Resources for Assuring Access: Health Promotion and Disease Prevention

126 Presentation RESOURCES FOR ASSURING ACCESS: HEALTH PROMOTION AND DISEASE PREVENTION BAILUS WALKER, Jr., Ph.D., M.P.H. Professor of Public Health Policy Graduate School of Public Health State University of New York at Albany This is indeed an appropriate time to reflect on the issue of health promotion and disease prevention because we are now in a time of rapidly changing national priorities and expectations both at home and abroad, priorities and expectations that will affect our effort to prevent disease, dysfunction, and premature death. The public health community, its constituency, and its allies will inevitably share in this change. In our society, change is inevitable. Perhaps the only immutable law of the universe is that nothing is immutable. Thus, forecasting events and decisions in health promotion activities is especially hazardous; even the general predictions are fraught with difficulty. In identifying the major forces most likely to influence health promotion and disease prevention services, one is immediately struck by the long list of items and their complexity: some are social, some are economic, and some are political; others are pedagogic, and still others are biomedical. What strikes one most forcefully is that they are all interrelated. They are interrelated because public health activities are part of a system, and systems, whether they are biological, mechanical or economical, have at least one characteristic in common: there can be no event in one part of the system which does not affect the rest of it. The parts are all interconnected and interrelated. For example: • what happens in the private practice of medicine affects the public's health; • what happens on Wall Street affects public health; • agricultural production or the lack of it affects public health; and • the quality of education affects public health. So, it is in this setting that we want to identify eleven factors that are Journal of Health Care for the Poor and Underserved, Vol. 1, No. 1, Summer 1990 ___________________________Walker___________________________127 converging to define the milieu in which we must pursue health promotion services. First, in the Congressional arena, health policy-making will continue to be episodic. Congress will act in direct response to health-related issues that generate a high level of public concern. The degree of public concern may have little correlation with the intrinsic importance of the public health problem. Second, during the early years of the Reagan Administration, most Americans were hopeful that new federal policies could control the explosive growth of national health care spending. By the early 1980s, the prospective pricing system had turned hope into sunny confidence. Today, that confidence and hope have faded. We are now spending at least double the share of GNP on health care that we spent in 1965. And few people can tell us what we are buying. In the years ahead, overt (not subtle or covert) rationing of health care will be commonplace. Third, the Administration will put much emphasis on harnessing market forces to achieve health and environmental goals. The proposed policy of buying and selling pollution rights allows the marketplace to decide the most economical way to contain smokestack emissions. This market strategy will be applied to several other policy initiatives of the Bush Administration. Fourth, consumers of health care services will become more activist. Fifth, epidemiologists will continue to have considerable difficulty in dealing with health policy issues, especially health economies, and the social and behavioral aspects of health care. Health care often depends on quick decisions, numerators without denominators, and the use of available data rather than on unique, independently collected data. Size, freshness, and applicability of data to the issue at hand are often more important than the quality of data, much to the chagrin of epidemiologists. Epidemiologists are rarely satisfied with a single point estimate but rather require multiple studies and careful analyses in order to measure the impact of confounding and bias parameters and to measure the confidence intervals around point estimates. Yet, epidemiological data are essential for the development of sound health policies, programs, and services. Sixth, on the social and demographic fronts, we should not be too disturbed by recent Supreme Court decisions that appear to set back affirmative action programs, and their implications for...