How depressing life could have been for those at work in local government health departments during the past decade. One report after another described the desperate state of their future, 1 their workforce, 2 their skills, 3 their organizations, and their lack of achievements to improve the public's health. 4
Not that we haven't appreciated these laments on our behalf. After all, in western culture, with thousands of messages competing for attention at any moment, it is often at the point of crisis or emergency that we summon an astonishing will to change ourselves for the common good. As taught in our crisis management classes, we must seize these clouded moments for the silver lining they contain.
Many did seize the moment. Through the creative intellectual energies, skillful politics, thoughtful decision making, and new technologies of many visionaries in public health practice, foundation world, academia, community life, and the private sector, exciting opportunities have allowed adults to be exposed to new ideas and methodologies to improve the public's health. An astonishing array of programs, initiatives, and funding opportunities has come our way (and to others).
For the past 10 years, two eponymous foundations have funded initiatives whose goal has been to retool the public health workforce. Turning Point, their recent joint initiative, is only the latest example. 5 Support for the government public health infrastructure at the local and state level has been a long-standing mission of the W.K. Kellogg Foundation, which in its earliest years helped conceive, organize, and fund local health departments in Michigan as part of its founder's goal to "help people help themselves;" 6 and in the last decade, it introduced the Community-Based Public Health Initiative. 7,8 The Robert Wood Johnson Foundation, with a traditional focus on access to care, substance abuse, and chronic conditions, recently has reorganized to recognize the important distinction between population health and health care. 9
Others have been at work too. Staff at the Centers for Disease Control and Prevention; at Health Resources and Services Administration (HRSA) and other offices of the Department of Health and Human Services; at some state and local health departments; in academia; at community-based and other non-profit organizations; and individual community residents have provided financial, logistical, intellectual, and moral support to do business differently.
Many public health practitioners and the residents of their jurisdictions have been the beneficiaries of this nurturing stream. Those who have benefited now are beginning to provide a return on these investments by sharing what they have learned with others, helping them develop new methods of practice tailored for their own communities.
As evidenced by the preceding three articles, reports of disarray in public health's infrastructure appear to have been heeded. Processes for better practice are being elucidated and demonstrated. Examples of how a process can unfold in our nation's most urban and rural communities are shared, illustrating the creativity of local folks when appropriately stimulated and supported over time. A description of a process currently underway to define, operationalize, and evaluate a style of leadership theorized to produce better health outcomes and human processes gives insight to the current challenge of how best to share with others what one group believes is best practice. As Foege commented, "(l)ocal public health workers are problem solvers." 10(p.viii) We'll hope for more reports as these efforts mature so that both their successes and failures can help our own communities benefit from those experiences.
Although some call for increasing uniformity in the day-to-day practice of public health, life and resources at the grass roots level vary from place to place, making sameness difficult to achieve. While the universe of possible roles may be constant 11,12 and the "average" roles may be similar, standard deviation is large and, I believe, acceptable around the mean of each role.
Essential and unique roles for public and private health organizations are being recognized community by community. There is a distinction between government public health agencies and other participants in public health's infrastructure. When the day is done, still left for the public sector-even when many of the specific daily tasks necessary to ensure the public's health are done by others-is to assess whether they have been done competently and completely (and to determine the criteria by which these attributes will be judged); determine whether there are additional policy incentives necessary to have them done better or differently the next time; and whether those tasks not done, or not done well by the private sector, should be completed or replaced by public servants with the public's tax dollars. All of this to be done with the public in mind, not the public of bought participation that the market applauds, but the public of our humanity. Government public health agencies always should remain as principals. Agents work best, theory and personal experience inform us, when their task is specified clearly and when systems are in place to monitor their work, measuring precisely whether the product desired has been completed to specification.
Government public health agencies are part of a societal structure that periodically and spontaneously allows each person the opportunity to express his or her preferences equitably, albeit primitively, through vote and voice. Despite the proponents of the marketplace as the arbiter of public opinion, we are many generations away from a marketplace in which we all-regardless of wealth, race, or culture-can participate as equals and in which we have the perfect information necessary to ensure the efficient operation of the market. Anyway, it's always a good idea to have a back-up system in place just in case the primary system fails; or as in the case in the United States, splendid redundancy and counterforce with market, government, and the people dancing in perpetual and ascendant spiral towards societal improvement.
Partnership is essential in the dance of constructing the public's health and government public health agencies must be rhythmic to achieve this mission. In mature partnerships, each member preserves his or her identity instead of surrendering it; goals are developed mutually and not always without conflict; strengths, weaknesses, and resources of each partner are known collectively and not exploited; and partners change themselves upon self-reflection and in the mirrors of others. In the best partnerships, known as collaboratives, partners redistribute power in its many forms. 13 Deming 14 tells us to drive the fear out of our systems as a step to best practice. Familiarity and trust built through conversation and experience in a relationship over time can erode even the densest fears, thereby making us less threatening to ourselves and others and, even more important, willing to distribute what we have to others.
Not mentioned in the preceding articles, but hopefully ready to bloom beneath the surface of the written word, is recognition of the importance of social justice. The reintroduction of those we serve as equals, not as target populations, into the public, private, and academic processes of assessment, policy development, and assurance helps confront us with the reality that contributing mightily to our bad health outcomes are disparities in wealth, housing, environment, place, sense of self, and racial experience, not as abstract constructs but as real life experienced by real human beings. A small sprout of renewed appreciation for social justice as a precondition for better health, broadly defined, dormant among the political and intellectual majority of our nation, hopefully is being given light and water to grow in the fora stimulated by Turning Point and its descendants.
An appreciation for the destructive and pernicious effects of racism and other sociocultural attributes of our culture on the health of our nation finally is dawning. Undoing "isms" is a precondition to lasting change. Our collective inability to ensure beneficence, respect, and justice 15 threatens our individual and collective quest for life, liberty, and the pursuit of happiness, not to mention health.
These articles suggest in a small way that we are in a period of change in the practice of public health. Across the nation new ways of doing business are starting to take hold. The breezes of new ideas and methods of work are freshening sails of all boats presently afloat and exciting the minds of those in practice, academia, and community who are helping to build the next generation of craft and, hopefully, of those who will captain and crew them.
These articles suggest that there is a way to introduce new ideas and ways of practice across our society and that there are lessons being learned to make that introduction more efficient yet open to continuous improvement: in the structure or content of the process so that it benefits from the knowledge generated by both science and life experience; in the process itself so that it is respectful of the cultures and knowledge of people in communities; and finally in outcomes because along the way toward one goal, we often are made aware of other equally attractive or more productive destinations. We must be taught to take the time to decide, and learn the best processes for deciding, among them.
The articles in this section suggest that we are building pauses into our own lives and the lives of our communities and recognizing the wisdom of doing so. We will all benefit from these moments of reflection: on our paths chosen, on the methods we use, and the effect they have on ourselves, others, and on our lives together now and in the future. We'll hope that the next generation of public health leaders will look back upon this last decade as a watershed moment in the history of public health practice, when the seed of a majestic tree was set.
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