The challenges to public health in the field are complex. The challenges are at once social, economic, demographical, environmental, technological, and ethical. The only way to address the complexity of "healthiness" and improve overall health status, inclusive of narrowing the disparity gap, is with a broader thought process. This process is system thinking and having a regard for the impact of decisions today and down the road. The restraints and conditions that come along with traditional funding sources are most times antithetical to this approach.

Let me introduce Mary B.

My name is Mary B. These folks asked me to tell you a little about myself. I'm 53 years old. I live in Cheatham Place Public Housing. I've lived here all of my life. Right now, I have custody of my two grandsons. Their mama is in jail for selling and using crack cocaine. It was a burden to take them in, but what else could I do. We get food stamps, a small government check, and they are both on TennCare. That's sure a blessing. They have their own doctor and can even get a ride to the clinic. I tried to get TennCare, but they were just signing up children. I hear folks say women my age need all these tests done, but that just can't happen. I haven't had money to see a doctor in years. Besides that, it's better not to know if there's trouble coming. Like this lump I felt in my breast. Yes, it's better not to know. I've prayed about it, but it won't do me no good to worry. I've got too many other things to lose sleep over.

How accommodating are we to persons with special needs-and I suggest that Mary's story, although quite common, is a special needs case. To treat her and facilitate her movement to "healthiness" locally requires a manipulation of categorically funded resources. Mary's situation does not quite fit the tenets of any one category. And at the local level as many as 21 streams of funding are potentially available to address the needs, but does either category of funding cause the impact that is desired?

Each year dollars are increased for education, but can a teacher "teach" away the image of a family member being killed in front of a nine- or six-year-old's eyes? Can we "teach" away the impact of not being loved as a newborn child or hunger? Is more money "the answer" or does the answer lie in the need for making different choices, individually, politically, and as a community?

Here are some stories of "too" many of our children:

* Raphael, age 10, 4th grade: mother incarcerated; waited all day to talk to mentor, wanting only to tell her about seeing his sister being shot the night before; expelled at end of school year, due to a confrontation because someone said something about his mother

* Renaldo, age 11, 6th grade: mother killed at age 6; father lives in East Tennessee; 3 cousins in household

* Kenny, age 12, 4th grade: 1 of 6 children, father incarcerated

* Amanda, age 8: mother on disability; older brother, age 17, in jail; older sister, age 15, pregnant; all three children have separate dad

* Christopher, age 12, 5th grade: 1 of 6 children; father on disability; suspended 2 weeks in school for anger; all brothers expelled from school, 2 older/2 younger

* Keisha, age 6, 1st grade: dad incarcerated; 5 siblings; older teenage sister has a baby

* Thomas, Kindergarten: crack baby; kicked out of school for attacking teacher

* Courtney, age 5, Kindergarten: mother incarcerated; aunt raising 7 children, none are hers

* Decinda, age 9, 4th grade: failing all classes; non-dad; several siblings-some same age

* Reggie, age 9, 4th grade: oldest of 4 kids; father killed before he was born

Whether 20 kids or 1,000, the apparent themes of these stories as told by the department's "Lunch Bunch" mentors are: incarceration, handicaps, violence, truancy, suspension, mixed families, failure, needing and/or wanting attention, lack of tools, adult indifference, low self-esteem, and anger. Which category of funding addresses these situations? Whose problem is it? Are we missing the opportunity to ensure that these kids and many like them will grow into adulthood healthy and able to lead responsible lives?

Let's look at the flow of dollars to local communities, the 21 directions resulting in the fragmentation with no guarantee of the desired result (this is the story of a pregnant female with children and a husband who is addicted to drugs). Figures 1-7 illustrate the flow of dollars from federal to state to local governments.

FIGURE 1. Set-up of a resource flow.

FIGURE 2. Resource flow of Health Care Financing Administration (now named the Centers for Medicare and Medicaid Services).

FIGURE 3. Resource flow of the Health Resources and Services Administration.

FIGURE 4. Resource Flow for the Centers for Disease Control and Prevention.

FIGURE 5. Resource flow of the Substance Abuse and Mental Health Administration.

FIGURE 6. Resource flow of the Office of Public Health and Science.

FIGURE 7. Resource flow of state funds.

FIGURE 8. Resource flows of all agencies and programs.

One of the major "system disabilities" stemming from national policy is categorical funding that interferes with comprehensive and coordinated strategies that respond to cross-cutting risks. Mary's issues are cross-cutting and requires the thinking to be different.

In cities, there typically are high concentrations of persons with characteristics that serve as barriers to receiving ongoing care from the same provider-a key factor in one's health status. These characteristics include: low income, less than a high school education, limited or no access to subsidized health insurance through employment, a language, ethical, and cultural background that is different from the majority population, living in one-parent families, living in a community with high crime rates, living in a community with substandard housing, living in a community with high rates of alcohol and substance abuse, and living with complexing issues. We should be reminded that policy plays out in the neighborhoods where Mary, Keisha, Decinda, and others live.

There will never be enough money!!!!!! So, it is prudent that we ensure dollars get spent for the right reason and further, for its ultimate impact!! It is the result that matters, and unless we always keep this in mind and are earnest in our deliberations, the "how" is irrelevant. As illustrated, however, implementation that is dependent on categorical funding cannot be easily or effectively shaped to meet the needs of the people we serve.

Neither the public health system nor the constituency type system are inherently of greater social value than the other, but in the course of developing the personal encounter system to its present high point of technologic effectiveness for the individual, we have failed to mount a comparable effort for the nourishment of the other system responsible for the medical welfare of every member of the group. Without such a healthy watchdog, we have allowed the personal encounter system to become unevenly distributed throughout our population and that the correction of this imbalance is the critical challenge facing medicine today. The imbalance of the two systems affects our efforts for the beneficial uses of science not only at the level of medical care for the community and the constituency, but in those even larger health matters that have to do with how the developing individual can be aided in his or her continuous interaction with the environment.1

A system is built over time, and each decision we make now influences that system. Without proper balance and without all the parts, Mary loses and a community loses. There will never be enough money!! So, the sooner we accept this, the sooner we can be more creative regarding the dollars we have. And-partnering becomes more significant as we realize that it is all ours to do and not just government/private business alone. And-courage evolves to stop spending on what is not working.

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