The Politics of Public Health in the United States

Kant Patel, Mark E Rushefsky

• Publisher: Routledge
• Year: 2015
• eBook ISBN: 9781317455264
• Topic: Betriebswirtschaft
• Subtopic: Wissenskapital

Our public health system is primarily concerned with the promotion of health and the prevention of disease. But while everyone may agree with these goals in principle, in practice public health is a highly contentious policy arena. that is inevitably entangled with sensitive issues ranging from occupational safety and environmental hazards to health education, immunization, and treatment of addiction and sexually transmitted disease. Today however, concern for protecting the population against bio-terrorism and new epidemics such as SARS is tipping the balance back toward increased support for public health. This book focuses on the politics, policies, and methodologies of public health and the twenty-first century challenges to the public health system of the United States. It explores the system's relatively weak position in the American political culture, medical establishment, and legal system; scientific and privacy issues in public health; and the challenges posed by ecological risk and the looming threat of bio-terrorist attack. Each chapter includes study questions. The volume also includes a chronology of major laws and events in public health policy along with an extensive bibliography.

CHAPTER 1

The Politics of Public Health in the United States

Laws and regulations in a democracy are only as good as public support for them. Where the public is informed, educated, and socially aware, the level of personal and community health is generally high. Unless the majority of citizens is convinced of the value of a particular law or regulation, it becomes meaningless. (Duffy 1990, 313)

The American health care system is built around two complementary yet, unfortunately, often competitive models of health care. The first model— the curative model—emphasizes treatment and cure of illness and diseases. It is built around efforts designed to improve diagnostic and treatment/cure capabilities through the discovery of better drugs, surgical techniques, and life-sustaining and prolonging technologies. The second model—the preventive model—emphasizes prevention of illness, diseases, and promotion of health. It is built around efforts designed to prevent illness and diseases through promotion of a healthy lifestyle at the individual level and to discover and address environmental factors that contribute to ill health at the community level. The activities and services associated with prevention of illness, diseases, and promotion of health are what is generally referred to as public health. Public health has often been defined to include all knowledge and measures designed to foster health or prevent disease. This includes the recognition that “health” means much more than just the absence of disease (Winslow 1977).

These two models have competed for preeminence in the American health care system. Despite the accomplishments and successes of public health services in the United States, the curative model has dominated the American health care system since the second half of the twentieth century. In contrast, the public health system in the United States has suffered significant damage due to the politics of benign neglect.

Accomplishments of the Public Health System

Public health in the United States has had many successes and accomplishments to its credit. During the twentieth century, public health activities helped significantly improve the quality of life in America. According to an annual report released by the Centers for Disease Control and Prevention (CDC), Americans are healthier today than they were twenty-five years ago because of fewer smokers, less hypertension, lower cholesterol levels, better infant survival, and longer life expectancy (“CDC report finds Americans …” 2001). During the twentieth century, life expectancy increased by almost thirty years. In fact, life expectancy for persons in every age group also increased (U.S. Department of Health and Human Services 2000). Of the thirty-year gain in life expectancy, twenty-five years of the gain is attributable to advances in public health (“Public health achievements” 1999). Smallpox has been eradicated and polio has not been seen in the United States since 1979. Cardiovascular deaths have also declined significantly (Lee 1994).

According to the CDC, the top ten accomplishments of public health in the United States during the twentieth century include elimination of several infectious diseases due to the widespread use of vaccines, decreases in deaths related to motor vehicle accidents, declines in rate of fatal occupational injuries due to safer workplaces, better control of infectious diseases due to better sanitation, fewer coronary and stroke deaths, safer and more healthful foods, dramatic decreases in maternal and infant mortality, better family planning, significant decline in tooth decay and tooth loss with the addition of fluoridation to drinking water, and prevention of millions of smoking-related deaths due to increased recognition of the hazards of smoking (“Medical triumphs” 1999; “Ten great public health achievements” 1999). The 1980s alone saw a major decline in death rates for three of the leading causes of death among Americans—heart disease, stroke, and unintentional injuries. Some childhood diseases were nearly eliminated, and infant mortality also declined (U.S. Department of Health and Human Services 1990).

Shortcomings of the Public Health System

Despite these accomplishments, many problems remain. According to the World Health Organization (WHO), the overall life expectancy for babies born in 1999 in the United States is seventy years. The United States ranks only twenty-fourth in healthy life expectancy ranking¹ among all member states (WHO Press Release 2000). Despite the fact that the United States ranks first among all WHO member states in health expenditures per capita in international dollars, it ranks fifteenth on the index of overall health-system attainment,² seventy-second on the index of performance on the level of health,³ and thirty-seventh on the index of overall health system performance⁴ (World Health Organization 2000).

Almost half of the deaths in America have been attributed to an unhealthy lifestyle. Of the total number of deaths from all causes in America in 1988, almost half were attributed to deaths from cancer, heart disease, pulmonary disease, and motor vehicle accidents. Smoking alone accounts for one out of every five deaths in America (Houston 1991).

During the 1990s, many criticisms were voiced of the U.S. public health system. Many of these criticisms attributed the decline of the public health system in the United States during the last half of the twentieth century to the politics of neglect. According to some critics, the U.S. public health system is inadequately prepared to deal with many of the health problems of today or of the future due to a decline in the very foundation of the public health system (Cahill 1991). They charge that the present public health system has taken on the role of a safety-net medical provider to the disenfranchised, the elderly, the uninsured, the poor, the homeless, and people addicted to drugs (Cahill 1991).

According to a report of the Institute of Medicine (1988), the role and mission of the public health system is not clearly defined nor fully supported. Many health departments suffer problems of health care delivery, financing, and quality of personal health services. Public health services have fallen into disarray and the ability of the public health system to take effective actions to deal with continuing and emerging public health threats is questionable. According to the report, public health as a vital function is in trouble and many public health issues have become inappropriately politicized. In addition, public health responsibilities have become highly fragmented, and the public health system suffers from a hodgepodge of fractionalized interests, organizational turmoil, and unbalanced appropriations. A recent report by the Institute of Medicine (2002) concludes that not a great deal has changed since its 1988 report. The report argues that public health law at all levels of government is outdated and internally inconsistent creating inefficiency and lack of coordination. It further argues that the public health workforce is not receiving appropriate education and training to perform its current role. The current infrastructure burdens the work of the state and local public health agencies with too many administrative requirements. Furthermore, the report concludes that the Department of Health and Human Services (DHHS) currently lacks the capacity for conducting regular evaluation of the adequacy and ability of the governmental public health infrastructure.

Critics also argue that the American public health system, once the envy of the world, has fallen into despair with government laboratories running short on funds and equipment, and emergency preparedness plans that are antiquated (Kluger, Bjerklie, Dorfman, and Goldstein 2002). According to a recent report issued by the Institute for the Future (2000), public health is likely to continue to be underfunded and marginalized; efforts designed to address some of the underlying problems will continue to be incremental rather than dramatic.

The CDC has listed ten public health goals for the twenty-first century. They include eliminating health disparities, establishing a rational system of health care, focusing on children’s physical and emotional development, achieving a longer “healthspan,” integrating physical activity and promoting a healthy lifestyle, cleaning up and protecting the environment, preparing to respond to emerging infectious diseases, reducing the toll of violence in society, recognizing the contribution of mental health to overall health, and making wise use of scientific knowledge and technology (Koplan and Fleming 2000).

A report by the Institute of Medicine (2002) calls for action and change in six areas to address the present and future challenges faced by the American public health system. The six areas for action include adopting a population-based approach that considers multiple determinants of health, strengthening the government’s public health infrastructure, building new intersectional partnerships, developing a system of accountability, decision-making based on evidence, and enhancing and facilitating communication between health professionals and community members.

The goals and challenges facing the U.S. public health system outlined by the CDC and the Institute of Medicine are daunting challenges, and meeting these challenges will require a strong political will, a significant commitment of monetary resources, and public health leadership.

The United States spends more money on health care than any other country in the world. National health care expenditures for the year 2000 were $1,299.5 billion. Private and public sector spending accounted for $712.3 million and $587.2 million, respectively, of the total amount. Of the $587.2 million spent by the federal government on health care, spending for public health activities accounted for only $42.2 million, a mere 7 percent of total national expenditures (Levit et al. 2002).

Of course, most public health activities in the United States are carried out at the state and local government levels. Historically, it has been very difficult to obtain uniform information about public health spending, especially state and local government spending on public health activities. Previous attempts to characterize public health expenditures failed to differentiate between expenditures for personal health care and population-based health services. Currently, efforts are under way to develop and test a new methodology to collect consistent and complete expenditure data on state and local health agency expenditures for personal health care services (Public Health Foundation 2000, 1998, 1997).

Public opinion polls suggest that Americans favor a health care system that spends more money on prevention and health promotion and less on treatment. According to a Harris poll, 91 percent of respondents considered prevention of infectious diseases very important, and 88 percent of respondents considered conducting research into the causes and prevention of diseases very important. Similarly, 87 percent of respondents considered immunization to be a key issue (“Americans support…” 2000). Unfortunately, despite the public’s support for public health activities, public opinion polls also show that barely 1 percent of the public can specify the mission of public health (Young 1998).

It is clear that the public health system in the United States has suffered from political neglect in the last fifty years or so, and the revitalization of the U.S. public health system will necessitate confronting many of the challenges facing it in the twenty-first century. To understand these challenges, it is first necessary to examine the evolution of public health services and public health policies in the United States.

History of Public Health Policy in the United States

“The history of public health in America has not been one of constant and steady upward progress. One has only to glance at present public health statistics to realize how much still remains to be done. Yet public health, like politics, is the art of the possible” (Duffy 1990, 315). One of the best and most comprehensive accounts of the history of American public health is provided by John Duffy in The Sanitarians (1990). Duffy identifies three themes that run through the history of American public health. The first theme centers around the fact that public and community reactions to periodic public health crises have alternated between apathy and strong collective responses. For example, during the colonial period the public reacted strongly to yellow fever and smallpox by taking collective preventive actions. Yet, the diseases responsible for most of the sickness and death, such as malaria and respiratory infections, did not generate much public and community reaction. Since America is a land of immigrants of different cultures, the second important theme in the history of American public health is the impact of acculturation upon public health, that is, how various groups of immigrants have been integrated into American society with respect to how to live and interact with their environment. The third theme is the constant friction between individual and civil liberties on the one hand and public welfare on the other as the government tries to regulate individual behavior in order to protect community health. This issue is certainly at the heart of a democratic society. The task of public health officials in the United States is made more difficult by the general American distrust of government laws and regulations (Cantril and Cantril 1999; Wills 1999).

Duffy (1990) also argues that American public health policy has been influenced by three key factors. First, at any given point in time, public health measures and policies to be used are always influenced by the medical concepts predominant at that point in time. For example, if a sickness or disease is attributed to the gods, then prayers and sacrifices may be considered the most appropriate responses for treatment. A second factor that shapes public health policies is the prevailing social attitude. If the public equates certain sicknesses or diseases with individual failings and sins, as was the case with venereal disease in the past, society may show no inclination to try to cure or prevent it. The slow response to the AIDS crisis in the United States to some extent reflected such societal attitudes (Shuts 1987).

The third factor that shapes public health policies is role of government in a country’s economy. Government regulatory policies are influenced by what the dominant political ideology views to be the proper relationship between government and business or industry. For example, in American society, mistrust and suspicion by the citizens of government in general and national government in particular do not allow the national government to play a major role in the national economy except during a period of crisis. The mistrust of government is a reflection of the constant tension between the philosophy of Lockean liberalism, in which government is supposed to play a neutral role to allow individual self-interest to prevail in the marketplace, and the philosophy of republicanism, which advocates a more positive role for the government in order to ensure the primacy of the commonwealth. The result is that businesses in the United States are subjected to piecemeal regulations for specific purposes without a clear overall purpose (Ballam 1994).

We add a fourth factor—prevailing politics—as another important factor that shapes the formulation of public health policies. Which party is in power and which political ideology is dominant at any given point in time determines how confidently government wields its authority and deploys its regulatory power to protect public health (Scheiber 1997). The formulation, ad...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Figures and Tables
• Foreword
• Preface
• Acronyms
• 1. The Politics of Public Health in the United States
• 2. Leadership, Politics, and Public Health
• 3. The Politics of Public Health and Private Medicine
• 4. The Politics of Public Health and Law
• 5. The Politics of Science and Public Health
• 6. The Politics of Genetics and Public Health
• 7. The Politics of Environment and Public Health
• 8. The Politics of Bioterrorism and Public Health
• 9. Conclusion
• Chronology of Major Public Health Laws and Events
• References
• Index
• About the Authors