The crisis of public health: implications for social workers.

During the past two decades, observers have noted that the U.S. public health system is in a state of "disarray" (Institute of Medicine [IOM], 1988). A 1988 report by the IOM described public health as a system in "shattered vision." The IOM noted that "society" had "contributed" to the problem by its failure to reach consensus on the "mission" of public heath and the role government should play in meeting "public health objectives" (IOM, 1988, pp. 6-7). Recent studies also warn that our public health system is in a state of crisis. According to Garrett (2000), although "[o]nce the envy of the world, America's public health infrastructure" is now in a state of "shambles" (p. 280). The authors of Health and Health Care 2010, a report prepared by the Institute for the Future (2000), predict that during the next decade, public health will be insufficiently funded and "efforts to address ... underlying problems...largely incremental" (p. 9). This column examines the crisis in public health and considers prospects for the future, briefly reviewing the development of public health in the United States and examining the curative model of health, which grew out of the separation of public health from clinical medicine. Finally, the column addresses the rise and limits of what many call the new public health and concludes with thoughts about how social workers might participate in efforts to create a new public health. THE RISE AND FALL OF PUBLIC HEALTH The period between 1900 and 1930 was a "golden age for public health" (Starr, 1982, p. 197). Although New York City had enacted public health legislation as early as 1796, and some states and cities created boards of health during the 1840s and 1850s, opposition from business and other groups stymied these efforts. "This theme--of tension between business and health sectors--would repeat itself so frequently in coming decades as to constitute a primary motif of the nation's struggle for population health" (Garrett, 2000, pp. 282-283). The rise of urbanization and industrialization created health problems that became impossible to ignore (Haines, 1991). Although members of the upper class could escape the overcrowded cities, by moving to rural areas, members of the emerging urban middle class did not enjoy this luxury (Baltzell, 1964). They "paid taxes, supported cleanliness and public education, recognized and abhorred corruption, and, as home owners, had an investment in their cities" (Garrett, 2000, p. 284). The middle class took the lead in advocating a wide range of reforms, including the enactment of health and safety regulations (Garrett). During the 1890s many cities "instituted new public works sanitation projects (such as piped water, sewer systems, filtration and chlorination of water) and public health administration" (Haines, p. 105). By the turn of the century, it had become increasingly clear that many diseases were communicable in nature. With the development of vaccines against rabies and diphtheria, many communities, particularly in the east, required their citizens to become immunized (Garrett, 2000). In New York City, Hermann Biggs, a leading public health figure, asserted that health authorities could resort to any measure that was "'designed for the public good'" and "'beneficent'" in its "'effects'" (cited in Garrett, p. 297). Authorities "routinely deployed police officers and zealous nurses or physicians to the homes of those suspected of carrying disease....In some cases, police officers pinned the arm of those who refused while a city nurse jabbed it with a vaccination needle" (Garrett, p. 299). These efforts seemed to pay off. Between 1900 and 1915, death rates (among children) from measles, whooping cough, scarlet fever, and diphtheria fell (Garrett). The golden age of public health did not last long, however. In 1920 a prominent theorist defined public health as the "science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community effort" (cited in Starr, 1982, p. …