An Evening with APHA Past Presidents & Executive Directors
An Edited Transcript from November 10, 1997
Moderated by Barry S. Levy, M.D., M.P.H., APHA President, 1997 & Carol Easley Allen, Ph.D., R.N., APHA Executive Board Chairperson, 1997
Barry S. Levy M.D., M.P.H., and Carol Easley Allen, Ph.D, R.N.
With this being the 125th Annual Meeting of the American Public Health Association, we scheduled this special session tonight and invited all living Past Presidents and Executive Directors of APHA to participate.
Our topics this evening are supporting health promotion and prevention, improving access to health care, promoting social justice at home and abroad, and supporting the public health infrastructure.
SUPPORTING HEALTH PROMOTION AND PREVENTION
Myron E. Wegman, M.D., M.P.H,
APHA President, 1972
Health promotion is much more ancient than some of us realize. When I left my medical school faculty position to go to work at the Pan American Health Organization and the World Health Organization, I was given by a colleague Galen=s Textbook of Preventive Medicine and Hygiene, which was published in 200 A.D. This remarkable book includes many kinds of associations working in health promotion. Specifically, he did a great job of writing about care of children, such as what could be done for 7- to 14-year-olds — much of it still true today.
In 1972, APHA resolved that we were going to start our second 100 years by combining science and activism — by providing a scientific basis for everything for which APHA stood. Today, however, we lack a sufficient scientific basis for our recommendations on health promotion and disease prevention. We are better on disease prevention — certainly on vaccination — than we are on advice on diet, behavior, exercise, and all the other things that so frequently are carried out. Our friends complain bitterly that we are on a yo-yo: One year it=s right to do this, the next year it is wrong to do that. I believe that APHA needs to provide the scientific bases for the specific advice that we give.
E. Frank Ellis, M.D., M.P.H,
APHA President, 1978
A major impact on the entire health care system was made by former Secretary of Health, Education, and Welfare Joseph A. Califano,Jr., when he asked the health community what is the level of immunization of our children in America. No one could tell him. That threw us into a managerial process looking at the entire health care delivery system in order to look at outcomes, and we continue in that same mode.
I remember that one of my mentors, Dr. Paul Cornely (the first African-American APHA President), once said to me, “Go into that room and pull together a group of African-Americans to talk about health care.” Eight people showed up. That was the beginning of the Black Caucus of Health Workers of APHA. That caucus set the prototype for all the other caucuses that followed. It also brought to the table those individuals who had a decision-making role in looking at the future of the health care system.
Today, we see that the future is very clear, that we have excellent individuals to support the system of health in order to be able to have APHA at the very top, guiding America and its 260 million people.
Myron Allukian, Jr., D.D.S., M.P.H.
APHA President, 1990
It is nice to be here in Indianapolis, a community that has been fluoridated since 1951, and in Indiana, which is fifth in the country in the percentage of people on public water supplies that are fluoridated – 96 percent of the public water supplies here in Indiana are fluoridated.
When I think of prevention, I’m reminded that Redd Foxx used to say, “The last thing I would want to do in my life is to be lying in the hospital bed dying of nothing.” If we can prevent premature death, disease, and disability, using all of the preventive measures that we know we have, we could make quite a great impact.
During my presidential year, we started working on a sense-of-the-Congress resolution. In developing that resolution, the Executive Board went from a foggy idea of what we wanted in a national health program to articulating community-based prevention. Since that time, APHA has built on that as have many of the federal agencies. Community-based prevention is where we are most effective as public health workers – whether we are dealing with policy or prevention.
It is very bothersome to me that we spend more money than any other country and we do not have a national prevention program. We do not have a national health education program in all our schools for children from kindergarten to the 12th grade. Our kids are not able to make healthy choices. In 1979, Dr. Julius Richmond, then Surgeon General, promulgated the Healthy People document for the 1990 national health objectives. Before that, we had a meeting at the Institute of Medicine with Dr. Michael McGinnis and Dr. Richmond to try and shake out these concepts. APHA was deeply involved in the beginning and, during my presidential year, the Annual Meeting theme was The Year 2000 National Prevention Objectives for the Nation. We have to make prevention a national priority again.
We are in Indiana, so I will quote Vice-President Dan Quayle, who is from Indiana: “If we don’t succeed, we will fail.” We, as an association, must provide leadership so that the 25 percent of our population, who are children, are really 100 percent of the future.
Joyce C. Lashof, M.D.,
APHA President, 1992
When I went to school, we talked about primary, secondary, and tertiary prevention. I think we have made a new advance when we now talk about preventive services, clinical services, and community-based prevention, as well as policy for public health prevention and health promotion. I would like to put the emphasis on the policy aspects, because we have tremendous policy tools and we have been learning to use them in legislation and regulatory measures. We have done nutrition labeling. In tobacco, we have used litigation as an important tool. And we have used a great deal of local initiative and regulatory policy to move us along.
During my presidential year, Healthy People 2000 was high on the agenda and we tried to look at the objectives and tried to ask, “Will we meet those objectives for the year 2000?” It was clear that the overriding factor that was present then is even more present now. What keeps us from moving ahead are poverty and social inequality. As long as there are poverty and social inequality we are not going to meet those objectives. When we challenge the U.S. Public Health Service for why it did not list the abolition of poverty as an important factor in reaching the healthy goals, it said, “We knew poverty was the major factor, but the Public Health Service can’t do anything about that, so we didn’t want to put that as a goal.” I submit that’s a cop-out. We need to fight that issue. Good luck to all of you. Carry on the good fight. We’ll be with you.
Managed care, as we know, has not fulfilled its potential for providing health promotion interventions to the American people. What can we do to change this?
Dr. Helen Rodriguez-Trias
Public health is really in a very good position to make the point that in order to make health care in the managed-care modality or any other modality, prevention has to be built in. Moreover, in order to really be effective, there has to be increased coverage of the population and to have population-based outcomes. So my firm belief – and we see some glimmers of it already – is that, if public health presents its position very strongly, it will make the case for the need of incorporating public health principles and practices to guide managed care to make it more effective.
Dr. Victor Sidel
If managed care had as its main purpose the maintenance and improvement of the health of people and communities, managed care might indeed be induced to invest in prevention. But managed care is largely about reducing costs and making profits in medical care, even in the non-profit sector. Therefore, until we change the very nature of what is called “managed care,” prevention will not be able to make any important inroads into this misnamed element of the U.S. medical care system.
Dr. Richard Brown
We can make some very strong inroads into managed care and force it into a mode in which it is active on behalf of population –based health and prevention of disease. Two examples. Minnesota has had the wisdom to pass two laws that are critical to making managed care serve the needs of people much better than managed care does in most of the rest of the country. One law prohibits any for-profit health plan from operating in Minnesota. So all of the plans in Minnesota are non-profit plans and most are based in Minnesota. The second law requires all health plans, including managed care plans, to develop collaborative-action plans with local health departments and community-based agencies to undertake activities that promote the health of the population and target specific health problems and risk factors in the community. Together, these two laws and their effective enforcement have actually brought about some significant changes and some significant prevention activity in Minnesota.
Dr. Myron Wegman
As a victim of the managed care program in Ann Arbor, Michigan, I have strong feeling about the supposed attention to prevention. I regularly receive health promotion pamphlets with lots of general advice. What disturbs me most is that, in my managed care program and in general, none of them have looked at individualizing prevention.
Dr. Eugene Feingold
Managed care is only concerned about managing the care or providing prevention for the “covered lives.” We still have in this country 40 million people who are “uncovered lives.”
IMPROVING ACCESS TO HEALTH CARE
Ruth Roemer, J.D.
APHA President, 1987
When the Executive Board met in 1987 at the beginning of the Annual Meeting, the stock market crash occurred. I remember thinking, “The net worth of APHA is going to go down. How are we ever going to manage?” Well, we managed, and now we are going to have a building of our own and no more worries of that kind. So this marks a very happy anniversary in that sense for me.
In 1987, when I had the most rewarding experience of my life serving as president of APHA, there were 37 million totally uninsured in the United States and many more with inadequate coverage. In the decade since then, the number of people who are totally unprotected against the cost of illness has risen to 41 million – not counting those with inadequate coverage. In my meetings with state affiliates around the country, it was very exciting to meet public health workers on the front lines and I talked at that time about what was one of the best kept secrets, the Canadian health insurance system with its one-tiered system of care covering the total population – despite my obvious bias. My mentor (and husband), Dr. Milton Roemer, urged that the United States replicate the Canadian strategy: The provinces of Saskatchewan first passed hospital insurance and then medical care insurance. Other provinces followed suit. And, finally, a national system covering the total population of Canada was established. All this is much more widely known today than it was then.
A similar state-by-state approach in the United States, however, has not been possible because of the barrier of ERISA, the Employment Retirement Income Security Act of 1974, which preempts state action related to employee benefits provided by self-insured plans. Today the growth of managed care has opened a window of opportunity to amend ERISA. Because ERISA has been interpreted as blocking state regulation of self-insured plans and even lawsuits against the plans for malpractice, federal and state legislative proposals to hold managed-care organizations accountable for the quality of care that they provide include some bills that propose amending ERISA to take account of the changing system of financing and organizing health care through managed-care organizations.
In the current climate of shifting responsibility for health and welfare to the states, a new day is dawning as the federal and state governments are expanding health insurance coverage for children who are poor. This is the most significant advance since the enactment of Medicaid. This success compels one to urge that in the next decade we should emulate Canada’s strategy by moving towards universal coverage through action on a state-by-state basis. Since South Africa is currently in the process of enacting a national health insurance system, we could thus overcome our lone shame of being the only industrialized country without a universal financing mechanism for health care. I hope that APHA will be able to take the lead in this strategy in the coming years.
E. Richard Brown, Ph.D.
APHA President, 1996
APHA has long played the leadership role in efforts to get health care access for the entire U.S. population. Universal coverage is a beginning, but there are many other aspects of people’s coverage and their ability to get health care that provide for access.
When I first joined APHA in 1975, it was very involved in struggles to get national health insurance or a national health service in this country. I was very impressed with that struggle and participated in it, and learned much in the process. When Ruth Roemer was president in 1987, she appointed me as Action Board chair. The struggle for national health insurance was then one of the major thrusts of APHA. In 1993, when Helen Rodriguez-Trias was president I was working in the White House on national health insurance and national health care reform. There were many of us who were APHA members who were working in the White House on that effort and a number of us who had formed a single-payer group within the Health Care Reform Task Force. That, of course, failed.
I am very happy to report that this year, under APHA’s leadership, again, we have enacted the first significant expansion of government-subsidized health insurance coverage in the United States in more than 30 years, providing $24 million over the next 5 years to help cover up to 5 million children. That is only the beginning. It is only a first step. It is undoubtedly policy that will be pushed forward by the future APHA leaders.
Eugene Feingold, Ph.D.
APHA President, 1994
Dan Beauchamp has said, “Public health is ultimately and essentially an ethical enterprise committed to the notion that all persons are entitled to protection against the hazards of the world and to the minimization of death and disability in society.” That’s clearly what this segment of this session is about.
The problem we face is that achieving universal access really requires governmental action. It is not something that can be done privately. At the same time, our society, particularly in recent years, but more generally does not place a very high value on government action. That makes life particularly difficult for those people who are less successful in making their way through life privately.
How we can get around this is the dilemma that I have been struggling with, and I think many people in APHA have been struggling with, and I think we really have to overcome. The less that government does for people, the less reason people have to have faith in government. And therefore the less likely they are to support government action, and the less likely we are to get government action that will give them more faith in government.
We have to find a way to reinspire public trust in government action to try and achieve the goals we want to achieve.
Bailus Walker, Jr., Ph.D., M.P.H.
APHA President, 1988
Failure to achieve universal access to care is a terrible indictment of the public health profession. All of us who have served in the role of leadership ought to be indicted because we have failed in our efforts to achieve universal access.
We must address poverty. If we do not address it, then 125 years from today someone will be standing here saying that we have 41 million people who are not insured.
I hope that we do not lose sight of Barry Levy’s address this morning. The 10 points that he laid out represent a clear roadmap for us to achieve universal access and improvement of health for all the people in this country.
Anthony Robbins, M.D., M.P.A.
APHA President, 1983
I want to talk about some opportunities. APHA is at its best when it seizes opportunities. I want to mention two such opportunities. The first of these may suggest some major chinks in the movement towards for-profit managed care. Kaiser Permanente, the Health Insurance Plan (HIP) of New York, Group Health of Puget Sound, Families USA, and the American Association of Retired Persons (AARP) have gotten together and requested governmental intervention for the protection of consumers in the medical care system. The news isn’t that they have asked for it; the news is that both the non-profits and consumers are at such risk in where we are going that there may be an opportunity for those of us who believe in doing something better – a single-payer universal system.
An even bigger opportunity, however, because I do not think there is any question that medical care is going to get more and more organized. People who were totally out of the system bought into it. And government is going to be asked to do that eventually. We in public health have always wanted to be in touch with everyone in the population, to be able to do proper and complete disease surveillance, and to be able to respond with the proper care and attention to individuals who are exposed to hazards in their community. Neither in Canada nor in Europe have we seen national or provincial health systems used for public health.
So the history is going to be made in this country when the public health movement recognizes that universal care systems are the way we can have eyes and hands that do the whole job of public health surveillance.
Quentin D. Young, M.D., M.S.
APHA President-Elect, 1997, and APHA President, 1998
First, a comment on incrementalism. We should not refuse small gains, but we should recognize the perils of incrementalism. There is a great crisis in the health care system – a moral crisis, an ethical crisis of tremendous profundity. It’s destroying as it is going forward. I would argue that the national conscience is out there. Whether we like it or not, whatever strengths we had – and we have a lot, we’re really not the giants who will do this so we are going to have to grow fast. I profoundly believe in recapturing the ethical essence, which is embodied in public health practice and in science, of altruism, of dedication, of public service. These ideals are not common in our society, let alone our health system. These are our strengths. But we have an enormous task to challenge to get to centerstage, given the powerful economic and political forces. But it’s a battle we’re forced into. We have no choice. I am very confident we can win because of the superiority of our position.
We have seen several examples in other states of incremental approaches to providing universal access to health care. Is incrementalism the answer or should we look to some other model?
Dr. Joyce Lashof
I have been fighting for universal health insurance since 1948. In the 1970s, when I was health officer in Illinois, we were holding forums around the state on national health insurance. Of course, we weren’t lobbying; we were providing information and education on the need for national health insurance. We were arguing incrementalism and saying that that was not the way to go. It would take the pressure off and move the people with the least voice out of the picture, and therefore that doesn’t work. But I have to admit at a symposium that we were having on the topic, I said that up until then I had opposed incrementalism, but I would take anything that we could get – I’ll take the incremental way if that’s the way to get there.
Dr. Eugene Feingold
I share some of Dr. Lashof’s feelings. My concern about incrementalism is that it isn’t necessarily, or most likely, a way to get to our final destination of universal health care more slowly. It is a way of changing the destination. I think we have to be very careful about that. At the same time, I welcome the child health initiative, recognizing its limitations. It’s certainly a step forward.
Dr. Richard Brown
Like Dr. Feingold, I feel that incrementalism can be a diversion from our goal. I think incrementalism or, on the other hand, a strategy that says that either we get coverage for the entire population under the ideal system that we would like to see in place or we will accept nothing are strategies for defeat. I think there are strategies that allow us to see our goal and then to put in place the building blocks to reach it. Incrementalism involves building a foundation to take us on the road to where we want to go is not an incrementalistic strategy that diverts us, but helps us to get there.
Dr. Helen Rodriguez-Trias
We in public health are not prepared to advance what needs to be done, like the relationship between public health services and private managed care plans, which now serve so many populations that were formerly being served by public health. The physicians aren’t there. The research hasn’t been done. The data have not been provided. We have not been ready. Admittedly, this is a runaway train in many ways. We have to be part of what has happened because we have not been directing these market forces. They are happening and they are going to happen, with or without us. We have to be there to defend the rights of the people whom we are committed to serve. We have to be there to point out what effect managed care is having on the uninsured, whose numbers have increased in California in the past 3 years since managed care took off. We need to build in the tools of accountability and participation in planning and quality control by the people who are users of these programs.
SOCIAL JUSTICE AT HOME AND ABROAD
Helen Rodriguez-Trias, M.D.
APHA President, 1993
When Joyce Lashof was APHA president in 1992, she developed America’s Public Health Report Card. This brilliant report enabled public health workers and the public to look at the social and economic determinants of health. She did many interviews with the media to disseminate this information all over the country.
This work needs to be continued. I know that many of you are working on the scientific basis of this, looking at the effects of poverty and other inequities on health. But how do we make the political connections? How do we translate this knowledge and this understanding of these correlations into action that is going to move us toward a more equitable society?
I am pleased that I no longer hear questions that I heard some years ago at APHA: What is this association about? Why are we having resolutions on child poverty? Why are we having resolutions on immigrants? Why are we having resolutions concerning many marginalized populations? Some people said that we should really be talking about the science of public health. I don’t hear that dichotomy any more. I think we have become a very united organization that is very secure in the belief that resolving social and economic inequities is necessary in promoting the health of the public. I am very proud that I have seen that transition. How do we implement it? How do we make it happen in the political arena? These are good questions for all of us.
Victor W. Sidel, M.D.
APHA President, 1985
Worldwide, there are an estimated 1.3 billion people who live in absolute poverty – one-fifth of the human population. In the United States, sociologist Ruth Sidel teaches that, despite gains that Bill Clinton has boasted about for the past year, the gap between the richest and the poorest people in our society has grown even wider. In the United States today, half of all black children live in poverty. So long as these and other disparities continue, there cannot be an adequate level of health for all our people.
As Bill Foege has repeatedly said, “Public health is social justice.” Unless we keep our eyes on that prize, we cannot succeed as health workers. Each day as I drive to my office in the Bronx, I pass the Bronx County Courthouse, which was built in 1935 during the administration of Franklin Roosevelt. On that building a frieze states, “Government is a contrivance of human wisdom to provide for human wants. Men have a right that those wants should be provided for by this wisdom.” That was a time when it was clear that the vast gaps in our society were not due to laziness or to evil in individual people, but were due to our economic system. Attacks on governments that seek social justice protect that system and are anti-health.
In the world today, vast gaps in income and in life chances are increasingly due to a work economic system that includes globalization, structural adjustment, and the transfer of wealth from poor nations to rich nations. These are all changes that individual people can’t control. Therefore, to move forward with social justice, we are going to have to work to convince people that such changes must be societal. In the United States, we pay among the lowest rates of taxes of any industrialized country, and the United States spends the lowest percentage of gross domestic product on economic development aid for poor countries. We cannot live that way in a world seeking health and social justice. If we do continue in our present course, we will not achieve any of the public health goals we are discussing here.
Lester Breslow, M.D., M.P.H.
APHA President, 1969
Public health, in the modern sense, began in the struggle for social justice. That was in the early days of the Industrial Revolution, when people flocked in from the farm lands to work in the factories under overcrowded conditions and in overcrowded homes with grossly inadequate sanitation, with child labor, with all of the things that we know that gave rise to the health problems of that day: tuberculosis and other infectious diseases. We have made much progress. We have overcome many of those conditions, not completely even yet. But we have made big progress in them and we have seen as a concomitant the improvement of health.
If we look at the modern situation, as Vic just pointed out, the social disparities in our country are increasing. The rich are getting richer and the poor are getting poorer. The health conditions in our inner cities particularly are giving rise to the modern epidemics. Those epidemics, such as coronary heart disease, started among the more affluent people in society
because they had enough resources to buy the fatty foods and to begin smoking cigarettes and to have a life of relative physical ease.
Now they have learned how to overcome those adverse health practices as we understand them. The people in the inner cities, however, have acquired just enough affluence to become vulnerable to our commercialized society, in which cigarettes, alcohol, and guns are pushed upon them.
In order to overcome that fundamental condition, which is increasing the chronic disease epidemics in the inner cities today, we must begin to attack that fundamental problem and overcome the social disparities. We need to give those folks in the inner cities the same conditions that those in the suburbs have now begun to obtain and thereby to overcome the epidemics.
So we really must join in the struggle for social justice in our modern day. We have not yet seen the vigorous and nonpolitical approach to that fundamental social problem. We, in the public health movement, have a great responsibility to point out the specific connection between the modern epidemics and life in the inner cities, and to develop the social justice movement of our day.
June Jackson Christmas, M.D.
APHA President, 1980
When I became president, California was in a leadership role. Proposition 13, a tax-cutting effort, resulted in that mentality that was supposedly fiscal austerity, but was really philosophical conservatism – all of the cuts and diminution in services of Reaganomics. Here we are a number of years later. California is in a leadership position again, with Proposition 209 that would dismantle Affirmative Action. I know that we felt then that the activism of APHA ought to be in preserving services and preserving the infrastructure of health, and then pushing for services for people who need them then.
I remember that, in presenting the APHA Presidential Citation to Rosa Parks, I said that her activism was a model for us, because it was a catalyst for changes that improved the health status of not only black Americans, but all Americans, and the social ethic as well.
We, as public health workers, have to look not only at poverty — terrible as it is and pervasive as it is, but we also need to look at the intersection between poverty and racism, and how it limits access to good housing and leads to toxic waste products in black and brown neighborhoods throughout the country. We know who lives in the most debilitated and deteriorated housing. We also know that the infants of black women tend to have a higher rate of low birthweight. We need to understand how social, biological, socioeconomic, and political factors interact in causing these problems.
I hope that, as members of APHA and affiliates, we can move forward beyond what President Clinton has called a dialogue on race. We must look at how inequities and racism interact with poverty if we are going to improve the health of the public.
William H. Foege, M.D., M.P.H.
APHA President, 1986
We are born into a world that is not fair. It is not built even, but we want to leave it more so. How can we focus on the practice of social justice? Four suggestions:
1. By concentrating on standard deviations instead of averages: It is possible to improve the average income in this country by simply increasing the wealth of Bill Gates. That doesn’t improve the standard deviation.
2. By being a voice for health in the rest of the world: But we fail to do so when we don’t pay our bills to WHO, when we fall short of other advanced countries in foreign aid, when we continue to export arms, and when we decide in favor of land mines.
3. By keeping a clear and ultimate goal in mind in global social justice: To settle for nothing less than actually closing the gap in health between the developing world and the United States.
4. By consciously being a collective force, joining with all public health people geographically and across time: In his rookie year with the Chicago Bulls, Stacey King had a very bad night where he made only 1 point, the same night Michael Jordan made 69. And King was asked to comment on his performance, and he said, “I’ll always remember this as the night I teamed up with Michael Jordan for 70 points.” We can look back from the future and say we each could do so little, but it was the time we teamed up to make social justice work.
Finally, as I told students recently, the era of Abraham Lincoln seems remote to them. But my grandfather lived at the same time as Abraham Lincoln. It seems much more recent to me. Lincoln has left no DNA in this world. He has no descendants still living. But he has left the equivalent. Indeed he has left something better — in the legacy of social justice. He has left his social DNA. And that is how we will individually, and as an association, achieve our immortality.
SUPPORTING THE PUBLIC HEALTH INFRASTRUCTURE
C. William Keck, M.D., M.P.H,
APHA President, 1991
An important element of APHA activity, which has largely been hidden from view over the years, has been the impact that APHA has had on services delivered at the local level, particularly in local health departments. At the same time, APHA has been very active in trying to educate Congress about global public health issues. APHA has arranged hearings in front of Senate and House committees, dealing with such things as the re-emergence of tuberculosis and other infectious diseases and the emergence of new diseases. It is very important to help members of Congress understand what public health is and how the profession responds to emergencies. APHA brought the medical community into the early, very emotional, debate about HIV and helped to transform that debate into one that produced policies that, by and large, made some sense.
I think that many of us don’t realize how much APHA did to support funding for activities of local health departments. A categorical program can sometimes get a bad name, but in many ways it is APHA that allowed the Reagan block-grant proposals in the early 1980s to succeed and continue. It was APHA that eventually succeeded in requiring mandated reporting of results of those block-grant expenditures to the degree that it was increasingly difficult for Congress to stop them B- which is what we thought the intent of that approach was at the beginning. Dr. Tony Robbins, who served as APHA President in 1980, had a great deal to do with model standards. He managed to get Congress to implement model standards through CDC and to require that APHA be involved in their development, an effort that has been very important for APHA and local health departments.
The effort that we put into public health issues in the Clinton health plan, though not successful, created a national stage on which public health importance was at least recognized in some areas. And I think it set the stage for doing what we might now try to think about doing next.
It has been encouraging to meet and hear our new Executive Director (Dr. Mohammad Akhter) and Executive Board describe their interests in dealing with local health issues and we certainly are going to need to do a great deal to build the capacity of our local health departments back up to a reasonable level. And I am encouraged that we might expect to see APHA continue to make some impacts in that regard.
Susan S. Addiss, M.P.H., M.U.R.S.
APHA President, 1984
When I was president in 1984, President Reagan had started the process of eviscerating federal data systems. I think it is appropriate that, in talking about infrastructure, I focus on data again 13 years later, because I think we have just as serious problems with data now, although I think they are somewhat different.
Data represent one of the most important parts of the infrastructure of public health and of all our activities. Information is power and we need good information in order to exercise power for the public weal. We have always used data for what we now call assessment, policy development, and assurance. We have always in the past faced issues of validity, comparability, and, particularly, timeliness, but not so much issues of confidentiality; data that went through local health departments was known to be confidential.
Now we face serious issues relating to confidentiality and privacy as technology changes the kinds of both personal and population-based databases that we use in our work and to which others have access. For example, there are potential uses to which genetic testing could be taken if we are not very careful to make sure that confidentiality and privacy are preserved. I am also concerned about what I see partly in the census, but also in other places, as a blurring of race and class. I don’t think that we have ever adequately separated those and the effects that they cause and their role in the etiology of disease. I think now, with some of the changes that are being made or proposed to be made in the census, that we are going to have more trouble separating race and class than ever before.
We all need to continue to monitor what is happening with data systems and to speak out to improve these systems, protect our confidentiality, and fight for data systems that will maintain their usefulness to us as we go about our work of protecting the public’s health.
Milton Terris, M.D., M.P.H.
APHA President, 1967
I think it is time for APHA to stop being a reactive organization – that is, one that reacts to everybody else’s proposals. I think APHA should become proactive. We should go to the Congress and to the state legislatures to fight for an expanding role of the local, state, and national health departments.
I think it is the duty of APHA to resurrect the health objectives act, which was discussed in the Congress several years ago, and that we take the initiative and that we approach ASTHO, NACCHO, and all the allies that we can get to fight for the health objectives act that will provide local, state, and national government with the money, the wherewithal, and the resources to meet the health objectives.
Iris R. Shannon, PhD., R.N.
APHA President, 1989
Recently, infrastructure has been characterized as the nerve center of public health. For a variety of reasons, I believe that the problems associated with public health infrastructure are recalcitrant. Infrastructure issues have been persistent a long time and they seem to be resistant to change.
I would like to comment on only two of many factors contributing to this resistant state:
1. Human resource component: There is a significant need to strengthen public health teams by adding members with appropriate social-service and political-science expertise. Such skills are needed to confront the increasing numbers of recognizable health consequences associated with social problems and the need for effective communication with policy leaders.
2. Organizational resources: There is increasing interest in formulating partnerships for health and in other formal and informal collaborative arrangements, whether they be networks, coalitions, task forces, or committees. They usually involve the public and private sectors and provide ways of sharing responsibility and accountability for improving community health outcomes. A particular public health infrastructure challenge occurs where conflicting and competing interests among population groups emerge and that must be resolved. Whether collaborative effort results in societal support for public health greatly depends on successful resolution of issues and successful interorganizational dynamics.
I believe very firmly, with APHA’s emphasis on infrastructure, that we will be able to reverse this situation – that we will be able to make an impact, a very positive impact on infrastructure issues. I leave it to the leaders of the Association to bring forth the direction necessary to make it happen.
John H. Romani, Ph.D.
APHA President, 1979
When one talks about the infrastructure for public health, we need to think about three different issues that we face as an association and as a nation. As Dr. Keck mentioned, we talk about a public health system that is very diverse and includes 3,000 local health departments – some of which consist of one person, and others of which are large-scale, well-organized departments. We need to think about the nature of that system and the way it must be reorganized if it is do the kinds of tasks that the Association has set forth in the priorities of its strategic plan. I am convinced that we need larger bases for local public health departments to function, so that they can bring together the kinds of resources and personnel to deal with the kinds of health problems that we confront in our society today.
That poses a dilemma for us. At the same time, we need to create in those organizations a capacity to be more responsive to the pecularities and the particularities of the needs of their communities. With large-scale organizations, this is sometimes not as easy to do, but it is something that we have to do if we are going to achieve our purposes.
Finally, following up on what Dr. Terris said about APHA being proactive, if we are to really reconstruct and try to create a different and more responsive and more effective infrastructure for public health, we need to think about standards, and, specifically, to what kinds of performance standards we want those agencies and those parts of the public health system to adhere. This may raise questions about accreditation or certification for public health agencies, with which the American Public Health Association has been concerned in its past. Here public health, particularly APHA, might be able to take a leadership role in partnership with ASTHO, NACCHO, and many of the other organizations.
Presentations of Three Former APHA Executive Directors
James R. Kimmey, M.D., M.P.H.
APHA Executive Director, 1969-1973
I come from the rural area of Wisconsin. There is a story about a Wisconsin farmer who was off working in his field when a traveling salesman came along who sold farming encyclopedias. So the salesman pulled his car over to the side of the road and hailed the farmer off his tractor and gave him a sales pitch about this encyclopedia. It was going to make him farm better. It was going to make his crop yields better. He wouldn’t have to work nearly as hard. And on and on and on. The salesman gave the farmer his best pitch. When he finished, he asked the farmer, “Will you take it?” The farmer said, “Nope.” The salesman asked, “What do you mean?” And the farmer said, “Son, I ain’t farmin’ half as good now as I know how to.”
Now think about that in the context of this discussion tonight. We have a lot of good ideas. And I would associate myself with Milt Terris’s remarks. I now am administrator of a large university hospital. Every year, like clockwork, I give my contributions to the Missouri and American Hospital Association political action committees. And they get things done.
The problem with APHA is not the dearth of ideas. It is not the quality of the people who represent us in Washington and elsewhere. It is that we don’t want to pay, and paying is how to get things done – as unfortunate as that might be our perspective in America. We are a special interest group, but we act as if science is enough. And science is not enough in our political system today. This association needs to be as aggressive financially as those who oppose us or we will never succeed in the wonderful goals we have discussed tonight.
Fernando M. Trevino, Ph.D., M.P.H.
APHA Executive Director, 1993-1997
It’s a great privilege for me to serve this organization, of which I’ve been a member for 24 years. The tenacity and loyalty of the membership of APHA has always struck me. The vast numbers of members who have been with us for 40 or 50 years and beyond speaks to the very powerful tenacity of APHA.
During the 4 years that I’ve been Executive Director, we have done a variety of things. We tried to help members communicate with one another in a timely fashion by getting APHA on the Internet. We tried to continue to increase the number of affiliates that are a part of, and work with, APHA. We started the Student Caucus to try to welcome those people who are going to be the members over the next 125 years. We started to try to reach out to other organizations and increase our constituencies, networks, and affiliated groups.
Five months after I began as Executive Director, we had the first meeting of APHA and the American Medical Association, an organization with which we’ve had differences over time. It was the first time in 121 years of coexistence that we sat down on equal footing to talk to each other. That meeting resulted in a very good dialogue and formation of the Medicine and Health Initiative, which now consists of many major professional associations and federal agencies to explore how medicine and public health can work together for the common good of this country. In 1996, APHA and the AMA co-sponsored the first National Congress on Medicine and Public Health, which was attended by 400 of the top leaders of America=s health system. Subsequently, the Robert Wood Johnson Foundation funded the New York Academy of Medicine to put together a monograph that could continue that dialogue. We and the AMA agreed to distribute a copy of the monograph to every identifiable primary care physician and every public health worker in this country. The monograph will be coming out shortly. And now the Robert Johnson Foundation has funded the American Public Health Association to continue that dialogue in four ways.
William H. MacBeath, M.D., M.P.H.
APHA Executive Director, 1973-1993
Not long ago, I was standing on a grassy knoll under a tree in the Lakeview Cemetery in Skaneateles, New York, and by me was a tombstone that had inscribed on it: “Stephen Smith, 1823-1922, A Loving Physician, Author, Humanitarian.” I thought a lot about Dr. Stephen Smith, who was the first president of APHA, as I prepared for this evening, and I also thought about other APHA past presidents, who have been a distinguished array of persons of broad perspective and range of interests, not unlike Stephen Smith.
One can see how the ontogeny (growth and development) of his professional career recapitulates the phylogeny (evolutionary history) of APHA, as reflected in tonight’s program. He was exemplary in almost every area of public health that=s been mentioned tonight. He had a very clean code of personal hygiene that was part of health promotion that helped him to live just a few months short of 100 years. He was committed to medical care during the time of the Civil War as a distinguished Bellevue Hospital health officer and Civil War surgeon, and later as a hospital director. In his career as a surgeon, the story is well known how he saw the cause of the typhus epidemic that he was dealing with at Bellevue as the environment in the tenements of New York City. It led him to government. It led him to the infrastructure. It led him to be concerned about the people. He wrote the first sanitary code of New York City. He was Health Commissioner in New York City and Commissioner of Charities of New York State. He was an advocate and first member of the National Medical Board. He in so many ways exemplified the concerns and interests of the past presidents here tonight.
We owe a great debt to all of them. They have led us in ways that were important in their years and will continue to do so in the future. As I listened to Barry’s address this morning, I thought about the vision, values, and leadership of Stephen Smith and these people. If we had the breadth of vision that they had, if we had the depth of commitment to their values, if we are to continue to be blessed in this association with the style of leadership that they have shown us, we will be worthy followers.
Dr. Carol Easley Allen
I want to thank all our presenters this evening. I hope that APHA will develop an oral history based on these Presidents and Executive Directors.
Dr. Barry Levy
I too want to thank all the APHA Presidents and Executive Directors who participated in this session. I think it is incumbent on all of us in the current and future leadership to tap into our past leadership for their tremendous expertise and experience in order to provide guidance to APHA as we move forward.