True or False: Public Health Core Functions Are Still Relevant Today? Mid-America Regional Public Health Leadership Institute St. Charles, Illinois October 25, 2006 Barney Turnock MD, MPH UIC School of Public Health

Instructions  Be Here on Time  Address the Institute’s Theme  Remember, Leaders from Outside Illinois Are in the Room  Make Core Functions Understandable  Be Upbeat  Be Provocative

“It’s all road-kill, and never a word about the chickens who get to the other side!”

Provocative?  What’s provocative about:  Core Functions?  Essential Public Health Services?  Public Health Infrastructure?  Provocative like George Carlin’s “7 words you can’t say on TV”?

Why Are We Here?  Don’t have all the answers  Previous performance not necessarily an indication of future  Lessons of past successes often misapplied  Churchill and Max Deus  Binghamton by way of Elmira?

A little history…  Three core functions (1988 IOM Report)  Assessment (What should be done? i.e. Needs)  Policy Development (What will be done? i.e. priorities)  Assurance (How well is it done? i.e. performance)  Core Functions Steering Committee (1994)  Public Health in America statement

Essential Public Health Services 1.Monitor health status 2.Diagnose and investigate health problems 3.Inform, educate and empower people 4.Mobilize communities to address health problems 5.Develop policies and plans 6.Enforce laws and regulations 7.Link people to needed health services 8.Assure a competent workforce - public health and personal care 9.Evaluate health services 10.Conduct research for new innovations

Public Health Systems Perspective Capacity Process (Core Functions/Essential Public Health Services) Process (Core Functions/Essential Public Health Services) Outputs Outcomes System Inputs WorkforceInformation Organization & Relationships FacilitiesFundingWorkforceInformation FacilitiesFunding Improved organizational performance + Improved program performance Improved organizational performance + Improved program performance Assess Address Assure Programs and Services consistent with mandates and community priorities Key Processes Improved Outcomes & Customer Satisfaction Improved Outcomes & Customer Satisfaction Increased Value & Public Support

“Well, actually they ARE written in stone!”

True or False: Public Health Core Functions Are Still Relevant Today?

Core Functions Still Relevant? It’s TRUE, Because…  All the easy problems have already been solved  We need a framework to assess, address, and assure effective responses to today’s wicked problems

Actual Causes of Death, 2000 (Source: Mokdad et al, JAMA 2004) Tobacco435,000 Poor diet & physical activity 400,000 Alcohol85,000 Microbial agents 75,000 Toxic agents 55,000 Motor vehicle 43,000 Firearms29,000 Sexual behavior 20,000 Illicit drug use 17,000

Anthrax Attack 2001: Mail Flow Network… State Department SA-32 (VA) AMI Building (FL) Brentwood Mail Facility (DC) Truck to Atlanta, GA Hamilton Processing Facility (NJ) Morgan Central Postal Facility (NY) Carteret Hub & Spoke Facility (HSF) (NJ) Boca Main Substation (FL) Blue Lake PO (FL) West Palm PO Main Branch (FL) Lake Worth PO (FL) Green Acres PO (FL) Radio City PO (NY) Rockefeller Ctr PO (NY) Ansonia PO (NY) 56 USPS Facilities including: Lenox Hill PO (NY) Times Sq. PO (NY) ENT Hospital (NY) Pataki’s Office (NY) NBC (NY) ABC (NY)CBS (NY) New York Post (NY) Distribution plants including: (Bulk Mail Ctr, Dominic V Daniels, Hackensack, Central NJ, Performance, Monmouth, Newark Main, Patterson, West Jersey) Dirksen Bldg P-St. Mail Sorting (DC) Hart Bldg Ford Bldg All DC City Mail for Zips W. Trenton PO (NJ) Princeton PO (NJ) ? 177 Federal Agencies including: Bellmawr Distribution plant (NJ) 48 local Post Offices including: Boulevard PO (NY) Other Post Offices State Department SA-3 (DC) Longworth Bldg Landover (Justice) Pentagon PO Branch Southwest PO Station Friendship PO Station Dulles PO Branch Anacostia mail room Walter Reed Complex DC VAMC BATF Supreme Court Local Businesses including: Kuser Road Business US Embassy in Yekaterinburg, Russia US Embassy in Lima, Peru US Embassy in Vilnius, Lithuania NYC Home Stamp Fulfillment Kansas City, MO Lantana PO (FL) = Environmental samples positive = Confirmed anthrax case associated with site = Suspect anthrax case associated with site November 7, 2001

Hotel M Hong Kong Guangdong Province, China A A B J H C D E I K † F G † Hospital 2 Hong Kong A H J B 4 other Hong Kong Hospitals Hospital 3 Hong Kong Hospital 1 HK Hospital 4 Hong Kong 2 family members CDE 34 HCWs HCW B Germany Bangkok Singapore United States I L§L§ M§M§ Vietnam Ireland K † 37 HCWs HCW 0 HCWs 28 HCWs 156 close contacts of HCWs and patients Canada G † F 4 family members 10 HCWs 37 close contacts 99 HCWs (includes 17 medical students) 4 HCWs* 3 HCWs HCW 2 family members Unknown number close contacts 2 close contacts SARS Transmission Spring 2003

Rodent Shipment Ghana TEXAS 50 Gambian giant rats (GR) 53 rope squirrels (RS) 2 brushtail porcupines (BP) 47 tree squirrels (TS) 100 striped mice (SM) ~510 dormice (DM) NJ RS, BP TS, SM TX-3 RS, SM DM IA † GR, DM TX-4 DM TX-5 DM TX-6 TS, SM DM TX-2 GR TX-8 DM TX-7 DM TX-9 DM Japan DM TX-10 DM MN DM WI DM IL-2 DM IL-1 § GR, DM MI No human cases SC No human cases MO Human cases: 2 confirmed KS Human cases: 1 confirmed IN Human cases: 7 confirmed 9 probable/ suspect IL ‡ Human cases: 8 confirmed 4 probable/ suspect WI Human cases: 17 confirmed 22 probable/ suspect 1 PD traced 200 prairie dogs (PDs) at facility 1 PD traced 11 PDs traced 24 PDs traced 14 PDs traced 42 PDs traced Monkeypox Outbreak 2003

Core Functions Still Relevant? It’s TRUE, Because…  When you’re a hammer, the whole world looks like a nail…

When you’re a hammer…  Specialization  Categorical Approaches  Silos Instead of Systems  Poor Charlie’s Democratic Principles

Core Functions Still Relevant? It’s TRUE, Because…  We need a plan…

LHD Participation in Community Health Assessment (CHA) CHA completion or plans Percentage Completed CHA in past three years 51% Plans to complete CHA in next three years 65% Either completed CHA in past three years or plans to complete in next three years 79% Both completed CHA in past three years and plans to complete in next three years 38%

LHD Participation in Community Health Improvement Planning (CHIP) Percentage Participated in CHIP 54% CHIP based on results of CHA* CHIP based on results of CHA*86% CHIP linked to state’s health CHIP linked to state’s health improvement plan* improvement plan*68% Participation in past three years *Of those LHDs that have participated in CHIP

Participation in CHA by State

Participation in CHA: Comparison with 1999 Infrastructure Study Population size All LHDs 55%51% <25,00044%42% 25,000 – 49,999 63%53% 50,000 – 99,999 65%57% 100,000 – 499,999 66%61% 500, %67%

Participation in CHIP: Comparison with 1999 Infrastructure Study Population size All LHDs 53%54% <25, ,000 – 49, ,000 – 99, ,000 – 499, ,

LHD Role in Community Health Planning

Core Functions Still Relevant? It’s TRUE, Because…  It provides a job description for public health  Countering the frequently raised argument: “That ain’t my job! Nobody told me I was supposed to do that.”

Ain’t my job?  Coming Soon to a Local Health Department in your neighborhood?

The MAPP Model

Road-MAPP

Public Health Systems Perspective Capacity Process (Core Functions/Essential Public Health Services) Process (Core Functions/Essential Public Health Services) Outputs Outcomes System Inputs WorkforceInformation Organization & Relationships FacilitiesFundingWorkforceInformation FacilitiesFunding Improved organizational performance + Improved program performance Improved organizational performance + Improved program performance Assess Address Assure Programs and Services consistent with mandates and community priorities Key Processes Improved Outcomes & Customer Satisfaction Improved Outcomes & Customer Satisfaction Increased Value & Public Support

True or False: Public Health Core Functions Are Still Relevant Today?

Core Functions Still Relevant? It’s FALSE, Because…  That’s not what they taught me in public health school!

“Hmmm…traces of oil, gas, lead, EDB … it’s water, all right.”

“Go about your business. Act normal.”

“To prevent a heart attack, take one aspirin every day. Take it out for jog, then take it to the gym, then take it for a bike ride…”

Core Functions Still Relevant? It’s FALSE, Because…  You get what you pay for?

Get what you pay for?

Actual Causes of Death, 2000 (Source: Mokdad et al, JAMA 2004) Tobacco435,000 Poor diet & physical activity 400,000 Alcohol85,000 Microbial agents 75,000 Toxic agents 55,000 Motor vehicle 43,000 Firearms29,000 Sexual behavior 20,000 Illicit drug use 17,000

“Tell the public we don’t want to hurt anyone. All we want is their money.” All we want is their money.”

Pop Quiz Question Over the past 50 years, total expenditures and per capita spending for public health activities in the United States has been: Over the past 50 years, total expenditures and per capita spending for public health activities in the United States has been: a. Increasing steadily b. Decreasing steadily c. Unchanged d. Don’t know

Adjusted total public health spending (in millions) from federal and state/local sources US,

Per capita public health expenditures from federal and state/local sources, US,

Core Functions Still Relevant? It’s FALSE, Because…  We assume it to be true and our assumptions are often incorrect!  Look what happens when we get what ask for!

“I guess he must have made it… It’s been more than a week since he went over the wall.”

Conventional Wisdom?  Public Health Workforce is shrinking  Average age is high (~47)  Public Health workers soon will be retiring in large numbers  Recruitment and retention are major issues, especially in rural communities  Key disciplines (such as public health nurses and epidemiologists) are increasingly scarce  Few public health workers have received formal training in public health  Public Health Workforce is not prepared for current and future threats

Pop Quiz Question Over the past dozen years, the size (# and ratio) of the public health workforce in the United States has been: Over the past dozen years, the size (# and ratio) of the public health workforce in the United States has been: a. Increasing steadily b. Decreasing steadily c. Increasing in the 1990s through 2000 and then decreasing d. Decreasing in the 1990s through 2000 and then increasing e. Unchanged f. Don’t Know

Pop Quiz Question Over the past dozen years, the size (# and ratio) of the public health workforce in Illinois, Indiana, Wisconsin, Michigan, etc. has been: Over the past dozen years, the size (# and ratio) of the public health workforce in Illinois, Indiana, Wisconsin, Michigan, etc. has been: a. Increasing steadily b. Decreasing steadily c. Increasing in the 1990s through 2000 and then decreasing d. Decreasing in the 1990s through 2000 and then increasing e. Unchanged f. Don’t Know

FTE Workers (per 100,000 pop.) of State and Local Governmental Health Agencies, U.S. (Public Employment Census Data, Selected Years)

FTE Workers (per 100,000 pop.) of State and Local Governmental Health Agencies, Texas (Public Employment Census Data, Selected Years)

Full Time Equivalent (FTE) Workers of Governmental Health Agencies, Source: Data from U.S. Bureau of the Census, Federal, State, and Local Governments, Public Employment and Payroll Data. Available at Year Fed (F) FTE State (S) FTE Local (L) FTES+LFTEF+S+LFTE ,048160,031208,588368,619493, ,846166,930219,655386,585506, ,999172,414251,399423,813546, ,979176,345252,326428,671553, ,828176,868253,888430,756555, ,933174,301249,857424,128552, ,163178,465246,300424,765549,918

Approaches to Public Health Workforce Development: Pipeline vs. Willy Sutton  Conventional Wisdom approach to workforce development: more schools, increase number of graduates, higher proportion of gradates into primary public health workforce through scholarships and loan repayment programs (Pipeline approach)  Willie Sutton approach to workforce development: focus on the work organizations (that’s where the workers are now and where they will be tomorrow).

Public Health Work-Doing System

What Should We Do with the Next $230 Million?  Pipeline Approach: scholarships and loan repayment programs  Willie Sutton: assess, enhance, recognize and reward ( i.e., manage)

It’s their way of thanking us for all we’ve done for them --- it’s called “tobacco”

Core Functions Still Relevant? It’s FALSE, Because…  Why else would we whine so much?

“That’s just great! I discover the cure for the common cold, and all you can do is criticize.”

When’s the Last Time You Heard Someone at a Public Health Conference Say…  The public health infrastructure is not crumbling  Public health workers are better prepared than ever  Accreditation and Credentialing are good things for public health practice  Those Essential Public Health Services really get my juices flowing

Reported change in selected LHD functions over the past three years as a result of efforts to improve emergency preparedness (N= 393)

Core Functions Still Relevant? Maybe TRUE?  Adapts to a dynamic agenda  Fosters systems, not silos  Provides the plan we lack  Serves as public health’s job description Maybe FALSE?  Not what they taught me  Hasn’t impacted funding  Assumptions often unfounded  We continue to whine

Some Days It Takes Hours to Get Dressed

Thanks, Now Its Your Turn..  Any Questions?  What Do You Think?

“I think you need to be more explicit here in Step 2”