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10 HEALTHY COMMUNITIES INTRODUCTION
<br />al., 1996). In the late 1980s and early 1990s, tuberculosis made a comeback in
<br />cities across the United States, with many drug - resistant cases arising (OTA, 1993;
<br />Gittler, 1994), and outbreaks of childhood diseases such as measles and mumps
<br />appeared among poor inner city children (Atkinson et al., 1992; Kelley et al.,
<br />1993; Vivier et al., 1994). The number of human immunodeficiency vines/
<br />acquired immunodeficiency syndrome (HIV/AIDS) cases has surpassed 500,000
<br />in the United States, and among persons aged 25--44 years, HIV infection is the
<br />leading cause of death in men and the third - leading cause in women (CDC,
<br />1995a).
<br />Despite these outbreaks, which remain important, the 20th century has seen a
<br />shift in the major causes of death , from infectious to chronic diseases, and
<br />behavioral risk factors have increased in importance. Behavior - related factors
<br />such as use of tobacco, alcohol, illicit drugs, firearms, and motor vehicles, as well
<br />as diet, activity patterns, and sexual behavior, are responsible for nearly half of the
<br />deaths in the United States and substantial amounts of disability (McGinnis and
<br />Foege, 1993). Reflecting these realities, behavior and lifestyle interventions are
<br />highlighted, for instance, in Healthy People 2000. National Health Promotion
<br />and Disease Prevention Objectives (DHHS, 1991), with attention paid not only to
<br />the behaviors themselves but also to lifestyle more generally and to the context and
<br />social circumstances that influence individual behavior.
<br />Consistent with the development of these trends, public health professionals
<br />have come to realize that health is a dynamic state that is influenced by many
<br />internal and external process, and that embraces well - being — physical, mental, and
<br />emotional health. For both individuals and populations, health improvement
<br />depends not only on medical care but also on other factors including individual
<br />behavior, genetic makeup, and social and economic conditions for individuals and
<br />communities. The Field Model, as described by Evans and Stoddart (1994),
<br />presents these multiple determinants of health in a dynamic relationship. A wide
<br />range of actors, many of whose roles are not within. the traditional domain of
<br />health activities, have an effect on and a stake in a community 's health (Patrick
<br />and Wickizer, 1995). Tl}e Field Model suggests a variety of public and private
<br />entities in the community that, through their actions, could influence the
<br />community's health. As communities try to address their health issues in a
<br />comprehensive manner, everyone involved will need to sort out their roles and
<br />responsibilities. They also should participate in the process of "community-wide
<br />social change" that is needed to improve health (Green and Kreuter, 1990).
<br />As the public health community was coming to appreciate these ideas about
<br />the root determinants of health, other concerns about the high and rising costs of
<br />health care, the lack of geographical and economic access to health services for
<br />many, and questions about the quality and timeliness of the care provided led to
<br />many governmental and private attempts to alter the organization, delivery, and
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<br />funding of health care. Foremost among these attempts in the past decade has
<br />been the growth in organized health care delivery systems, including managed
<br />care, and the size of the organizations that deliver it (Gabel et al., 1994; Robinson,
<br />1996). However, the implications of these changes in the mode of service delivery
<br />and funding for public health agencies are uncertain. Has access for disadvantaged
<br />Populations improved or worsened? Can public health agencies delegate or
<br />contract their clinical health promotion and disease prevention and control
<br />programs to emerging health care organizations? If they can, can the quality and
<br />effectiveness of such programs be assured? Is ensurigg adequate clinical health
<br />care for all an important public health priority?,
<br />As the health system has changed, so too has the political landscape. Although
<br />Americans have been skeptical of government since the founding of this country,
<br />in recent years there has been a growing mistrust of government, government
<br />institutions, and politics (Dionne, 1991; La Porte and Metlay, 1996; Washington
<br />Post, 1996). Although distrust of government has received considerable attention,
<br />trust in other institutions such as the press, religious institutions, banking, and
<br />business has also been challenged. Related to this lack of confidence in
<br />government, or perhaps in response to it is a decided shift in responsibility from
<br />the federal government to state and local levels. Furthermore, there has been a
<br />growing movement to "reinvent government," including making it more
<br />decentralized, responsive to clients or "customers," community-oriented, and
<br />entrepreneurial by employing performance monitoring and outcomes standards
<br />(Osborne and Gaebler, 1992). In many communities, public health functions
<br />previously performed directly by government employees are being carried out by
<br />employees of private organizations. As a result, the opportunities for public -
<br />private partnerships are greater than ever before.
<br />SUMMARY AND ORGANIZATION OF THIS REPORT
<br />In summary, the discussions initiated by the Committee on Public Health have
<br />suggested that three key forces shaping public health are (1) the rise of organized
<br />health care delivery systems, including managed care; (2) the changing role and
<br />public expectations of government; and (3) the increasing involvement and
<br />mobilization of communities in matters pertaining to their own health. Drawing
<br />on the committee's activities and discussions, this report addresses two critical
<br />public health issues in the United States as it enters a new century—the
<br />relationship between public health and managed care, and the role of the public
<br />health agency in the community—and their implications for the broader
<br />infrastructure and capacity issues raised in The Future ojPublic Health.
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