Community Health Planning and Policy Development
CHPPD Chair's Letter
Greetings to CHPPD colleagues across the country and beyond. Section Council has been busy on several fronts since the APHA Annual Meeting.
The major change is that we will realign our budgeting process to allow for funds to be available to the section for the period in between conferences. These funds may be applied to ongoing learning and dialogue sessions on major planning and policy matters. We will shift funds from events and items that only benefit those who attend the conference to provide for broader benefit to all, while simultaneously becoming proactive in policy dialogues. Soon we will issue a blast e-mail to solicit a work group for these learning and dialogue sessions that may be delivered via Webcast, podcast, threaded and moderated discussion boards, or good old-fashioned conference calls.
We will also use the business meetings at the Annual Meeting in 2007 for independently facilitated sessions for visioning and for establishing the mission, goals, and objectives of Section activities. Such steps are needed in order to formulate a work plan – a new APHA requirement. They are also needed to inform the budgeting process which is now, by virtue of section manual changes, a Section Council process, not a chair prerogative.
Additional changes to the member manual have streamlined committees, making many of them functions or time-limited work group assignments. These manual changes will be posted to the section Web site by the end of July with a 30-day comment period for general membership.
We are also moving to create a system for mentoring those who wish to advance policy. It is my expectation that we provide leadership or major support to critical policy propositions in each and every year we operate.
We have established a "whip" for our Governing Council who also serves as chair of the Policy and Resolutions Committee. Congratulations to Shari Kinney, who will be first to assume this role. Look for opportunities to provide substantive comments as we work to prepare our governing councilors for many important votes at the Annual Meeting. We will be issuing blast e-mails and/or posting these opinion surveys online prior to the meeting.
Priti Irani has done an outstanding job transitioning the leadership of the Communications Committee into new, very capable hands – Renée Wilson-Simmons and Brad Wright (student).
Under Emylou Rodriguez’s direction, the Membership Committee has been aggressive in reaching out to undecided members, handling local arrangements, and taking on booth and member social responsibilities. Anyone interested in these areas should contact Emylou.
Our students (as you can see) continue to be vital contributing member-leaders across the board in this section. Amy Carroll Scott has joined the Governing Council, helping us transition to having student liaisons in strategic positions.
Lastly, we modified our call for abstracts, taking advantage of our trans-disciplinary strengths in work force development and emergency preparedness, among others. We had an increase of approximately 25 percent in submissions, with a fairly low number of low-scored submissions. This was a competitive cycle, indeed.
Your Section Council strives to create maximum benefit to maximum numbers of members, while becoming increasingly proactive in planning and policy arenas. We’re moving in the right direction.
With warm regard,
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“CHPPD newsletter: A window to the world”
Dear CHPPD Members
Thanks go to all of you who have contributed to the Section newsletter by writing for it or reading it. I have enjoyed being the editor for the past couple of years and look forward to future issues under the new co-editors, Renée Wilson-Simmons and Brad Wright. The section newsletter is one of my windows to the world.
I am looking forward to hearing Laurie Garrett, Senior Fellow for Global Health at the Council on Foreign Relations, make the keynote address at the 2007 APHA Annual Meeting in Washington, D.C. John Steen reviewed her book, Betrayal of Trust: The Collapse of Global Public Health, in the Fall 2006 issue of the newsletter. Laurie Garrett is the only person to have been awarded the three “big P’s” of journalism - the Pulitzer, the Peabody, and the Polk. She received her second George C. Polk Award, Best Book of 2000, for Betrayal of Trust.
John Steen, in his review, wrote that “the author details the recent epidemiological threats that have challenged world public health, including pneumonic plague in India, Ebola in Zaire, the collapse of public health in the former Soviet Union, and last but certainly not least, the erosion of public health in the United States at the very time when we are threatened by bioterrorism. And …. she would have us add that all public health is global.” I was also interested to read “Minnesota can be seen as having briefly developed a population health system with a communitarian focus that was arguably the best ever achieved by any state.”
In the Winter 2007 issue, Lucy Vogel offered a historical perspective into “Health Planning in the Indian Health Service,” and I look forward to reading Part 2.
We even know the first prize winner in the Kaiser Essay Contest that was announced in the newsletter. It was Brad Wright, our new CHPPD Newsletter co-editor, who won the first prize among graduate students. The winning essays can be read online at http://www.kaiseredu.org/essayprizes2007.asp.
Finally, on behalf of our section, I would like to express my sympathies to our colleagues in Blacksburg, Virginia, with regard to the tragic events of April 16. Our thoughts are with you.
Past CHPPD Newsletter Editor
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28 policy proposals offer glimpse into national debates on disparities, health care, environment and public health
Chemical Hazards. Tobacco. Privacy and Confidentiality. Vitamin D. Breastfeeding. End of Life Issues. War. Veterans. Sustainability.
These are some of the key words that came up as four reviewers from the CHPPD Section read the 28 policy proposals and submitted comments to APHA. The policies were organized into four topic areas: (1) health disparities; (2) environment and occupational health; (3) access to care; and (4) public health science and infrastructure. Writing and reviewing proposals are intense tasks, made even more so when emotion and evidence are intertwined.
In all, approximately 14 sections, one affiliate, and two caucuses submitted proposals. Two sections, Environment and Food & Nutrition, submitted five policy proposals each.
CHPPD reviewers’ comments were submitted to the Joint Policy Committee. After review, the JPC makes recommendations to either reject or move forward proposals for hearings and consideration by APHA’s Governing Council. The JPC may also work with some of the authors on revisions suggested by its members. By September, the revised policy proposals will be posted at http://www.apha.org/advocacy/policy/.
The policy proposal sponsored by CHPPD, Call for Education and Research into Vitamin D Deficiency, was written by Section member Dr. Azzie Young in coordination with Priti Irani. Although the JPC gave the proposal a “negative assessment," the committee stated that it dealt with an important area of public health. Explaining that the proposal needed more research, the JPC suggested that its authors collaborate with another section to develop a revised version. Dr. Young has talked with members from within and outside the Section and is considering all options for getting the Vitamin D policy proposal on the APHA agenda for 2007.
Passed by APHA in 2004, Creating Policies in Land Use and Transportation Systems that Promote Public Health illustrates how policies should work,” says Donald Hoppert, APHA's director of Government Relations. Built on the actions of APHA members in child health, it drew attention to the fact that transportation is an important public health issue and related it to current areas of concern such as obesity among children. APHA relied on this policy to organize the 2006 National Public Health Week around the theme “Designing Healthy Communities: Raising Healthy Kids.” Public health practitioners around the United States organized fitness events, art contests, walkability assessments, health fairs and other outreach efforts.
In addition, the actions proposed in the APHA policy had key champions in the Senate and Assembly. The Healthy Places Act of 2006 (S. 1067/H.R. 398), a bill introduced by Sen. Barack Obama, D-Ill., and Rep.Hilda Solas, D-Calif., during National Public Health Week, calls for a series of measures that would expand efforts to improve the planning and design of communities that can promote healthier lives for children. Among its measures, the bill would establish health impact assessment programs to help states and local communities examine the health effects of health policy or program changes. The legislation would also: create a grant program to address environmental health hazards, particularly in regard to health disparities; provide funding for research on the link between the built environment and health status; and create an interagency working group on environmental health to facilitate collaboration. The bill was reintroduced in the Senate and House of Representatives in 2007.
CHPPD members are encouraged to review the revised APHA policy proposals and let the CHPPD Policy Committee know whether or not the Section should support them. APHA has posted a new policy review form for guidance at http://www.apha.org/advocacy/policy/newpolicy/2007policies.htm.
CHPPD Policy Committee reviewers will articulate the section's views at the policy hearings on the afternoon of Sunday, Nov. 4, at the APHA Annual Meeting. Authors or their proxies will be given a chance to defend their proposals at that time. On Tuesday, Nov. 6, Governing Council members will discuss, possibly amend, and vote on the proposals. Proposals approved by the Governing Council then become official policy of APHA.
Earlier this year, CHPPD members Calvin Roberson of the Indiana Minority Health Coalition and Islara Souto of the University of Miami reviewed old APHA policies in order to make suggestions for archiving. They identified three potential areas for policy efforts: (1) developing diversity in clinical trial participation; (2) mandating cultural competency training among public health workers; and (3) addressing the varying requirements and practices among states by requiring HIV testing on all individuals released from correctional and detention settings. Members are invited to provide input on these suggestions.
Here is what some reviewers said about their experiences with the APHA policy proposal process.
Azzie Young: Lesson Learned -- If we want a policy to be passed by APHA, it's important to get the perspectives and support from other sections upfront, as early as the Annual Meeting. To do that in a timely manner, it's not too early to start discussions of policies for 2008 with key section representatives at the 2007 Annual Meeting.
Calvin Roberson: APHA policy review serves as a platform to gain more insight and understanding in regards to current and emerging health issues and their respective effects on society. The review of former APHA policies can serve as an indicator of the progress made to impact, or may reflect the evolution of previous health issues.
Harry Perlstadt: APHA uses its policy statements to inform legislators, government leaders, and the media about important public health issues. The development of these statements is very important and well worth the time we put into the process.
Joe Schuchter: Especially as a student, it's often easy to get caught up in theory and feel isolated from practice. Participation in the policy review process yields insights on current APHA thinking and initiatives and is a great way to be a part of the action.
Karen Valenzuela: APHA’s policymaking process is one of my most favorite things about being active in APHA. I love reading members’ ideas about what positions APHA should adopt and engaging in the debate around shaping the policy in its final form, both at the Sunday afternoon policy sessions and on the floor of the Governing Council.
Priti Irani: There's something new to learn from reading policy proposals written by APHA members. For example, when Azzie Young started talking about the importance of Vitamin D for people of all ages and ethnic and racial backgrounds, I couldn't help noticing it in everything I read. The writers are passionate about what they write about, and that's always exciting to read.
Shari Kinney: APHA policy is an important venue to communicate to the membership and to the public the issues that we as APHA members are passionate about. These policies are a first step in making change that impacts the health of the public. Participating in policymaking is an important responsibility we have as APHA members, and I encourage everyone to participate!
If you would like to be involved in the policy process -- by reviewing the revised proposals, attending a policy session at the Annual Meeting, reviewing policies for archive consideration, or writing a new policy for 2008 -- please contact CHPPD Policy/Resolution Committee co-chairs Shari Kinney at firstname.lastname@example.org and Calvin Roberson at email@example.com by August 2007.
Several CHPPD members involved with reviewing and writing policies jointly wrote this article. The authors are: Priti Irani, MS, New York State Department of Health; Shari Kinney, MPH, MS, RN, Cleveland County Health Department; Harry Perlstadt, PhD, MPH, Michigan State University and a member of APHA’s Science Board; Calvin Roberson, MHA, MPH, Indiana Minority Health Coalition; Joseph Schuchter, MPH, Cincinnati Children’s Hospital and a health policy doctoral student; Karen Valenzuela, MA, MPA, Washington State Department of Health; and Azzie Young, PhD, MPA, Mattapan Community Health Center, Boston.
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Health Care Reform in New York: Looking Forward and Looking Back
Prior to being elected governor, Eliot Spitzer served for eight years as New York State attorney general, where he won national recognition for landmark cases protecting investors, consumers, the environment and low-wage workers. Any doubt about his continued dedication to the public interest was removed on Jan. 26 in a speech he delivered at the Rockefeller Institute of Government entitled "An Agenda to Fundamentally Reform New York's Health Care System." In it, he defined reform as restoring to government its proper functions in protecting its citizens, and his judgment about the last 12 years in the state was pointed: “Government abdicated its responsibility to set standards, demand results and hold institutions receiving billions in state tax dollars accountable to the state and to the people those institutions serve.”
About the New York State Commission on Health Care Facilities in the 21st Century, he said, “This was a process that should never have been necessary in the first place....Now we face dramatic instead of gradual change to rationalize a system in desperate need of reform.” He continued: “For too long, we have financed the health care system we have, not the health care system we need. So we're left pumping billions of dollars into a broken system with no deliverables and no accountability.”
Spitzer went on to insist that New York’s health care system must once again be made accountable to its people, that it must be patient-first, and that “no patient-first health care strategy can be complete without a comprehensive effort to address public health...that targets primary and preventive care — resources that will go to support programs that decrease obesity rates and increase healthy eating and physical exercise, prevent childhood lead poisoning, expand access to cervical cancer vaccines, prenatal and postpartum home visits, and public health education on the quality of mammograms and other important issues.”
Dr. David Axelrod, Health Commissioner Par Excellence
In hearing Spitzer's speech, I was reminded of Dr. David Axelrod, who was responsible for innovative policies as New York State's health commissioner for 12 years (1979-1991). In praising Dr. Axelrod, a 1991 New York Times editorial stated that, "In a job that all too often reflects the narrow interests of the medical profession and its institutions, Dr. Axelrod saw the state's whole population as his patient. He treated it with uncommon compassion, vision and courage." 
Dr. Axelrod's pioneering policies, which ranged from stringent regulation of doctors and hospitals to universal health insurance,  anti-smoking legislation, and unbending protection of the confidentiality of AIDS patients and funding for AIDS research, were supported by then-Gov. Mario M. Cuomo. Cuomo’s active support enabled Dr. Axelrod to earn a reputation, unique among health commissioners, for taking on vested interests in the state’s medical-industrial complex. In 1987, he used the state’s hospital rate-setting program to realign reimbursement toward the provision of primary care by community clinics. Had Dr. Axelrod not suffered an incapacitating stroke in February 1991, he would surely have continued his ground-breaking work.
The Pataki Era
In 1995, Gov. George Pataki took office and immediately began to dismantle the state health department’s resources and role in policy leadership. Also in that year, he captured the revenue stream that had been funding the state’s eight health systems agencies. This funding stream, which constituted about half of the agencies' budgets since the cessation of federal funding in 1986, was diverted into the state’s general fund. Today, only the agencies in Rochester and Syracuse survive as smaller community-supported units.
State officials’ explanation was that the growth of “free market forces” such as health maintenance organizations and managed-care plans had rendered much of the traditional review and approval process obsolete. Consumer and community groups saw the demise of the process as the stifling of forums for their input, ensuring that provider initiatives would remain unknown and unchallenged. Their concerns were confirmed in 1996, when Pataki appointed 14 new members to the State Hospital Review and Planning Council, the state’s CON review body, to replace 16 members whose terms had expired. Prior to the new appointment, eight of those 16 were consumers; just one of the new appointees was a consumer. And contrary to the council’s authorizing legislation, none was an HSA representative. The move was widely seen as payback for the council’s rejection in 1995 of a series of hospital “regulatory reforms” proposed by the Pataki administration. Also in 1996, the administration was successful in having the legislature eliminate the state’s hospital rate-setting program.
Health Care Reform and the Institutionalization of Civic Life
So Spitzer’s challenge will be to recreate a health department befitting the state’s history of leadership in public health, health planning, and health regulation. Dennis Whalen, who has been first deputy under a number of health commissioners, will be New York's deputy secretary for health, operating out of the capitol, an arrangement that will provide Spitzer with his considerable experience and memory of "how they used to do it" in that effort.
Dr. Axelrod’s principled refusal to have the state’s Medicaid administration within his health department will be honored through the new Office of Health Insurance Programs, which will assume control of Medicaid and the state’s other insurance programs. He maintained the inherent conflict made it inappropriate. You can't regulate an industry and at the same be a major supplier of its funds.
In remembering the Axelrod-Cuomo era, I was also reminded of the New York Health Department’s 1989-1992 proposal for UHI. Called UNY*Care — Universal New York Health Care — it was modeled after Medicare and was as promising a state UHI program and national model as any introduced since that time. It was not pursued once Governor Cuomo decided not to enter the Democratic primary for president, but its promise was as unique and as strong as its foundation in the state’s history of fostering civic and community life through the institutions it created.
In Spitzer’s words, I could hear a return to the political ethos of the last half century of the state’s governors and other elected officials, one founded on public life and open public process. UNY*Care’s chief designer, Deputy Health Commissioner Dan E. Beauchamp, expressed his opinion succinctly: “The point of health care reform is precisely to strengthen the public and its power vis-à-vis the health care system — to use policy to create a more populist and civic-centered system.” Once created, that system can then give life in the public mind to the policies that inspired it. Daniel Patrick Moynihan, the late senator from New York, explained it this way, “The central conservative truth is that it is culture, not politics, that determines the success of a society. The central liberal truth is that politics can change a culture and save it from itself.”
Will this be the new governor’s agenda, too? If so, he faces an uphill battle against the legislature, and he will have to count on the public support he may get by making an open public process out of his battle. The last reform governor who did that was Theodore Roosevelt in 1899, and he proved successful.
Spitzer acquired much experience doing that as attorney general, and he explained his approach in an interview published in The New York Times:
A status quo does not want itself revealed, whether it’s to investors, shareholders or voters,” he said. “It pushes back in a strenuous way. My response every time is, let’s just get out the facts, what are we trying to do and why. And I have this very simple-minded belief that we will win by presenting those facts.
Meanwhile, Spitzer can find inspiration in how Mayor Michael Bloomberg is supporting his great health commissioner, Dr. Thomas R. Frieden, in providing the most progressive current initiatives in public health to be found in any American city.
 For a description of its November 2006 Report, see my Policy Perspective column in the 4th Quarter 2006 Health Planning Today.
 "Dr. Axelrod's Courage" New York Times Editorial, April 19, 1991.
 During the Reagan years, he often found himself a lone figure among physicians in his advocacy, and in 1989 he proposed his own plan, UNY*Care, that would have guaranteed basic health care to every resident of New York State.
 In 1989, Stuart H. Altman, the dean of the Florence Heller Graduate School for Social Policy at Brandeis University, stated that ''New York hospitals are by far the most tightly regulated and most effectively regulated in the United States.''
· Not-for-profit hospitals are required by statute to file an annual report that reviews the hospital's mission statement, incorporates the views of the communities served by the hospital on the hospital's performance and service priorities and the hospital's commitment to meeting the needs of the community. We will work… for the repeal of this statute.
· NYS regulations for emergency departments are more prescriptive than the federal requirements, particularly regarding staff education and experience. … DOH will assess how the current requirements can be streamlined.
 Health Care Reform and the Battle for the Body Politic (Temple University Press, 1996), p.41. Beauchamp wrote that in their preoccupation with the distance between American political values and the values of a reformed health care system, social scientists “miss the point of the capacity of national health plans as institutions to change values and politics.” Ibid. He is saying here “that civic institutions such as national health plans – because of the patterns and ways of thinking they create in society – have a powerful way of creating their own politics, their own social reality.” Ibid., p.47. One has only to consider the role that Medicare has played and now plays to appreciate the validity of this point. The distance between our profit-driven market approach and the solidarity of Europe’s egalitarian system is accounted for primarily by their having long since institutionalized more definitive social insurance systems than ours.
 The Godkin Lectures at Harvard, 1986.
 Michael Cooper and Danny Hakim. "Spitzer's Fight with Assembly Grows Fiercer." New York Times. February 9, 2007.
 See, for example, “New York City Plans to Promote Circumcision,” The New York Times, April 5, 2007,
http://www.nytimes.com/2007/04/05/nyregion/05aids.html?hp, and “New York Bans Most Trans Fats in Restaurants,” The New York Times, December 6, 2006,
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A regional model for rebuilding the health infrastructure along the Gulf Coast
The Regional Coordinating Center for Hurricane Response (RCC), operated since October 2005 by the Morehouse School of Medicine through its Centers of Excellence on Health Disparities, is continuing to respond to the devastation in the health care infrastructure in areas impacted by Hurricanes Katrina and Rita. Funded by the U.S. Department of Health and Human Services, Office of Minority Health and Health Disparities, RCC is coordinating the work of all the Centers of Excellence on Health Disparities in the southeast region, rebuilding and enhancing the health infrastructure in affected areas.
The damage to the Gulf Coast by Hurricanes Katrina and Rita is estimated to exceed $100 billion. There have been more than 1,800 deaths, which amount to the costliest and deadliest hurricanes in the history of the United States. The full extent of the health care and financial impact on the health system of the Gulf Coast remains undetermined. However, it is evident that this disaster will complicate the delivery of care in a region that experienced major health disparities even prior to these severe tropical storms.
The RCC, at Morehouse's National Center for Primary Care, has developed significant partnerships with groups in the Gulf region to provide the practice-based infrastructure needed over the long term to eliminate health disparities in communities of greatest need. These include relationships with Centers of Excellence on Health Disparities, community health centers, local health departments, private health care providers, state primary care associations, businesses, and academic health care centers. This collaborative approach is designed to facilitate the building of a replicable and sustainable model of a balanced community health system in which public health, primary care, specialty care, and the research-based academic health center are integrated for the benefit of the larger community.
Evidence shows that people who were traumatized by the events which occurred during the hurricanes will most likely have a higher incidence of psychiatric disorders, including depression, which is also linked to a higher risk of hypertension, diabetes, and heart disease. The project's telemedicine initiative, with a focus on telepsychiatry, as well as health screenings and ongoing community surveillance, are addressing chronic diseases associated with the storms. The RCC has also implemented electronic health records in medical offices and targeted personal health records projects for individuals in the most affected communities along the Gulf Coast. Some of the center's other activities have included the following:
- New Orleans Health Recovery Week 2006: Co-sponsored with the New Orleans Health Department and Remote Area Medical, it provided more than 6,000 people with free health care, including free prescription medication, dental care, optical examinations, and eyeglasses. $1.2 million in services were rendered.
- Katrina Phoenix Project: A partnership with the Healthcare Information and Management Systems Society (HIMSS) that provides electronic health record and practice management system (PMS) hardware, software, and consulting services to medical practices.
- Research at Centers of Excellence on Health Disparities in the Gulf Region: Current projects include health needs assessments of hurricane evacuees and surveillance projects.
The RCC is also striving to identify lessons learned and link them to policy and practice options to improve access to an equitable, responsive, and sustainable health system for under-served populations and to reduce health disparities across socioeconomic and racial groups. One example of this commitment is the use of telehealth programming to address disparities in mental health care. This project is establishing telehealth sites in clinics in the Gulf region. In doing so, RCC is also working to eliminate some of the credentialing, malpractice insurance, and geographic barriers associated with delivering mental health care to hurricane-impacted areas.
What began in 2005 as a humanitarian effort to provide relief to the devastated Gulf Coast could develop into a more balanced community health system utilizing health promotion, disease prevention, and access to health care building a network that begins in one region and becomes translated into approaches that help to diminish health care disparities across the United States.
Averhoff F, Young S, Mott J, Fleischauer A, Brady J, Straif-Bourgeois S. Morbidity surveillance after Hurricane Katrina -- Arkansas, Louisiana, Mississippi, and Texas, September 2005. MMWR 2006;55(26):727-31.
Rudowitz R, Rowland D, Shartzer A. Health care in New Orleans before and after Hurricane Katrina. Health Affairs 2006;25:393-406.
Weisler RH, Barbee JG, Townsend MH. Mental health and recovery in the Gulf Coast after Hurricanes Katrina and Rita. JAMA 2006;296(5):585-8.
By Ayanna Buckner, MD, MPH, Katrina Brantley, MPH, & Kimberly Bell, MHA, CHE, Regional Coordinating Center for Hurricane Response (RCC), Centers of Excellence on Health Disparities, Morehouse School of Medicine
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Health Planning in the Indian Health Service: Trends and Issues: Part II
Distribution of Benefits:
Health Care Service
Health Care Needs:
Distribution of Benefits:
Health Care Service
Recent federal initiatives such as the Program Assessment Rating Tool (PART) and the Government Performance and Results Act (GPRA) have placed increased emphasis and importance on measuring outcomes to assess effectiveness and efficiency. The figure presented below illustrates the model of service delivery used to plan for health services throughout Indian Health Service history.
Health Care Needs:
Indian Health Service Delivery Plan
Evaluation of planning and outcomes occurs throughout the process. For example, prior to funding and the assignment of a contract for construction of a facility, the project undergoes additional review and assessment at the Department of Health and Human Services level using an evaluation tool, the Project Definition Rating Index (PDRI). This tool benchmarks facility planning and compares the process to other facilities within DHHS.
Once the facility is built and in operation (i.e., within one year), it undergoes review for accreditation by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) or other national accreditation bodies such as the Accreditation Association for Ambulatory Health Care (AAAHC). This comprehensive review assesses services, departmental organization, safety, staffing, and quality of care. Currently, all IHS facilities maintain national accreditation.
An additional evaluation of individual projects is the Post Occupancy Evaluation (POE) . This evaluation by a multi-disciplinary team of independent planners, engineers, and architects who did not perform the original planning identifies areas for improvement in the process and planning tools.
Adding to the evaluation process is the growing importance of evaluative measures such as the Program Assessment Rating Tool (PART) and the Government Performance and Results Act (GPRA), measures initiated by the Office of Management and Budget. The OMB reviews link clinical measures to service delivery with a focus on the ultimate outcome of improved health indicators such as increased years of productive life. These measures are based on the construction of logic models that link inputs to outputs and outcomes. They play an increasing role in defining the success of service delivery in the area and in budget allocations for the whole IHS. The coordination of these measures is often co-located within Planning and Statistics at the area and headquarters levels.
New Planning Initiatives
IHS has recently implemented three new planning initiatives: (1) development of an agency strategic plan; (2) authorization for new and updated master plans for each of the areas; and (3) development of a new priority system for facility construction. In June 2003, IHS completed a strategic plan with goals to build healthy communities, achieve parity in access by 2010, provide compassionate quality health care, and embrace innovation. This strategic plan, updated in 2006, focuses on the increase in community-oriented primary care and the development of community and public health infrastructure. One of the action performance goals is to expand appropriated funding for health delivery infrastructure, replacement of medical equipment, health facilities construction, and staffing. It provides the base to broaden health planning to public health and other service concerns to address important health issues such as obesity.
Each area was also called on by the IHS director to develop, by July 2004, a Area Health Service Delivery Plan that includes existing health services, the primary service area delivery plan with maps of native communities and other population clusters, a visiting professional summary plan, an IHS area referral delivery plan, and contract health summary. In addition, the Area Health Service Delivery Plans are to include a facilities master plan with IHS supportable space, size, and condition for each health care facility, travel time, and distance from each service area to nearest clinics, and innovative health care initiatives. These plans, approved by the area directors, will assist areas in conducting needs assessments for planning for services and facilities, and will also document the total unmet need for health care services and facilities among American Indians/Alaska Natives.
The IHS has also developed a new methodology for ranking facilities for funding priority. The factors include facility deficiencies, health resources, isolation/barriers to service, size and type of facility and innovation. It uses elements of the Federal Employee Health Benefits Program Disparity Index (FDI)[i], a comparison of benefits to Indian recipients with those covered by the Federal Employees Health Plan as the measure of the availability of health resources. This priority system establishes the order in which planned facilities receive IHS funds for construction.
Additional Planning Factors
Recent factors that have influenced the planning process within IHS include the impact of staff downsizing during the 1990s and the growth of tribal contracting and compacting. A combination of these two trends has led to a decrease in staffing for planning at both the area and headquarters levels. Many of the individuals serving as area planners wear several hats and may also serve as an area statistical officer or facility manager. A smaller planning staff at the headquarters has led to increased dependence on the formula-based software tools, with less time for individualized review and consultation, particularly for population projections and services review.
Overall, the IHS continues to operate with very limited resources relative to much unmet need. Even with projects comprehensively planned and thoroughly reviewed, waits for funding are so long that by the time the facilities are actually built, the local circumstances and needs may change. Likewise, technological advances in health care provision and equipment, such as the use of digital radiology, may change the needs for staff and space.
Coordination remains an important issue. There are many players in the planning process with different perspectives, expertise and focus, such as engineers, clinicians and planners. Staffing within the service includes three sets of employment regulations: the Commissioned Corps service, the federal civil service and tribally funded staff. Even coordination of the staff at headquarters is difficult with so many offices and individuals involved in the planning process. Currently, three different offices at headquarters work with area planners for the approval of services, staff and space. Coordination with these three offices may create misunderstanding, delays and duplication of effort.
The American Indian/Alaska Native population is quite diverse, requiring negotiations with 550-plus sovereign nations for 78 self-governance compacts and 293 self-determination contracts. These negotiations are extremely important to providing health care that is responsive to tribal needs. However, doing so requires time, resources and cultural sensitivity.
The major planning focus remains on meeting primary health care needs and delivering efficient services with insufficient resources. Planning will need to move beyond focusing on facilities alone. Area Health Service Delivery Plans will document needs for public health and preventive services that planners should include in the repertoire of IHS services. Continued collaboration with other federal and state agencies will be necessary to meet the documented needs. Training and use of new planning tools such as geographic information systems (GIS) will help area planners focus on how to provide the comprehensive services necessary to meet needs. Added skills in facilitation and communication will augment efforts in tribal consultation and collaboration with health care agencies. Efforts should continue to streamline the review and approval process at the headquarters level.
The real need is for additional resources. IHS is one of the few places where population and needs-based planning still operate in the public sector. While IHS planning is needs based, the actual provision of care does not begin to meet the identified needs. Many disparities in health care measures remain, with American Indians lagging behind most population groups. Even though the system is comprehensive at no direct cost to the patients, budget constraints limit the availability of services. The average amount spent in 2002 for IHS care was approximately half that spent on U.S. per capita users: $2,533 ($1,914 appropriations plus $619 collections) versus $5,065 as shown in the following figure.
Furthermore, funding for new staff must be coupled with new space, creating an incentive for new, larger facilities. While many facilities have adopted business-oriented practices to expand services and staff through collections of third-party reimbursement, these efforts have not begun to address the gap in a significant way. Future planning must identify effective strategies for augmenting Congressional funding with tribal resources and private sector funds.
 Planning for Project Success (Rockville, MD: U.S. Department of Health and Human Services, February 2004).
 Learning from Our Buildings: A State-of-the Practice Summary of Post-Occupancy Evaluation (Washington, D.C: National Academy Press, 2001).
 Regional Differences In Indian Health 2000-2001. (Rockville, MD: U.S. Department of Health and Human Services, Indian Health Services, Division of Program Statistics).
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Excerpts from the emails of a CHPPD member posted in Iraq
Working in Iraq
"On training at Fort Bliss, Texas, in preparation to go on assignment to Iraq”
Feb. 24, 2007
The evening before going to the firing range, we attended a didactic lecture regarding the use of firearms. They also offered a special course for people “who are not comfortable with weapons.” I opted for it to satisfy my curiosity.
A young woman, barely more than five feet tall, marched resolutely into our classroom at the precise starting time, quickly taking command with her presence. My curiosity quickened. She began by relaying the following story:
I know that many of you are medical types, and that you don’t have much use for weapons. I have considerable experience with people like you and intend to shake your beliefs for the purpose of saving your lives. About four years ago, I trained a female doctor, and did so two more times before her third deployment. She finally came around the third time and it saved many lives. While she was working at a forward medical facility, an insurgent attacked her clinic and killed her medic. As he was preparing to kill the Iraqi patients on her ward, she moved out of the adjacent room where she was not seen and caught the eye of the attacker. Before he could move, she ensured he would not be able to hurt anyone else, ever again, by calmly and professionally using the skills she was taught in my class. I intend to do the same for you.
Needless to say, I paid attention in this class. The following day, while on the firing range, I took advantage of her tutoring, and became very comfortable with the weapon.
The hot, barren desert
On hill training days in Kuwait, April 28, 2007
Last but not least, we learned how to escape from an overturned HUMVEE through lectures and a simulated model. This was the physically challenging part. Without the added armor, particularly what is added to the turret to protect the soldier operating the machine gun, the HUMVEE is quite stable and not too susceptible to rolling over. However, with the above modifications, it can turn over easily in certain circumstances. Thus, though we were adding extra protection to safeguard soldiers from high-velocity lead poisoning, we were increasing their risk of injury and death via HUMVEE crashes. As a result, the Army established another training procedure to counteract this new threat. I believe most soldiers prefer the armored HUMVEEs and do not mind the added turnover risk. The doors are extremely heavy with all of the extra armor, and it takes strength and skill to open them when the vehicle is turned over. It is easy to get disoriented. Once we got out of the overturned vehicle, we then practiced establishing security around it.
At the gym later that evening, one of the other trainers told me I would be leaving on an early morning flight and would need to report to the airport around midnight. He would pick me up at my tent around 2300 (11:00 p.m.) to drive me there. I was disappointed. I was going to miss this place.
Camels; lots and lots of camels
After I finished packing in my cavernous tent, I lay back on my cot one last time. In many respects I was pleased with this experience. I learned a great deal despite myself, and perhaps I had grown some as a person, but I wondered how long I might retain this knowledge or perspective. Would I need to learn some of the lessons over and over again, or had some change taken place within me that clearly established a new foundation for my future? Only time would tell, and I hoped I could continue standing as time tested me, and that I would learn what was truly important before time ran out.
A member of the Community Health Planning and Policy Development (CHPPD) Section worked with the Iraqi Health Ministry, and others, to support medical and public health infrastructure development. His first stop was Texas, where he experienced an abrupt transition from civilian to military life. He then traveled to Kuwait via some stops in Europe. He is en route to various locations in Iraq where he will support civil affairs activities. He has been sending periodic e-mails on his experiences. Excerpts of e-mails were selected by Priti Irani, past CHPPD newsletter editor.
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Asking the Right Questions
The following are the President's Messages from Health Planning Today , 3rd and 4th Quarter 2006 issues .
Asking the Right Questions
My temperament is that of an idealist and my education prepared me to teach moral philosophy, so it shows in how I now write on health policy. It leads me to want to address the categorical shortcomings I always find in the otherwise growing body of serious writing on universal healthcare and the healthcare system this nation deserves, and to do so the way I used to teach philosophy in graduate school.
To teach is to show others how to think clearly, and that can't begin unless we have questions in mind. So what I'm asking is, "What questions should guide us in determining how to describe the healthcare system that would provide optimal benefits for the American people?" To answer that we must have a context in which we see the whole picture: Our nation, its people, and our values.
With what tools do we proceed? Clear thinking requires that logic governs thinking driven by moral values, for we must begin with the insight that we are raising major moral questions. And beginning with a vision, we must proceed from the general to the particular, from our goals for our society to the means for reaching them – the healthcare system we would design. It will save time if we list our questions simply as, "who, what, why, and how" though logic requires that we address them in a somewhat different order. The context for our thinking will be developed in considering how to answer them:
- What: Good health. What are the conditions that produce good health in a society?
- Why: Because health is fundamental to enjoyment of the "life, liberty, and the pursuit of happiness" that we hold to be our birthright. Compassion for our fellow man and concern for our communities as places supportive of the flourishing of those qualities implies that health is to be seen as an important national goal. This imperative can be expressed by promoting health as a human right.
- How: By maximizing the ability of individuals, families, and communities to define and realize their own well-being.
- Who: It will require the participation of everyone to realize these benefits.
These are questions that can be addressed by national health planning, the sort of questions that were raised by the World Health Organization in producing its World Health Report 2000. The ultimate questions for a discipline must be answered by principles from another, more fundamental one. Commentators usually refer to the roles played by competition and regulation, business and government, but these are political and economic policy questions that need to be addressed in the same way as our questions about what kind of a healthcare system we ought to have. Because ours are moral questions, they must be answered by each and every one of us, and to do so effectively, we need education in clear thinking.
We Americans need to relearn responsibility for our own development and the role of education in empowering that process. With better education comes more personal discipline and greater participation in public life. Only then can the universal aims of public health be realized through a society that holds education and government in high esteem. There are many excellent articles on improving health in our society in our most informative newspapers, magazines, and journals, not to mention books, but these are all written by and for those well-educated individuals we've come to see as an elite. The distances between people need to be reduced by closing the economic, social, and political divides that we've allowed to develop through a deficiency of caring.
Of paramount importance is how these values are perceived. The business sector fully understands W. I. Thomas's principle that "if men define situations as real, they are real in their consequences," and they spend enormous sums ensuring that we see their products in the best light, and remain blind to their faults. To counter this, we must all teach each other to see more clearly what we've been missing – the big picture. For a society as for an individual, its ultimate expression is the face it puts on itself.
More than any other nation, throughout our history we have revered the freedom and the initiative to maximize profits, and we have celebrated those who succeed. But having succeeded, the best of them acknowledged their debt to the nation that offered such opportunities. Rather than setting them apart, wealth opened their eyes to their connectedness to all those who helped to earn it for them. In this, they saw themselves as trustees for the interests of the communities that truly owned the resources they had tapped and expanded.* They still knew how to ask, "If I am only for myself, then what am I?"
Education is key to this because these are the ultimate questions for all of us: What is the healthy life? So it all leads back to Socrates/Plato and Aristotle. Are you surprised? And from them we get some fundamental clarifications for our thinking. One is that nothing requires us to adopt a moral perspective for our vision. It has to be our own bent as a person to see these questions within a moral context, and to use a moral compass in deciding them. How else to see compassion and reverence for life as the greatest human qualities, and good government's fostering of egalitarian principles of human rights and social justice through public health as the right healthcare system? For it is universal health caring that we most lack in our country now, and the effort to revive it should have what William James called "the moral equivalent of war."
Winston Churchill's prosecution of World War II solidified his small nation through such an approach, and at the time he stated that "Americans always try to do the right thing – after they've tried everything else." Haven't we done that by now? And, if not now, when?
In the last issue, I wrote about "asking the right questions." A report has just been published in which some of those questions are implicit. It is Why Not the Best?
Results from a National Scorecard on U.S. Health System Performance, Commonwealth Fund Commission on a High Performance Health Care System, September 2006 [ http://www.cmwf.org/publications/publications_show.htm?doc_id=401577 ] and it is associated with an article, "U.S. Health System Performance: A National Scorecard," by Cathy Schoen, Karen Davis, Sabrina K. H. How, and Stephen C. Schoenbaum in Health Affairs 25 (2006): W457 – W475. [ http://content.healthaffairs.org/cgi/content/abstract/25/6/w457 ]
The questions I raised there were about the healthcare system that would provide optimal benefits for the American people. And I was led to editorialize about it because, although I was pleased to see so many articles and commentaries on the subject, none of them addressed it as a question of good governance. Their writers implicitly accepted the economic and political "upstream conditions" that are most responsible for the mess we're in! Perhaps I need to ask whether we're still the "can-do" nation we've always been, or if we've become so disillusioned over political stalemate and mendacity that we no longer believe in the values we thought defined us. I think that those of us who speak or write owe it to our fellow Americans to be uncompromising in attempting to dispel the ignorance of all the great civic lessons that now retards our progress as a nation. I suggested that the way to begin answering the healthcare question is by asking ourselves what sort of a society we wish to be.
Ask a health planner what is wrong with our healthcare system, and you're likely to hear that we don't have one. That is precisely the right answer, for it avoids blindly making a multitude of assumptions. If we all looked at our nation in relation to comparable ones that way, we could better understand the situation. What we have is like a patchwork quilt where the pieces don't fit together, leaving large gaps, and where groups continually conduct a tug of war with it, as it becomes ever more expensive to try to rent access to it. And so it gets ever more expensive in human terms.
If we were actually to plan and design a healthcare system, might we not wish to see what works well elsewhere and why? Would we want to make the profit motive the genie that runs it, or would we prefer to encourage public service with compassion, the ethos of public health? And would we breathe life back into the mantra of "government by the people, and for the people?"
This new report measures how well we're doing by looking at what works well anywhere. Its Scorecard contains 37 scored indicators, although many of these are composites. The way its measurement of performance is organized is based in large part on the framework used by the Institute of Medicine in its series of reports on quality and insurance coverage, but its specific indicators draw on those developed by the U.S. Department of Health and Human Services, the Agency for
Healthcare Research and Quality (AHRQ), the National Committee for Quality Assurance (NCQA), and other experts. The report also includes many new indicators developed for the Scorecard, including efficiency indicators, and is the first to combine indicators for quality, access, efficiency, and equity in one scorecard.
The indicators are grouped into five broad "domains:" health outcomes, quality, access, efficiency, and equity. A score of 100 on a given indicator represents not perfection but rather benchmarks set by top-performing countries or the top 10 percent of U.S. states, hospitals, health plans, or other providers. By comparing indicator scores from up to two dozen countries, the report places American healthcare in a global perspective, one in which our performance can be seen as mediocre.
The report's Overview begins, "Once upon a time, it was taken as an article of faith among most Americans that the U.S. health care system was simply the best in the world." Its principal finding about our nation is summed up as follows: "For the 16 percent of its gross domestic product that the United States spends on health care… it achieves neither the best outcomes nor the best quality of care when compared to other nations. Wide variations within the United States in quality, access, and costs pull national averages down to well below benchmarks achieved by top-performing states, hospitals, or other providers." U.S. ratio scores to benchmarks for the five domains range from 51 to 71 percent. Across the 37 indicators of performance, the U.S. achieves an overall score of 66 out of a possible 100 when comparing actual national performance to achievable benchmarks. Scores on efficiency are particularly low just as they were in the World Health Organization's World Health Report 2000.
The Scorecard findings show that if the U.S. improved performance in key areas, the nation could save an estimated 100,000 to 150,000 lives and $50 billion to $100 billion annually.
U.S. Score for "Outcomes" = 69
The Scorecard includes five system-level indicators of health outcomes: two on potentially preventable mortality, one on life expectancy, and two on the prevalence of health conditions that limit the capacity of adults to work or children to learn. Among 19 industrialized countries, the U.S. ranked 15th on "mortality from conditions amenable to health care," or deaths before age 75 that are potentially preventable with timely, effective care – 115 per 100,000 people, compared with 75 per 100,000 in France. Out of 23 industrialized countries, the U.S. was lowest in life expectancy at birth and tied for last with Portugal, Ireland, Denmark, and the Czech Republic on healthy life expectancy at age sixty. The most damaging finding: the U.S. ranked last on infant mortality as of 2002, with rates 259 percent of the average of the three leading countries (Iceland, Japan, and Finland).
U.S. Score for "Quality = 71
This domain includes getting the right care (71) that is well-coordinated (70), safe (69), patient-centered, and timely (72). The lowest scores were for: Ability to see doctor on same/next day when sick or needed medical attention (58)*; and Very/somewhat easy to get care after hours without going to the emergency room (53)*.
U.S. Score for "Access": 67
This domain includes participation in the health system (65), and affordability of care (69). In 2003, 35 percent of adults under 65 (61 million) were either underinsured or were uninsured at some time during the year. And 34 percent of all adults under 65 have problems paying their medical bills or have medical debt they are paying off over time.
U.S. Score for "Efficiency" = 51
Scores for these indicators tell the story about: Potential overuse or waste, an indicator for multiple related measures (58); Went to emergency room for condition that could have been treated by regular doctor (23); Hospital admissions for ambulatory care sensitive conditions (57).
U.S. Score for "Equity" = 71
The report's authors state that, "Having an equal opportunity to lead a healthy and productive life is consistent with the founding principles of this country. In fact, the elimination of disparities in health and health care has for years been a national policy priority." Belying that is our performance on the four indicators: Uninsured (66), Low-Income (62), African American (76), Hispanic (80).
Many of the scores for the above areas reflect variations in performance among the 50 states that are even greater than found among all the nations studied. For example, with respect to potentially preventable deaths, the five lowest scoring states were all below Portugal, the lowest scoring of the 19 industrialized countries, while the highest scoring states were equal to the highest scoring countries.
Future editions of the Scorecard will assess changes in performance on this initial set of indicators and will also include new indicators as data become available.
The report concludes with this prediction: "In the future, transformative change within the U.S. health care system will likely come from innovations in the way care is organized and delivered, and from better research in support of evidence-basedmedicine."
But only if we are asking the right questions.
* The Nobel Laureate (1978) economist Herbert A. Simon wrote: "Access to the social capital – a major source of differences in income, between and within societies – is in large part the product of externalities: membership in a particular society, and interaction with other members of that society under practices that commonly give preferred access to particular members. How large are these externalities, which must be regarded as owned jointly by members of the whole society? When we compare the poorest with the richest nations, it is hard to conclude that social capital can produce less than about 90 percent of income in wealthy societies like those of the United States or Northwestern Europe." "Universal basic income and the flat tax," Boston Review, 25(5), 9-10 (2000). Simon understood social capital to include good government and the educational, organizational, and technological skills of a nation in addition to its natural resources. His arguments for a just society are presented along with differing ones in Joshua Cohen & Joel Rogers, eds., What Is Wrong With a Free Lunch? (Boston: Beacon Press, 2001).
By John Steen, Consultant in Health Planning, Health Regulation, and Public Health
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The Primacy of Public Health
The following is the President’s Message from Health Planning Today, 1st Quarter 2007 issue. Reprinted with permission.
Over 10 days in January, the British Medical Journal (BMJ) conducted a poll among its readers to determine what they thought is the most important medical advance since 1840, the year of its founding. From a list initially suggested by its readers, an expert panel chose the top 15, which formed the basis for the vote. It also published a supplement in which experts argued the merits of each individual advance.
Among the 15, just four advances each received over 10 percent of the vote. They are:
1. Sanitation (clean water and sewage disposal): 15.8 percent.
2. Antibiotics: 14.5 percent.
3. Anesthesia: 13.9 percent.
4. Vaccines: 11.8 percen.t
The knowledgeable readers of the BMJ who voted (11,341) include physicians (28.6 percent), members of the public (22.8 percent), students (14.2 percent), and academic researchers (10.2 percent), and live largely in the United Kingdom (37.7 percent) and the United States (20.0 percent). Once again, its readers find that public health is principally responsible for the advance of medicine in that sanitation and vaccines are its province, while antibiotics are shared by public health and personal health care.
Here in the United States, our media are full of articles about the need to improve health status, reduce racial and ethnic disparities, and reduce national health spending, with nary a one about the value of public health. It would seem that they should be addressing the need for public policy that gets at the root determinants of premature death and disability. In a now classic 1993 research article, J. Michael McGinnis and William H. Foege related the 10 leading diagnoses of death in the United States in 1990 to the actual causes of those deaths. They found that 50 percent of deaths were attributable to behavioral choices – as opposed to genetic and external factors – and therefore were potentially responsive to public health education and prevention interventions. The distribution of causes of death was found to be essentially the same 10 years later when assessed again by Mokdad and colleagues in 2000.
The most prominent contributors to mortality in the United States in 1990 were tobacco (an estimated 400,000 deaths), diet and activity patterns (300,000), alcohol (100,000), microbial agents (90,000), toxic agents (60,000), firearms (35,000), sexual behavior (30,000), motor vehicles (25,000), and illicit use of drugs (20,000).
The leading causes of death in 2000 were tobacco (435,000 deaths; 18.1 percent of total U.S. deaths), poor diet and physical inactivity (365,000 deaths; 15.2 percent), and alcohol consumption (85,000 deaths; 3.5 percent). Other actual causes of death were microbial agents (75,000), toxic agents (55,000), motor vehicle crashes (43,000), incidents involving firearms (29,000), sexual behaviors (20,000), and illicit use of drugs (17,000).
Since 1900, the average life expectancy for Americans has increased by about 30 years. More than 25 of the 30 years can be accredited to public health initiatives, while medical advances account for fewer than four years. How bizarre it is that U.S. health care expenditures total nearly $7,000 annually for every man, woman, and child, whereas in 2005, federal support for CDC was roughly $25 per person per year, and state support for public health averaged $35 per person. It has been estimated that a "fully effective" population-based public health program could be implemented with about 3 percent of our national health care expenditures.
Public health’s top 10 achievements in the 20th Century include:
• Safer and healthier foods
• Motor-vehicle safety
• Healthier mothers and babies
• Safer workplaces
• Family planning
• Control of infectious diseases
• Fluoridation of drinking water
• Decline in deaths from coronary heart
• Recognition of tobacco use as a health disease/stroke hazard
So what are the factors that influence health status? Here they are:
• Health Behaviors – 50 percent
• Genetics – 20 percent
• Environment – 20 percent
• Access to Care –10 percent
Eighty percent of health status, including the prevention of premature deaths, is preventable, 70 percent by public health, and 10 percent by medical treatment. All of these factors assume that an infant has survived its first year of life, but the U.S. rate for infant mortality is among the worst of all large industrialized nations. Among 33 industrialized nations, the United States is tied with Hungary, Malta, Poland, and Slovakia, with a death rate of nearly 5 per 1,000 babies. That is primarily a reflection of barriers to prenatal care and maternal health, a consequence of our lack of universal health care, and of racial and income health care disparities. Among U.S. blacks, there are 9 deaths per 1,000 live births, closer to rates in developing nations than to those in the industrialized world.
Public Health Is the Answer, Just Ask the Right Question
I can think of no more stirring symbol of man’s humanity to man than a fire engine.
-- Kurt Vonnegut
What we need is basic primary and preventive health care services, but we do not have a delivery system that is designed to provide primary prevention. We don’t even have one that has been designed at all, just co-opted and driven by profitmaking. However, there is no profit for business in prevention, just for people. That is what public health does, and it is uniquely a government function. Our poor health rankings are pointed testimony to its underappreciation and underfunding. It is the misfortune of public health that its greatest benefits are invisible. While it protects everyone against maladies unimagined today, its detractors are able to criticize it with impunity.
That was not always so, but we forget. The mistrust of government clouds public health in its role of primary prevention, but that view is only a generation old. Before the advent of good sanitation and vaccines, plagues were feared far more than cancer is today, and childhood was something more to be survived than enjoyed. In 1796, when Edward Jenner first successfully immunized a child against smallpox, it was the world’s deadliest infectious disease. For the next century and a half, medicine and public health systematically eradicated all those deadly childhood diseases save one, polio.
The Salk vaccine (1955) was both the triumph of this process and its last effective publicity. A generation later, we had already become used to the luxury of our ignorance, that luxury underwritten by the effectiveness of public health. And the fastest growing sector of the health care industry thrives in the shadow of that ignorance, offering its sham procedures and cures as wish fulfillment for those age-old yearnings of mankind continually being addressed in much more practical ways by public health. Today, it would take a vaccine against all cancers, a newly virulent smallpox, or the Ebola or Marburg viruses to remind us how to be grateful for primary prevention.
Public Health in the 21st Century: A Better Society
What would it take to get us to see that our best interest is served by strong support for public health? What would it take to get us to see that our support for the highest standards for education is far more fundamental… to everything? A recent research article looked at vital statistics data for 1996-2002 in order to determine the number of averted deaths attributable to medical advances and the number of deaths that would have been averted if adults with lesser education had experienced the mortality rates of college-educated adults. The result: medical advances prevented 178,193 deaths, whereas giving all adults the death rate of those with a college education would have saved eight times as many, 1,369,335 lives. "On the basis of how many lives can be saved, our data suggest that efforts to correct the social conditions causing education-associated excess mortality should be proportionately greater than society's investment in medical advances.” The authors concluded. “Formidable efforts at social change would be necessary to eliminate disparities, but the changes would save more lives than would society’s current heavy investment in medical advances. Spending large sums of money on such advances at the expense of social change may be jeopardizing public health.”
 McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA.1993; 270:2207-2212. Abstract.
 Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004; 291:1238-1245. Abstract
 Turnock, BJ. Public Health: What it is and How it Works, 3rd Edition. (Jones and Bartlett Publishers, 2004).
 The Core Functions Project, Health Care Reform and Public Health, A Paper on Population-Based Core Functions, Rockville, MD: U.S. Public Health Service, 1993. In 1993, public health spending ($8.4 billion) represented 0.9% of total health spending, whereas “fully effective” spending ($25 billion) would have required 2.7%.
 CDC. "Ten Great Public Health Achievements—United States, 1900–1999." Morbidity and Mortality Weekly Report 48 (1999): 241–243.
 CDC and the University of California, Institute for the Future, 2000; and Prevention Report, “A Time for Partnership, Report of State Consultations on the Role of Public Health,” U.S. Public Health Service, December 1994/January 1995.
 In its World Health Report 2000, the WHO asserted that governments should be the “stewards of their national resources, maintaining and improving them for the benefits of their populations. In health, this means being ultimately responsible for the careful management of their citizens’ well-being.”
 Nevertheless, in nationwide Harris Poll results released in February for a survey conducted online among 2,337 adults in mid-January, ninety percent of those surveyed said they know what the CDC does, and 84 percent gave it positive marks, the highest performance marks among 13 federal agencies they were asked to rate.
 Information on National Public Health Week 2007 may be found at
http://www.nphw.org, which offers an overview of what public health can do. It is what should be publicized throughout the year, not just during the first week of April.
 Steven H. Woolf, Robert E. Johnson, Robert L. Phillips, Jr, Maike Philipsen. “Giving Everyone the Health of the Educated: An Examination of Whether Social Change Would Save More Lives Than Would Medical Advances,” American Journal of Public Health, 97: 679-683 (April 2007). http://www.ajph.org/cgi/content/abstract/97/4/679.
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Taha Muhammad Ali
In the last issue of the newsletter, I highlighted books recommended for an introduction to public health ethics and to the ideals of human rights. Here I wish to highlight a poem and its poet, and another perspective on human values.
Taha Muhammad Ali is a 76-year-old Palestinian poet who has experienced human rights abuses throughout his life, having been bombed and driven from his homeland during the Arab-Israeli War in 1948 when he was 17 years old. He returned a year later to live in Nazareth, one mile away from the ruins of his former village, and he has lived there ever since.
He writes in Arabic where the word for poet is sha'ir, "one who knows through feeling." Much of his poetry has the quality of storytelling by a village elder, a source of homespun truths. As an auto-didact poet, he defines humanity through his search for man’s dignity in the pathos of the human condition, and offers us hope and wisdom when he finds it. His poems are windows on everyday experience through which universal themes are indelibly revealed, with much sadness, but with optimism.
He is well known to Palestinians, but his international career is only now being nurtured by Jewish, Arabic, and American poets and editors. In his poetry, we can appreciate the soul of what inspires public health – goodwill and humanism that transcends politics.
At times … I wish
I could meet in a duel
the man who killed my father
and razed our home,
a narrow country.
And if he killed me,
I’d rest at last,
and if I were ready—
I would take my revenge!
But if it came to light,
when my rival appeared,
that he had a mother
waiting for him,
or a father who’d put
his right hand over
the heart’s place in his chest
whenever his son was late
even by just a quarter-hour
for a meeting they’d set—
then I would not kill him,
even if I could.
Likewise … I
would not murder him
if it were soon made clear
that he had a brother or sisters
who loved him and constantly longed to see him.
Or if he had a wife to greet him
and children who
couldn’t bear his absence
and whom his gifts would thrill.
Or if he had
friends or companions,
neighbors he knew
or allies from prison
or a hospital room,
or classmates from his school …
asking about him
and sending him regards.
But if he turned
out to be on his own—
cut off like a branch from a tree—
without a mother or father,
with neither a brother nor sister,
wifeless, without a child,
and without kin or neighbors or friends,
colleagues or companions,
then I’d add not a thing to his pain
within that aloneness—
not the torment of death,
and not the sorrow of passing away.
Instead I’d be content
to ignore him when I passed him by
on the street—as I
that paying him no attention
in itself was a kind of revenge.
April 15, 2006
© 2006 by Taha Muhammad Ali. English translation and copyright 2006 by Peter Cole, Yahya Hijazi, and Gabriel Levin.
His poem, “Twigs,” begins
fame, nor wealth,
not even poetry itself,
could provide consolation
for life’s brevity,
After we die,
and the weary heart
has lowered its final eyelid
on all that we’ve done,
and on all that we’ve longed for,
and all that we’ve dreamt of,
all we’ve desired
hate will be
the first things
 TWO LINES #14: World Writing in Translation features "Revenge," translated by Peter Cole, Yahya Hijazi, and Gabriel Levin. (2007)
 So What: New and Selected Poems, 1971-2005 (trans. from the Arabic by Peter Cole, Yahya Hijazi and Gabriel Levin) (Copper Canyon Press, 2006)
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