Carrying out the public health mission described in Chapter 2 requires systematic identification of health problems and the development of means to solve those problems. This volume has described the history of the development of this problem-solving capability and its current status in the United States. With that description as a backdrop and drawing on a review of the literature, site visits, statements at the four open meetings, review of other case studies (Miller and Moos, 1981; Institute of Medicine, National Academy of Sciences, 1982b), and the recent evaluation of progress by the U.S. Public Health Service—The 1990 Health Objectives for the Nation (Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services, 1986), the committee has identified some appreciable barriers to effective problem-solving in public health. These barriers include:
- lack of consensus on the content of the public health mission;
- inadequate capacity to carry out the essential public health functions of assessment, policy development, and assurance of services;
- disjointed decision-making without necessary data and knowledge;
- inequities in the distribution of services and the benefits of public health;
- limits on effective leadership, including poor interaction among the technical and political aspects of decisions, rapid turnover of leaders, and inadequate relationships with the medical profession;
- organizational fragmentation or submersion;
- problems in relationships among the several levels of government;
- inadequate development of necessary knowledge across the full array of public health needs;
- poor public image of public health, inhibiting necessary support; and
- special problems that limit unduly the financial resources available to public health.
Unless these barriers are overcome, the committee believes that it will be impossible to develop and sustain the capacity to meet current and future challenges to public health while maintaining the progress already achieved. Deaths and disabilities that could be prevented with current knowledge and technologies will occur. The health problems cited in Chapter 1, and many others, will continue to take an unnecessary toll, and the nation will not be prepared to meet future threats to health.
Public health faces the simultaneous challenges of responsiveness and continuity. Sustained successes frequently lead to apathy, and the visibility and excitement surrounding new problems promote ad hoc decisions that fragment programs and divert resources from established and successful programs.
This chapter concentrates on identification of barriers most needing attention, thereby setting the agenda for the recommendations to follow. Emphasis on barriers rather than accomplishments may seem to cast public health in an unduly negative light. Public health has a record of accomplishment that should be a source of pride. Yet problems that can erode current and future capacities of public health should be identified and faced if public health is to continue its record of accomplishment.
