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POLICY ARTICLE

Epidemiology In in the Era of Reform

PHILIP R. LEE, MD, ScD This article is based on remarb prepd for delivery by KATHLEEN E. TOOMEY, MD, MPH Dr. Lee intheannualSelrs-McCroan lecture beforethe Georgia Public Health Aociation and the Division of Public Health, Georgia Department of Human Resources in Atlanta, GA, Dr. LeeistheAsistatSecrtyfor HealthoftheDepartment September16, 1993. Ithasb rvisedandeditedforpublication. ofHealth and Human Savices and Head ofthe Publc Health Tearshoet requests to Office of Communications, Public Service. Dr. Toomey is the Sta Epidemioloist and Direor Health Serice, Room 717H, Hubert H. Humphrey Bldg., 200 of the Ep miolgy and Pvention Branch of the Georgia Independence Ave., SW, Washingto, DC, 20201; tel. 202-690- Division ofPublic Health. 6867.

INADDmONTOTHERBASIC REspoSBiLS, many public emphasis shifted again with the great bulk offunding health agenies at the State and local levels have had increases in the 1980s allocated to HIV-AIDS and to assume the responsibility of serving as the safety net substance abuse programs by the Federal Government. to meet the basic medical and preventive health care Whilemanyothercategorical programscontinued,they needs ofpeople without access to other direct medical received only modest incrses, if any. services. When they were not serving directly in this With the President's health care reform plan (the capacity, State and local health departments had to Health Security Act), the need for many categorical compete with other public agencies charged with this programs that fund direct personal medical services, responsibility for limited resources. such as maternal and child health block grants, sub- The Federal role in public health was transformed stance abuse and services block grants, with the passag ofthe Social Security Act in 1935 and Ryan WhiteHIV-AIDS caregrants, breastand cervical the authorization for the Federal Government to make cancer screening, immunization, grantstosupport Statepublichealthagencies. Theearly centers, and migrant health centers will be redefined emphasis in Federal grants was in the control oftuber- as servicespreviouslyfundedbyFederalgrantsthat will culosis and venereal disease and in grants for maternal bepaidforbyhealthplans. In some cases, the payment and child health, including services for crippled chil- by health plans will cover fully some services, such as dren. These programs grew slowly after World War II. immUnzations, while, for others (HIV-AIDS), only In the 1960s there was a dramatic shift in the role around half of the services currently funded will be of the Federal Government in dealin with domestic covered. Theseprograms will continuetoreceivedirect social problems from civil rights and poverty to envi- Federal support. ronmental health, mental health, health care for the The Health Security Act not only provides universal poor, health professions educaton, and biomedical health with comprehensive benefits, it also research. In atdditio theCivil RightsAct, , provides additional support for the current safety net andMedicaid, newprograms werecreatedand old ones programs and capacity expansion to assure access to expanded. There were numerous new grant-in-aid pro- careformedically underservedpopulations. TheHealth grams, some going to State and local governments, Security Act also provides funding to strengthen and some to universities, some to individual investigators, expand core public health activities at the State and and sometocommunity-basednonprofit organizations. local level. In the late 1960s, an effort was made to balance The public health role can return to its primary broad-based support of public health and the need to purpose in protecting and promoting the public health meet high priority national needs through categorical throughpopulation-basedprograms. Thecorefunctions Fedealgrants. The success ofthis effort, implemented ofpublic health - assessment, assurance, and policy through the Comprehensive Health Planning Act of development - as described in the 1988 Institute of 1967, was short-lived as more and more emphasis was (IOM) report, "TheFutureofPublicHealth," placed on categorical grants. will again become critical. In each of these areas, With the advent of the HIV-AIDS , the plays a key role.

January-Februwy 1994, Vol. 100, No. I I The authors ofthe IOM report found that the infra- cies at the local, State, and Federal levels. These data structre to support epidemiology at the State and local are needed to inform policy decisions, to develop pro- levelsislimited. Many States lackthecapacitytoassure grams, to allocate resources, to inform legislative de- protection ofthe public's health. They lack the trained cisions, and to educate policy makers about issues of people to coordinatcollection ofdata at the local and concern. State level, and they lack the capacity to critically A well-functionig epidemiology unit should be the analyze data to identifyproblems and setpriorities. As cornerstone - the assurance program in public health health care reform takes shape, it will be essential to -to identify areas where programs are lacking and to reestablish this infrastructure so thatepidemiologycan evaluate the effectiveness of policies and progrms. play this crtical role. Also itsanalyses should indicate areaswhere programs Because of the multiple Federal categorical pro- are not meeting stated objectives, identify inequalities grams that do not support core public health functions, in needs and services, and basically be the foundation it has been difficult to examine the interrelationships of quality control within the health department. among many public health problems. This limits the Health departments must also monitor and evaluate ability of States to look critically at information in an the performance ofhealthplans and alliancs to assure integrated fashionoracross program lines. In Georgia, that public health objectives are achieved, that all for example, zip codes with the highest STD rates also Americans have access to services, and that those ser- have the highest rates ofAIDS cases and tuberculosis vices meet the established standards. With the emer- cases. Theseare oftenthe same people. There is a need gence of health care reform, clearly there is a need to to lookatthis categorical epidemiology across program link traditional surveillance activities with other indi- lines to develop the most effective ways to reach those cators in orderto evaluate the impact ofhealth services at risk. onindividualsandthe populationatLarge. Healthplans The assessmen and surveillance capacity that iden- under the Health Security Act will have incentives to tifies problems, provides data to assist in decisions achievepublichealthobjctives, suchas immunization, aboutappropriateinterventions, and monitorsprogress and their success in this needs to be carefully assessed. is a function ofepidemiology. According to the IOM, Public health and personal health care systems need to "Epidemiology has long been considered the essential work closely together to identify needs and devise science ofpublic health, and a strong assessment and effective strategies for intervention. surveillance system based on epidemiologic principles For example, analyzing the data on STD morbidity, is a fuatal part ofa technically competent public linked toMedicaid data on reimbursement forsequelae health activity." of STD, can help to define the magnitude and cost of Whether fighting the old diseases such as tubercu- STDs atthe State and local levels. Usingthis approach losis and cholera or newer ones such as Hanta virus, to define the current public expenditure for complica- Lyme disease, or antimicrobial resistant infection, tions of STD and using the epidemiology and surveil- public health's primary tool is epidemiology. The lance data to estimate cost savings of STD screening recent outbreak ofHanta virus infection in the South- and prevention activities can lead to the development west illustrates the importance of linking clinical ob- of sound public health practices. In some areas, STDs servations, epidemiology, and laboratory science to will be a major problem, in other areas they will be a solve a major threat to public health. lower priority. The ability of public health agencies to identify Epidemiology is key to public health in the future. health problems, decide on appropriate interventions, Itwillbeimportanttoensurethatepidemiologycan link and monitor progress are all dependent on sound across program lines and interact with all programs to epidemiologic data. The traditional assessment and ensure that the assessment, asuae, and policy func- surveillanefunctions ofpublichealthmustbe strength- tions can be carried out. Links are needed to chronic ened, and they must be linked to other data sources for disease programs and as well as evaluatingthe quality ofcare in health services. Policy infectious disease control and STD-AIDS prevention. makers, alliance plan managers, physicians, and con- Linksare neededtovital records sothatinformationcan sumers need information to evaluate plans and provid- be cross-referenced to maximize analytic potential. ers and to hold them accountable for the health of a Links are needed to enrollment data, encounter data, population that they serve. outcomes data, andpatient survey data to permit assess- Policy development is also dependent on the infor- mentofperformanceinrelationshipto healthoutcomes. mation andanalysisprovidedbyepidemiologic studies. During recent weeks, the Health Security Act sub- It is essential to develop the capacity to translate mitted to the Congress by the President has been dis- epidemiologic information into action plans and poli- cussedextensivelywith Congress, and detaileddescrip-

2 Public Hguth Reports tions have appeared in the media. The plan boils down activity, eating habits, sedentary life style, use of to these basic purposes: alcohol and other drugs, violent and abusive actions, and other risk taking that leads to injury. These behav- 1. Security - guaranteeing that all Americans will iors, which tend to be blamed on the individual, occur be insured with a comprehensive benefit package and within the context ofa social environment. Behaviors including clinical peventive services and prescription thatputpeopleatgreater risk suchascigarettesmoking, drugs and long-term care programs; heavy drinking, and illicit drug use are more likely in 2. Saving - controlling the growth of health care communities where poverty rates are high, housng is costs; inadequate, educational services are inadequate, scial 3. Simplicity - reducing the flood ofpaperwork in support services are inquate, andjobs are not avail- the system; able. Unhealthy behaviors don't occur in . 4. Choice - expanding consumer choice of plans As universal access to personal medical care is and providers; assuredwithhealthcarereform, thereare severalthings 5. Quality - emphasizing continuous quality that must be done to strengthen population-based ap- improvement and performance evaluation; proaches to achieve public health goals. First, it is 6. Responsibility- all in the will necessary to strengthen public health activities that contribute our fair share. support thepersonalmedical care systemandthepublic healthneedsof the entirepopulation- thingslikedata, The plan contins a major public health initiative health services, biomedical and behavioral sciences that includes programs that strengthen both the public research, and changes in the work force. health and the personal health care systems; for ex- Reinventingpublic health means investing in epide- ample, prevention research at the National Institutes miology,consolidatingcurrentyfragmentedpublichealth of Health, programs designed to assure access to the data systems, and integrating these systems with a underserved, and plans to strengthen population-based regional and national data network that can serve the public health programs. needs of consumers, practitioners at the local level, While much of the attention has focused on the health plans, and health alliances, as well as the gov- reform of the personal health care system, equally ernment agencies responsible for protecting the public important is the task of what some of us would call, health. "reinventing public health," in order to achieve pre- The second essential element in the Health Security vention objectives. The public health infastructure at Act is the Access Initiative that is designed to assure the State and local level must be strengthened in coor- accesstopersonal medical care forthosewhohavebeen dinationand collaborationwiththepersonalhealthcare medically underserved in rural and urban areas. The system. Ifthe goals of an increase in the healthy life Access Initiative includes continuation and strength- span for all Americans and increased reduction in the ening of safety net progrs (for example, community health disparities of socioeconomically disadvantaged health centers), expansion ofthe National Health Ser- groups are to be achieved at an affordable cost, reform vice Corps, a new capacity expansion program, a new of the personal health care system must be paralleled adolescenthealthinitiative, expansionof substanceand by reinvention of the public . mental health services, and strengthening and expan- Whether historical advances against infectious dis- sion of the Indian Health Service. eases or contemporary gains against heart disease Finally, the Health Security Act calls for a major which have been dramatic in the last 20 years are expansion of Federal support for core public health assessed, the greatest improvements in health status functions at the State and local levels and support for have been derived from public health approaches, not local initiatives designed to meet public health pro- from the increased expenditures for medical care. In grams of regional or national significance. 1982, a study bty the Institute of Medicine stated that Healthcare reformposesagreatchallenge forpublic only 10 percent ofpremature deaths among Americans health. To assure that the goals of health care reform could have been avoided through improvements in are met, it is essential that both the present health care access to medical treatment. Little has changed since systemandthepublic healthsystembe reinvented. This 1982 to alter that judgment. canbe accomplishedonlyifthisreformincludesamajor The IOM report attributed 20 percent of premature publichealthinitiative, aswellasreformintheplannig mortality to environmental factors. Most importantly, and delivery of personal medical care. the report went on to state that another 50 percent of premature deaths could have been avoided by changes in individual behaviors such as tobacco use, sexual

January-February 1994, Vol. 100, No. 1 3