor. On the other hand, public health departments have seemed arrogant and often too busy to deal with the average physician. This lack of collaboration must stop, and a true partnership needs to begin between medicine and public health. These sectors need to work on common problems that require the expansion of partnerships in order to be solved.

There is now a growing body of evidence that enlightened leadership from the medicine and public health sectors is expanding collaboration, including partnerships in preventive health services. There are many examples from recent years of successful collaboration that has resulted in immunizations, treatment and investigation of sexually transmitted diseases, injury-prevention efforts, and diabetes initiatives. These partnerships need to be expanded in order to successfully pursue the prevention of chronic diseases.

It is ironic that public health departments must forge partnerships with the very individuals who make the most money from an unhealthy population. In fact, the self-interest of our medical complex is threatened by a country that practices healthy behaviors. The field of public health is undergoing a major change as the system of health care delivery is very slowly moving toward a model of prevention, away from the old curative model. The key player in health care, the physician, receives very little training in preventive care while in medical school and virtually no continuing education in this area after graduating. It is an absolute necessity that public health departments and physicians partner in the improvement of community health. The lack of cooperation between physicians and the public health sector must end.

These partnerships must flourish if our country is ever going to improve the health of the public. To this end, there must be public health education in medical schools, financial incentives from insurance companies to keep people healthy, and strong leadership from the medical care and public health systems. Tilson and Berkowitz (2006) argue that public health agencies have an obligation to develop a better relationship with medical care providers in order to make preventive care the norm in this country. Medical care providers must also recognize that population-based health services can be provided more effectively and efficiently by public health agencies.

There seems to be universal agreement that our current health care system is not working very well. In fact, many health policy experts believe that the current health care system is in a state of crisis. This system costs too much; many Americans do not have access to it, and even though we are living longer in this country, the quality of life is quite poor for many older Americans.

A large number of our policymakers are focusing on the millions of Americans without access to the health care system and demanding some form of national health insurance for all. However, is the problem in our health care system really one of access, or does it stem from the fact that the system does not concentrate on wellness but rather allows us to become ill? If it is an issue of a desire for good health, then access alone is not the answer. Individuals can generally obtain and preserve good health by practicing good health habits. If one is healthy, the access problem loses some of its importance. The lack of information concerning good health behaviors—and the question of how to direct health care resources toward rectifying this dearth—are the most significant health care problems we face.

Satcher (2006) points out that our health care spending lacks balance in regard to population-based prevention, which represents less than 2 percent of the health care budget. According to Satcher (2006, p. 1010), “The burden of chronic disease is increasingly making the U.S. health system unaffordable and causing much unnecessary pain and suffering.” Turnock (2009) argues that public health remains a mystery to the vast majority of the general public. The amazing accomplishments of underfunded public health departments are now being called upon to defeat the current epidemic of chronic diseases and their complications. However, the major portion of the money spent on health care is allocated for the cure of disease rather being directed toward the prevention of disease through health education and health promotion programs primarily found in public health departments. Public health departments must take the lead role in helping health care system providers appreciate that they cannot provide preventive services as efficiently or effectively as can public health departments (Tilson and Berkowitz, 2006). These go on to argue that our health care system is a very important component of the public health system, because the health care system needs to deliver preventive services if public health is to achieve its mission. As McGinnis (2006) has argued, it is mandatory that the health care system form a partnership with the public health system if the crisis in health care in this country is ever to be solved.

The Need for Improved Accountability of Public Health Professionals

Public health professionals require additional training in order to accomplish the public health objectives of the twenty-first century. Public health departments in this country cannot continue to do business as usual; they cannot continue to use antiquated tools, spend dwindling resources, or rely on visions of past successes to deal with the new and emerging threats to the public's health. The IOM (2002) recommends a system for regularly assessing the adequacy, capacity, and competence of the various public health agencies in this country. Tilson and Berkowitz (2006) call for the use of national performance standards and accreditation for our public health departments to ensure they are prepared for their vital role in health care delivery in this new century. Finally, a means of checking accountability for outcomes needs to be built into public health funding.

Tilson and Berkowitz (2006) argue further that because there are public health employees of varying competence levels, there should be standardized training programs to prepare all public health workers for the tasks ahead. Mays, Miller, and Halverson (2000) maintain that there is increased interest in the establishment of public health performance standards and a national system of accreditation for public health departments. Such standardization could yield comparative data, which all public health departments could use to improve their quality and accountability. Employees and volunteers, especially at a local level, need continuous training in all areas of preventive health care. In addition, it is clear that public health professionals need to receive instruction in the advanced use of computers and marketing techniques; they also require leadership training to assume the new role of guiding communities toward better health. Once trained, they need to be held accountable for outcomes.

Local Health Departments

As discussed in Chapter One, the IOM (2002) acknowledges that public health departments perform three core functions: assessment, policy development, and assurance. These functions are usually performed by a unit of government at the federal, state, or local level. At the local level, they are best performed by a local health department (LHD), which receives its authority and responsibilities from the state and local laws that govern it. The National Association of County and City Health Officials (NACCHO) published an Operational Definition of a Functional Local Health Department in 2005 that listed the following functions of an LHD (2005b, pp. 6–10):

Characteristics of Local Health Departments

NACCHO (2005a) recently completed a national profile of local health departments, reporting on the characteristics of the nation's local health department infrastructure. Because public health programs are services, it stands to reason that the largest costs associated with offering them on a local basis are those invested in hiring, training, and employing their staff. The NACCHO survey was sent to 2,834 LHDs; 2,300 participants returned the questionnaire, representing a 77 percent response rate. The following information represents an overview of LHDs in the United States.

Over 70 percent of LHDs serve a county or combined city-county jurisdiction, and 60 percent serve small populations. The medium-size LHD serves a population base between fifty thousand and five hundred thousand individuals. Almost three quarters of the LHDs are under the control of a local board of health. Most boards of health are appointed by elected county officials. Their functions include governing, policymaking, and advising the county health director.

There is great diversity in the budgets of LHDs, with yearly expenditures ranging from as low as $10,000 to as high as $1 billion. Local sources provide the greatest percentage of revenues for LHDs, followed by sources directly from the state and federal funds passed through to LHDs by state agencies.

Approximately 86 percent of the LHDs have a chief operating officer who may have one of the following titles: health officer, director, administrator, health commissioner, nurse manager, or hometown improvement leader. This position is always a full-time responsibility, and the vast majority of chief operating officers hold an advanced graduate degree. The mean time of tenure for this position across the country is eight years.

Approximately 160,000 full-time workers are employed by LHDs. Most LHDs employ administrative or clerical personnel, nurses, managers, and directors. Other personnel found in LHDs include but are not limited to sanitarians, environmental health specialists, health educators, physicians, information management specialists, disease intervention specialists, and epidemiologists. The average complement of full-time employees for LHDs varies in size depending on the size of the population. That population includes 5 managers or directors, 20 nurses, 9 environmental specialists, 23 clerical staff, 3 nutritionists, 2 health educators, 1 physician, 1 epidemiologist, and 1 information management specialist.

The vast majority of LHDs have received federal funds from the CDC for preparing for bioterrorism, and most LHDs have improved their ability to respond to emergencies over the last few years. The funding has been used to hire and train people in preparedness planning, surveillance and epidemiology, and information technology.

The LHD plays a very important part in transforming a community into a healthier place to live. Turnock (2009) points out that the services an LHD most frequently provides in this country include

• Adult immunizations
• Childhood immunizations
• Communicable and infectious disease surveillance
• Tuberculosis screening
• Food service establishment inspection or licensing
• Environmental health surveillance
• Food safety education
• Tuberculosis treatment
• High blood pressure screening
• Tobacco use prevention
• Maternal and child health programs
• Injury prevention programs
• Oral health programs

Planning and Performance Improvement

LHDs are also very involved in community health assessments and community health improvement planning. These agencies spend a great deal of time gathering, analyzing, and disseminating valuable health data to communities. They also concern themselves with constantly improving the quality of the services they offer to their respective communities.

In recent years, LHDs have spent a great deal of time developing partnerships with other community agencies in the attempt to improve community health. This includes partnerships with schools, businesses, emergency responders, the media, and other health care providers. There has also been an increasing effort on the part of LHDs to reach the disparate populations in their community.

Information management has become a critical component of the LHD. Almost all LHDs have access to computers and high-speed Internet, and can rapidly communicate with federal and state health agencies, increasing LHDs' ability to provide valuable health information to communities. Most LHDs have developed their own Web site, which allows easy access to a wealth of public health data that can be shared with other health agencies and the general public.

Epidemic of Chronic Diseases

As we have already argued, the public health problems our nation faces have changed over the years, moving from very noticeable outbreaks of communicable diseases to the very quiet but more dangerous epidemic of chronic diseases, many of which are caused by our own behaviors. In 1900 the leading causes of death were influenza, pneumonia, and tuberculosis. Today the leading killers are all chronic diseases, including cancer, heart disease, and stroke. Because the chronic diseases have long incubation periods, the health care system usually chooses not to deal with them until they manifest themselves in complications. There is also no real incentive in our health care system to prevent illness, because physicians and hospitals receive payment for treating or curing diseases, not preventing them.

This waste of scarce resources must change through the leadership of public health departments. All providers of health care must move toward a prevention model of medical care for their patients. This is a major shift for the vast majority of health care providers, and public health agencies have to provide the guidance necessary to make this change a reality.

Behaviors like using tobacco, maintaining a poor diet, being physically inactive, and misusing alcohol are responsible for over 40 percent of the premature mortality in this country each year. One of the answers to preventing these high-risk health behaviors lies in behavioral interventions, or the practice of behavioral medicine. This type of medicine involves preventing or changing high-risk health behaviors so that chronic diseases do not develop, constituting primary health care delivery, which does not return high profits to those dispensing the care. This is a very difficult concept to sell to a medical establishment that has developed and grown under the rules of capitalism, and at which profits determine the actions of the players. If we are ever going to get the costs of health care to a manageable level and deal with the enormous access problem for many Americans, we are going to have to combat the epidemic of chronic diseases in the United States. This is going to be one of the most difficult tasks the public health sector and our health care system have ever undertaken.

One of the best ways of preventing chronic diseases and their complications is through health education programs designed to prevent high-risk health behaviors in individuals and communities. These programs are not hard to develop, but they offer tremendous challenges in regard to their implementation and evaluation. There is also a need for a different type of evaluation to measure the success or failure of health education programs whose goal is the reduction of chronic diseases, because these diseases' long incubation period and multiple causal factors complicate the evaluation process. It has therefore been difficult to discover what types of intervention programs will be successful in preventing or delaying the onset of chronic diseases. It has been even harder to obtain adequate funding to slow the development of high-risk health behaviors on the part of younger Americans. It is very challenging to educate these individuals about their health behaviors, because they cannot relate the practice of risky health behaviors when they are young to the possibility of poor health later in life.

The payoff for reducing the incidence of chronic diseases in this country is enormous. The CDC (2009a) maintains that the medical costs for individuals with chronic diseases accounts for almost 80 percent of the total health care costs in the country. More important than the monetary burden of these diseases are the years of potential life lost for people under the age of sixty-five. These human and monetary costs can be avoided if we work to remain healthy.

Public health departments are making progress in their response to the growing epidemic of chronic diseases in this country, but they cannot win the battle on their own. These departments do not have the resources necessary to triumph against the most difficult public health problem that they have ever faced. They have to become the catalysts in the formation of partnerships with the medical establishment, businesses, and other agencies in order to develop an effective strategy for helping individuals develop and maintain healthy behaviors. These needed partnerships are much easier to develop and nurture on a local level. At this level it is much easier to involve the community, which is a required prerequisite for success in the development and implementation of chronic disease prevention and health education programs. The local community is a potential source of resources, human and financial, for the new educational intervention.

Information Management

The science of public health involves using the tools of epidemiology, conducting surveillance, and preventing disease. Information management is a critical component of these activities, because the most important factor in any effort to improve the health of populations is the availability of accurate information. Very few agencies do a better job at managing and interpreting health information than do public health departments. Because of their responsibility to investigate reportable diseases, they are allowed to receive and use confidential medical information. They can then develop and implement sophisticated passive and active surveillance systems to gather a great deal of very accurate data concerning diseases and other health problems.

The IOM (2002) has argued that the use of information technology to improve surveillance systems for disease reporting, which is so necessary in the improvement of the health of communities, presents great opportunities and challenges. This prestigious group went so far as to recommend that government public health agencies should use information technology to collect and disseminate information more efficiently in order to help the public and public officials better understand what health services should be offered. This would include conveying to a large number of people the advantages of using preventive services for circumventing or postponing the development of chronic diseases and their complications. According to Novick et al. (2008), information management has evolved as one of the most important processes available to public health departments because of the sheer volume of health data available and the emergence of technology to swiftly disseminate these data.

Due to the availability of computing technology, public health departments are now able to rapidly gather health-related data, analyze these data, and share them with those responsible for the improvement of the health of the population (Novick et al., 2008). The future holds great promise for the further development of information technology to be used in delivering public health information to larger audiences. Information delivered by public health departments, especially at the local level, should include notices pertaining to education programs to prevent diseases and their complications, notifications about other preventive services, and data concerning quality of care issues. Also necessary to improve health outcomes is a partnership with medical providers, which should involve sharing medical information with them and helping each patient to understand the relevance of that information to the quality of his or her life and the lives of family members. Information sharing can help patients implement their own prevention strategies in order to avoid chronic diseases and their complications.

Expansion of Health Education Programs

The Healthy People concept, which began in 1979 and continued with the release of Healthy People 2010 and most recently Healthy People 2020 (CDC, 1999a, 2009d), has put the concept of good health in front of the American population for their review through media releases to the public. The Healthy People reports have resulted in a change in the attitude of the general public about the value of good health. McKenzie, Neigeral, and Thackeray (2009) note that consumers are now demanding information about their health in order to be part of the medical decision-making process. Today consumers are pressuring health professionals to help them make quality health decisions.

Health education programs have never received the credit they deserve because it is hard to place a value on that which is unable to be seen. However, public health departments are now placing a great value on health education programs because research has been able to demonstrate cost-effective results from many of them. By preventing expensive chronic diseases and their complications, health education programs are becoming an important adjunct to modern medicine. Appreciation for health educators and health promotion programs is only going to increase as we get more serious about keeping Americans healthy.

The success of public health education programs is evident in the reduction of many high-risk health behaviors in this country over the last several decades. The use of tobacco products has dropped dramatically, the incidence of cardiovascular disease has plummeted, much progress has been made in reducing the incidence of cancer, and Americans have become more knowledgeable about the causes of disease. We must now expand on these success stories.

According to McKenzie et al. (2009), many individuals are now motivated to maintain good health, producing a need for accurate health information. Public health agencies can meet this need, especially at the local level. This country has never invested a large amount of resources in health education programs designed to prevent individuals from engaging in high-risk health behaviors. In fact, health education programs are not even a priority in elementary or high schools in the vast majority of U.S. states. This is probably because school districts believe that health education for children is the responsibility of the parents. This lack of health education at an early age is one of the reasons for the epidemic of poor health behaviors among youths, including maintaining an unhealthy diet and getting insufficient physical exercise. This must change if we are ever to solve the problems of our current health care system. It is known that health behaviors develop at an early age, and that once developed these behaviors are very difficult to change. That is why public health departments must play a leadership role in fostering the development and expansion of health education programs for all grade levels in U.S. schools.

Local health departments have the expertise and the ability to provide health education programs to schools and workplaces. They are capable of developing strong educational campaigns with these captive audiences, measuring results and attracting government and foundation resources to accomplish their objectives. The time has come for an expansion of education initiatives that can improve the health of a community and actually be viewed as a community investment. The payoff for this investment will be a reduction in high-risk health behaviors, which in turn should result in a decrease in chronic diseases and their expensive complications. We have to view this investment the way we envision our retirement contributions: we plan for our retirement years by saving money in our working years; and we can plan for our health in our older years by investing in health education programs for ourselves and our children in our younger years.

Therefore, the solution to the vast majority of health problems rests on the use of public health expertise to reduce the expensive chronic diseases that are causing death and disability for so many Americans. This is a challenging but not impossible task, requiring leadership with a vision of reducing the development of chronic diseases through health education programs in schools and workplaces. It also requires a U.S. population that appreciates the value of using health education and health promotion to prevent disease. Public health departments have to lead the effort while the opportunity is present.

Public Health and the Legacy Concept

There is no question that public health departments have had great successes in improving the health of Americans with very limited resources. Unfortunately, it seems that the more success these public health departments achieved, the more their budgets were reduced. Those who fund public health have never looked at the dollars given to public health as an investment that will actually save money if disease is prevented. It is sad that public health departments have done so little to market their successes to those responsible for supplying their funding. It seems that public health has become a victim of the legacy concept, which we will now explain.

Herbold (2007) defines the legacy concept as the tendency for successful businesses to believe that they are entitled to continued success. Because of their past successes, they become complacent and stop looking for new opportunities that would serve to further their success in the future. The assumption inherent in this concept is that the past practices that produced success will work in the environment of the future. The legacy concept is responsible for the failure of many businesses that were unprepared to deal with the strategy changes necessitated by shifts in the external environment.

The problem of the legacy concept is not limited to for-profit businesses. It is also at work in the nonprofit sector, and we believe it has become part of public health departments in the United States. The public health sector has collected many success stories over the years, which include winning the war on communicable diseases and increasing the life expectancy of most Americans. Recently, however, public health departments have been content to use the same old set of tools that once helped them succeed—but these tools are not as effective as they used to be, and the successes of the past are not continuing. The chronic disease epidemic requires a new set of tools from public health departments.

Herbold (2007) argues that success often results in the damaging behaviors of entitlement thinking—espousing an attitude that is proud and protective and lacks urgency in responding to problems. This absence of urgency is probably the most serious effect of the legacy concept for those who work in public health. Not only are public health professionals convinced that all of the old tools will eventually work on chronic disease epidemics but also they do not see the urgency of intervention in these severe public health problems. Tobacco, obesity, unsafe sex, and poor diet are major public health issues that require immediate response. The time for simply meeting to discuss these threats is over. Public health departments know what the problems are, and they know what needs to be done. These problems have produced an opportunity for public health agencies to provide leadership in dealing with the health care crisis.

An article in The Nation's Health reported in early 2009 that the health of Americans had failed to improve for the fourth consecutive year (Currie, 2009). The reasons listed for poor health included obesity, increasing numbers of uninsured individuals, and the practice of high-risk health behaviors like using tobacco. At least two of these causes of poor health, obesity and tobacco use, are going to result in chronic diseases that cannot be cured and usually result in premature death and disability. This same article reported that the prevalence of obesity has more than doubled in this country in the last nineteen years. This epidemic of obesity has resulted in more than one in four Americans becoming obese, and these numbers are certainly going to rise in the short term. What is more, this tremendous weight gain will most certainly increase the incidence of such chronic illnesses as type 2 diabetes and heart disease.

These public health problems require a different set of tools, which will only be used if the legacy concept in public health is replaced by a new attitude that encourages innovation, risk taking, and the building of new partnerships. This innovation in public health programs will require new ways of thinking about and acting on old and new public health problems. We must expand and rapidly disseminate best practices of health promotion throughout the country for use by all. This cannot be accomplished without the formation of partnerships among strong leaders and empowered followers.

In many cases public health departments are attempting to use the same tools that brought them such great success in dealing with the communicable disease epidemics of the past. Chronic diseases are very different from communicable diseases and, therefore, warrant a different approach by public health departments. This approach requires an emphasis on preventing disease from occurring in the first place rather than allowing disease to occur and then using contact tracing and treatment.

When Ronald Reagan was elected president in 1980, public health departments became the ultimate target for budget cuts and elimination (Sultz and Young, 2009). The subsequent dramatic decline in authority and funding caused these departments to become very quiet because of fear of elimination. Meanwhile, the health care system expanded, spending more and more money on curing disease, and the public health system moved to the sidelines, happy to have any budget at all. The two systems should have been working together to improve the U.S. population's health, but that was not where the money was going.

Sultz and Young (2009) argue that one of the major weaknesses in our current public health system lies in the fact that public health departments are constantly reaching for arbitrary and unobtainable goals that make them look like failed agencies. This is happening despite all of their great successes in the past. In order for public health agencies to move forward, they need to be developing public health leaders with marketing skills who can help them gain political clout to reverse past budget cuts.

The Need for Leadership Development in Public Health

This is a book about how to take the public health system in America to its next great achievement through the development of leadership skills in the administrators and staff of public health programs. Our health care system needs skills of prevention to solve the current health care crisis in America. Public health practitioners have these skills, but must learn how to develop the leadership capabilities necessary to exploit the current opportunities present in our evolving system of health care. Most public health departments already are capable of achieving unbelievable feats if only given the necessary resources for success. The missing ingredient that is needed to improve the health of Americans is public health leadership that is capable of supplying the vision and securing the resources necessary to achieve that vision.

Developing an effective public health system requires bringing together the vast array of public health skills to be found within and outside of government agencies. There are a large number of private agencies, including schools of public health, that have a great deal to offer in the movement of our health care system from an emphasis on curing disease to an emphasis on disease prevention. Public health leadership is needed to achieve collaboration among different entities with varied agendas—to forge community partnerships that involve all stakeholders in the improvement of the health of the population. This is not an easy task; in fact, many would call it impossible to achieve.

Public health leaders have had little to no formal training and development in leadership, mainly because schools of public health have not offered a curriculum that included any business education. The focus in these schools has been on the sciences, including environmental science, epidemiology, health education, and public policy. These are all very important topics, but in order for leaders to accomplish goals in a large agency, they must have had some exposure to topics that help them understand how to lead people from diverse disciplines toward the achievement of a common goal. Any public health leader must also have an understanding of culture, worker empowerment, communication skills, conflict management, and marketing in order to be successful.

The IOM (2002) has been calling for the development of leadership programs for those who work in public health for several years. Whenever large companies in the private sector are in crisis, they usually bring in new leadership to help them change their direction and improve their performance. These businesses are attempting to turn a crisis into an opportunity by looking at new ways of doing business, under the guidance of new leaders. This example also applies to public health agencies in the United States: the health care system in this country is in crisis, and the change that is required entails a new approach of keeping people healthy rather than allowing them to become ill. The obvious choice for leadership assignments in public health would be those with public health expertise; but these people must also have training in leadership that allows them to work with the thick culture found in public health agencies and in the context of our powerful medical care establishments. Such leadership training ought to be available to all public health employees so that they can better use the skills they possess to do their part to make Americans healthier.

Clark and Weist (2000) argue that public health leaders need to spend a great deal of their time organizing communities around embracing the values of disease prevention. This effort requires tremendous leadership skills, and an understanding on the part of leaders that members of the medical community will express little gratitude for their efforts because they fear change and the loss of power.

Public health professionals are being asked to make use of their interpersonal skills as part of a team approach to decision making. This is a real change from the bureaucratic approach of delivering only mandated core public health services. Such interpersonal skills are found in those who have received training in leadership, and there is absolutely no reason that public health employees could not receive ongoing leadership development. They also have to be instructed in marketing principles that they could use to inform the public and political leaders of what they do and how important public health departments can be in solving the health problems in this country.

Public health employees are now being asked to collaborate with other agencies in order to improve the health of the community. These new responsibilities are coming with very little, if any, new funding or even direction. This is why leadership skills are so necessary for those working in public health departments. The old public health departments used power to achieve results by virtue of their being government entities authorized to protect the health of the population. The new public health system has to learn how to empower others to achieve even greater results in preventing disease. Public health professionals must become the leaders of the change in health care that will reduce illness and increase wellness. This new assignment will not be easy, but it can be accomplished if we invest in public health and the programs that public health departments are so good at offering to the population.

Summary

The American health care system is in dire need of change in regard to the delivery of medical care. The medical model of care must be replaced by a primary care model that focuses on healthy behaviors—and on health promotion programs that provide information to individuals on how to avoid high-risk behaviors.

Public health agencies have a long history of dealing with population-based health programs focusing on disease prevention. These agencies have had tremendous success in reducing disease and extending the life expectancy of most Americans. They have skills that need to be employed in the reform of our current health care system.

Public health agencies, health care system providers, and communities need to form partnerships to develop population-based health programs designed to keep people healthy. These programs should focus on the dissemination of health information to communities in order to help reduce the occurrence of disease and prevent complications from diseases already acquired. Public health leaders must be catalysts in this reform effort.

Key Terms

Discussion Questions