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1990s Milton Terris National Association for Public Health Policy and Journal of Public Health Policy, 208 Meadowood Drive , South Burlington, Vermont 05403

INTRODUCTION The Editorial Committee has given me a difficult task, that is: "We hope to obtain your projection of what to seek and what to expect in the next ten years, based on your assessment of needs and trends." The task is made more difficult by the fact that this volume includes 21 other reviews, each con­ cerned with the prospects for specific areas of public health. Caution would dictate that

I retreat to the safe haven of general statements on policy and

eschew judgments on specific areas, for the latter run the risk of comparison with more expert knowledge and opinion. However, to limit discussion to the general factors that influence public health policy is to ignore the fact that conditions specific to a certain area of policy may neutralize the effect of general circumstances. On the other hand, it is not uncommon to make the error of failing to take general factors into consideration when estimating prospects for specific areas of public health. As in all areas of knowledge and action, it is best not to take an either-or approach-in this case, to confine analysis to either general or specific factors-but to attempt to take into account all factors that will influence public health policy in the 1990s. The word "attempt" is used advisedly, for anyone trying to take all factors into account is limited by lack of knowledge and objectivity. I am acutely aware of my own limitations in both regards; this essay is therefore to be regarded as a contribution to the discussion rather than an authoritative review of the field.

GENERAL FACTORS The general factors cannot be viewed in isolation; they interact with each other and with the factors specific to a given area of public health policy. 39

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Furthermore, they are not limited to the United States; the international scene is crucial in the determination of our domestic policy.

International Perhaps the greatest single obstacle to achieving health

THE ARMS RACE

policy goals in the world today is the arms race. In the United States, the enormous escalation of the military budget in the 1980s was carried out at the

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expense of social needs. Between fiscal years 1981 and 1986, the military share of the federal budget rose from 23 to 29%, while the share for low­ income programs dropped from 13 to 10% of the total. Ruth Leger Sivard lists the consequences



(9):

The US Conference of Mayors reported that one fifth of the requests for emergency food could not be mef: that in half of the big cities, shelters routinely turned away homeless people for lack of space.



An increasing shortage of low-cost housing raised the estimated numbers of homeless people to between 350,000 and 3 million.



In urban centers, the largest increase in the numbers seeking shelter was among families with children.



The number of individuals living below the poverty threshold increased from 29 million in 1980 to 33 million in 1985, about 14% of the population.



About 35 million Americans had neither private nor government-sponsored



In a single year, one million families were refused medical care for financial



Infant mortality rates in inner cities ranked with high rates in some of the



"Super-rich" families (wealth of $2.5 million or more), representing 0.5%

health insurance. reasons. poor countries of the Caribbean. of US households, owned 35% of the country's wealth, up from 25% ten years earlier. •

In the largest food-producing nation in the world, an estimated 20 million Americans were without adequate nutrition on a regular basis.





One third of mothers on welfare were functionally illiterate. The share of total income going to the poorest 20% of the population dropped to

4.7%, the lowest in 25 years, while the share of the richest 20% 42.9%, a post-war high.

increased to

THE COLD WAR

The main stimulus to escalation of military expenditures

has been the cold war between the US and the USSR. The Gorbachev-Reagan summit meetings began the slow process of ending the cold war; there have

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PUBLIC HEALTH POLICY

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been limited agreements on nuclear weapons, joint negotiations to end current armed conflicts, and unilateral arms reductions and military withdrawals on the part of the Soviet Union. The Bush Administration, however, is resisting these developments: It is dragging its feet on arms reduction in Europe, and it continues to supply arms that prolong the conflicts in Afghanistan and An­ gola. Whether the cold war will end in the 1990s is problematical; this depends in large measure on the pressures exerted by the nations of Europe, by world opinion, and by the people of the United States. It is safe to say, however, that the cold war is beginning to abate and there is a possibility for some reversal of the nation's priorities, i.e. there may be less military spending by the United States, and more spending to meet health and other human needs. How rapid the process will be, and what the extent of the change will be, cannot be predicted with any certainty.

Domestic ECONOMIC GROWTH Much will depend on the health of the economy and the growth of the gross national product (GNP). To predict what will happen in this decade would be folly---o ur expert economists have been less than accurate in their forecasts. It should be noted, however, that economic growth is dependent not only on domestic factors but on the international economy. Furthermore, government is no longer a passive bystander observing the operation of economic "laws"; it intervenes actively in the process in many ways, using its laws, regulations, customs duties, taxes, subsidies, bailouts, and other means to influence the economy. The term "political economy" aptly describes the current situation.

No discussion of the prospects for public health in the coming decade---or in any decade-can avoid the general political situation in the country. Let me give a poignant example. On May 8, 1988, a group of Boston occupational health and safety professionals pre­ sented and discussed proposals for a new Occupational Safety and Health Administration: strengthening OSHA inspections and enforcement, resurrect­ ing the general duty clause, developing systematic hazard surveillance and a new focus on hazard controls, and revitalizing worker education. The sym­ posium was published in the Autumn 1988 issue of the Journal of Public Health Policy, with the title "A New OSHA: The Tasks for the First 100 Days" (13). Clearly the authors expected a Democratic Party victory. Instead, the electorate chose the Presidential candidate of the Republican Party. Far from making any positive changes in the occupational safety and health program, the Bush Administration proposed to cut the budget for the POLITICAL DEVELOPMENTS

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National Institute for Occupational Safety and Health (NIOSH) from $71 million in fiscal year 1989 to $45 million in 1990, a decrease of $26 million (1). The electorate also chose a Democratic Party majority in both houses of Congress. If one evaluates the Senators and Representatives, not in terms of party affiliations but their basic ideology as reflected in voting records, it is clear that there is a sizable conservative majority in the US Congress. Faced with a conservative Administration and Congress, public health workers must anticipate a considerable gap between "what to seek and what to expect in the next 10 years, based on ... assessment of needs and trends." Will conservative rule continue during the decade of the 1990s? Much will depend on the further development of the populist upsurge associated with the Rainbow Coalition and the Jackson candidacy for the Democratic Party Presidential nomination. The conservative leadership of the Democratic Party has succeeded in maintaining its domination; its strategy is to co-opt the insurgent leadership, offering high positions to individual leaders in exchange for "moderation" in political demands. The outcome is difficult to predict; a great deal depends on the strength of the progressive movement and its determination to play an independent political role. Progressives in the United States are badly fragmented. They form in­ numerable organizations to deal with individual issues of national and in­ ternational policy, but fail to recognize the need to combine their efforts in a single political organization with a common political platform. They are divided by class boundaries; working-class and middle-class progressives move in different spheres. More important, the curse of racism effectively segregates white progressives from their African-American allies. The fact that the only two industrial countries that do not have a national medical care system are South Africa and the United States is not accidental; in neither country have working people been able to surmount the racism and s egreg a­ tion that prevent them from joining together for independent political action. Canada has demonstrated that advanced social programs can be achieved by the development of a political alternative to the traditional conservative parties. In 1933, workers, farmers, and professionals organized the Cooper a­ tive Commonwealth Federation (CCF), a social democratic party that came to power in the province of Saskatchewan in 1944. In 1961, in alliance with organized labor, it reorganized as the New Democratic Party (NDP), which has become a major political force in Canada. There is no doubt that the advanced, comprehensive social programs of Canada-universal health in­ surance, old-age pensions, family allowances, unemployment insurance, pro­ gressive labor laws, civil liberties, equality rights, and government support of culture-were the direct result of the entry of the CCF and NDP into the political life of the nation (6).

PUBLIC HEALTH POLICY

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Whether the progr essives of the United States will learn the lessons of Canada before the end of this century remains to be seen. As long as they fail to do so, national policy in all areas, including public health, will continue to be made by the conservative political parties.

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SPECIFIC AREAS There are three basic areas of public health policy. In order of importance, they are (a) health promotion, i.e. improving the standard of living, (b) disease prevention, and (c) medical care, i.e. treatment services.

Health Promotion The concept of health promotion refers to the development of healthful living standards. These have a profound effect on positive health, which is not only a subjective state of well-being (including such elements as vitality, freedom from excess fatigue, and freedom from environmental discomforts such as excessive heat, cold, smog, and noise), but also has a functional component, namely, the ability of the individual to participate effectively in society: at work, at home, and in the community. The standard of living also plays a major role in the prevention of disease and injury. Infant diarrhea, for example, the single most important cause of death in the world today, is caused only secondarily by salmonellae, shigellae, and other microorganisms; it is caused primarily by underdevelop­ ment, poverty, lack of basic sanitation facilities, undernutrition, illiteracy, and ignorance of personal hygiene. The state of nutrition is a major factor affecting resistance to many dis­ eases. Inadequate education, resulting in both formal and functional illiteracy, is a serious obstacle to learning the use of preventive measures such as personal hygiene, immunization, and lifestyle changes. Poor working con­ ditions and hazardous environments are the cause of much preventable disease and injury. Dead-end jobs, inadequate incomes, poor housing, discrimination and segregation, and lack of educational, cultural, and recreational opportuni­ ties combine to produce low self-esteem, mental dysfunction, alcoholism, drug addiction, suicide, homicide, wife and child abuse, and other violence directed against self, family, and community. Access to medical care is markedly affected b y factors other than financial barriers. Low educational levels, transportation problems, and overcrowded, inadequate clinical facilities are particularly conducive to preventing optimal utilization of available resources. Rehabilitation of the sick and disabled cannot stop with physical measures; it must include social and vocational rehabilitation as well. Societal facilities-buildings, sidewalks, buses, cars, parking lots, etc-must incorporate provisions to meet the needs of handi-

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capped persons. Jobs must be available for them, a difficult task to accom­ plish when a significant portion of the able-bodied workforce is unemployed. Canada has played a very important role in fostering greater understanding of the role of living standards in all aspects of health: enhancing well-being and functional capacity, preventing disease and injury, and treating and rehabilitating the sick and disabled. It was no accident that Ottawa became the site of the first International Conference on Health Promotion in November 1986; the Canadian Minister of National Health and Welfare had previously emphasized "the means essential for the preservation of health-food, shelter, transportation, recreation, a healthy workplace, " and urged intersectoral coordination in these areas (4). The Ottawa Charter for Health Promotion (8) puts the issue squarely, stating: The fundamental conditions and resources for health are peace, shelter. education, food, income, a stable eco-system, sustainable resources, social justice and equity. Improvement in health requires a secure foundation in these basic prerequisites. The prerequisites and prospects for health cannot be ensured by the health sector alone. More importantly, health promotion demands coordinated action by all concerned: by governments, by health and other social and economic sectors, by non-governmental and voluntary organizations, by local authorities, by industry and by the media. People in all walks of life are involved as individuals, families and communities. Professional and social groups and health personnel have a major responsibility to

mediate between differing

interests in society for the pursuit of health.

In the United States, however, health promotion has been officially defined as lifestyle modification to prevent disease (10). This failure to accept the improvement of living standards as a basic element of public health policy reflects the extraordinary influence of conservative ideologies in American intellectual life, culture, and politics. The difference between the Canadian and American definitions reflects the wide gulf between the two nations in their orientation toward social programs. That gulf is illustrated by the fact that the evasive American definition was made by the Carter Democratic Administration, while the progressive Canadian definition was made by the Mulroney Tory Government. Another reason for Canadian recognition of the public health importance of living standards is that Canada, unlike the United States, has achieved almost complete equity in medical care through its universal health insurance system. To their dismay, the Canadians, like their British colleagues (15), have discovered that achieving equity in medical care does not bring equity in health. Russell Wilkins and Owen Adams have calculated disability-free life expectancy for Canada in the late 1970s by income level (14). They found a stepwise progression by income level from the lowest to the highest fifth of the population:

PUBLIC HEALTH POLICY Table 1

4S

Life expectancy and disability-free life ex­

pectancy for Canada, late 1970s

Life expectancy

Disability-free life

(years)

expectancy (years)

Total

74. 6

61.0

Lowest

71.9

54.9

Second

73.8

59.9

Third

74.7

62.7

Fourth

75.5

63.1

Highest

76.4

65.9

Income level

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(fifths)

From Ref.

(14).

In the late 1970s in Canada, the difference in life expectancy between people in the lowest and highest income levels was 4.5 years; for disability­ free life expectancy, the difference was 11 years. Poor people in Canada have, on the average, only 55 years of healthy life, that is, life free from disability, as compared with 66 years of healthy life for rich Canadians. The need for health promotion in the United States is both urgent and crucial. Whether a reorientation of American public health policy in this direction will occur in the 1990s depends on the general political factors discussed above, and on the ability of public health workers to move beyond their narrow, specialized concerns.

Disease Prevention The prospects for disease prevention are more hopeful than those for health promotion, for three reasons. First, disease prevention is generally less expensive than the improvements in education, housing, employment, in­ come, nutrition, recreation, and cultural opportunities that are necessary to raise the standard of living. Second, there has been a groundswell of public support for regulatory action on disease prevention issues, such as clean air acts, increases in excise taxes on tobacco and alcohol, seat belts and air bags in automobiles, and more effective protection against environmental pollution. Third has been the leadership of public health agencies-in the first place the US Public Health Service-in developing the 1990 Health Objectives for the Nation (11) and formulating the Nation's Health Objectives for the Year 2000. The public health movement has become much bolder recently in putting forth its agenda for prevention. The National Association for Public Health Policy, for example, has declared: "PUT PREVENTION FIRST! While 93.6% of all health dollars spent in the United States is for medical care, and an additional 3.5% is for research and construction, only 2.9% is

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spent for government public health activities. The nation's health demands that we spend: 6% FOR PREVENTION." A major step forward is the National Health Objectives Act, proposed at the beginning of 1989 by the Association of State and Territorial Health Officials, and supported by other major public health organizations (2). The Act calls for federal aid to state health departments to ensure a concerted national effort to reach the Nation's Health Objectives for the Year 2000. It recommends an initial funding level of $4 per person, or 1 billion dollars for an estimated 1990 population of 250 million. Since current health expenditures are well over 500 billion dollars, the ASTHO proposal would add less than one fifth of 1% to total health expenditures in the United States. Far from being in disarray, public health in the United States has developed a coherent, weU-thought-out program to improve the health of the population, i.e. the Nation's Health Objectives for the Year 2000. And the public health movement is proclaiming to the Government and the electorate the urgent need to implement this program by providing state and local health de­ partments with sufficient funds to achieve the objectives. During the next ten years the National Health Objectives Act will be passed by the US Congress. It will serve to strengthen existing preventive programs and to stimulate the development of new and more effective preventive measures designed to fulfill the health objectives for the year 2000. Expanded health education activities will not only stimulate individual action to change lifestyles in the interest of personal health, but will increase public knowledge and support of regulatory measures and more adequate funding of preventive services. We may therefore expect a substantial increase of funding for government public health activities beyond the current miserly sum of 2.9% of all health expenditures. It is doubtful, however, that the 6% called for by the National Association for Public Health Policy will be achieved in the coming decade. Success in categorical preventive programs will vary considerably. The infectious diseases for which effective vaccines have been developed will be well controlled in the coming decade. The sexually transmitted diseases, including AIDS, will not. Neither will salmonellosis nor the major respiratory diseases. Success in preventing noninfectious diseases will also vary. For diseases in which the main obstacle to prevention is a single industry, such as the alcohol or tobacco companies, we will see a considerable reduction in exposure to the agent, and, depending on the length of the incubation period, a subsequent decline in disease incidence. Heart disease and cerebrovascular disease will continue to decline with more effective programs to reduce consumption of saturated fats and cholesterol (unlike the tobacco and alcohol companies, the food industry is in a position to adjust to the necessary changes rather than

PUBLIC HEALTH POLICY

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engage in frontal counterattacks); expansion of antismoking educational and regulatory measures; and more thorough case-finding and maintenance of treatment regimens for high blood pressure. Occupational and environmental diseases will be more difficult to prevent because of the tremendous resistance by industrial corporations, and their dominant role in the present Administration and the Republican and Demo­ cratic Parties.

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Success in preventing injuries will vary depending on the epidemiology of specific types of injury. Occupational injury prevention faces formidable opposition, as indicated above. There are conflicting trends related to motor vehicle injuries: on the one hand, for example, the adoption of seat-belt laws and air bags as well as more stringent controls on drunken driving; on the other hand, the widespread relaxation of highway speed limits. Residential fire deaths should decline with the expected passage of the Fire-Safe Cigarette Act early in the decade. Injuries caused by hazardous consumer products will probably not decline in view of the antiregulatory, pro-industry bias of the present Administration and its conservative Republican and Democratic majority in the Congress. The decline in infant mortality will be severely limited by the failure of purely medical measures to prevent infant deaths in socially disadvantaged sections of the popUlation. Until the United States learns the lessons from Europe-that social measures are more important than prenatal care in reduc­ ing infant mortality ( l2)-progress will be disappointing. It is not to be expected that the current Administration and Congress will do much to combat discrimination against African-American and other minorities; pro­ vide adequate maternity protection for all (prenatal and postnatal paid mater­ nity leave, paid leave for sick pregnant women, paid prenatal leave for care of a sick child, paid nursing breaks for breastfeeding, and other protective measures); foster the development of a strong midwifery service; institute family allowances; improve housing and nutrition; make quality day-care centers universally available for infants requiring them; etc. Yet these are measures that need to be taken to reduce the unnecessarily high infant mortality rate in the United States. Prevention of drug abuse and its health and social consequences will not succeed in the coming decade in view of the current confusion and disarray in the nation's policies on this issue. There will be little headway in the 1990s in the area of prevention of mental disorders. No effective means are available to prevent the major organic psychoses: schizophrenia, manic-depressive psychosis, and Alzheimer's dis­ ease. Other mental disorders are largely the result of social and psychological pathology, and their prevention depends on major restructuring of economic, social, and interpersonal relations.

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Medical Care The crisis in medical care will become even more evident in the 1990s. The United States spends 12% of Gross National Product for medical care-more than any other country-but a large proportion of the population has neither health insurance nor adequate coverage; Medicare for those age 65 and older pays for only 40% of their medical care costs; the limited eligibility for Medicaid has been further curtailed by the states; and the costs of medical care continue to escalate. Attempts by the states to provide universal coverage have failed and will continue to fail because of the opposition of small business to compulsory coverage of employees, the high costs of care, and the financial inability of the states to meet those costs. At the federal level, Senator Kennedy has proposed that every employer be required to offer basic health insurance, covering dependents, to every em­ ployee who works more than half time. But American corporations, many of which pay part or all of the health insurance premiums for their employees, are reducing health benefits in collective bargaining agreements. Further­ more, the escalation of costs has caused a reappraisal of the current situation by the corporate leadership of the nation. On August 9, 1988, the New York Times (3) carried a lead editorial, "For Rational, National Health Care," which opened with these words: "National health insurance: for 40 years the words have meant politically impossible, utopian. Now, perhaps, this idea's time has come." The motive for this startling about-face is made perfectly clear: "The most sensible solution would be a national one-a truly national program in which costs are shared by all and not simply dumped on employers." On April 5, 1989, the Wall Street Journal (16) reported that "A longtime dream of the liberal establishment-a national health-care program-is be­ ginning to attract an unlikely advocate: big business. Frustrated by rising health costs and the failure of a decade-long effort to rein them in, some companies are ready to consider a radical fix. " Furthermore, "the Washington (D.C.) Business Group on Health, which represents Chrysler, Ford and about 180 other Fortune 500 companies on health issues, is one of several groups drafting a national health care plan. . . ." It is clear that the question for the 1990s is no longer whether the United States should adopt a national medical care program. The issue now is: What kind of a national program? The National Association for Public Health Policy has formulated "A Progressive Proposal for a National Medical Care System" (7), which calls for coverage of the entire population for all medical care services, including dental, mental, and long-term care, without deductibles, copayments, or extra charges by providers.

PUBLIC HEALTH POLICY

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No payments will be made to individual practitioners, but rather to provider organizations: community health centers, group practice organizations, and individual practice associations. Payments will be made by an annual global budget based on the demographic characteristics of the persons served, and on the estimated cost of providing care, based on the experience of salaried group practice prepayment plans and community health centers. These estimated costs will be applied to all provider organizations, including individual practice associa­

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tions that pay practitioners on a fee-for-service basis, in order to prevent un­ necessary hospitalizations, surgical operations, and procedures. Salaried group practice plans and community health centers have 40% lower hospitalization costs and

25% lower overall costs than individual-practice fee-for-service plans, with (5).

equal or better results in terms of health status outcomes

Provider organizations will be classified as public utilities, with their records open to public scrutiny, and with profit margins and uses regulated. Every provider organization will be required to establish a Consumers Coun­ cil and an Employees Council, each of which will meet regularly with the administrator and have the right to appeal to local, state, and federal health departments for investigation and action on deficiencies in the care and treatment of patients. Large-scale government grants and loans will be avail­ able to assist consumer-controlled and health worker-controlled provider organizations to form community health centers and salaried group practice organizations that provide a wide range of health services. The system will be administered by federal, state, and local health de­ partments responsible to Boards of Health consisting

100% of public repre­

sentatives comprising all sections of the population. In order to ensure flexibility, the states will submit plans that meet all the basic requirements of the national system, but will have considerable latitude to devise ways to improve the system. Quality of care will be improved by federal standards; evaluation of the services of all provider organizations with respect to qualifications and per­ formance of personnel, suitability of facilities, compliance with performance standards, and effectiveness of eare; prompt health department response to appeals by Consumers Councils and Employees Councils; consultation, train­ ing, and other governmental assistance to improve quality; and regulatory action to correct abuses and gross deficiencies. The system will be financed by the federal government and the states. The federal share will vary between

75 and 90% of the total, with the higher

proportions going to the poorer states. It will be supported by progressive, graduated income taxes, corporation taxes, and excise taxes on tobacco, alcohol, foods rich in saturated fat and cholesterol, firearms and other weapons, and toxic substances used in industry, agriCUlture, construction, and the community.

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Will such a progressive proposal for medical care be adopted in the coming decade? The odds are not favorable. Powerful vested interests are at stake. The insurance companies will obviously oppose being excluded from the medical care system. The medical profession will campaign for maintaining fee-for-service as the dominant method of payment. The most powerful labor unions-those which have been able to obtain full employer payment of health insurance premiums-will resist the loss of their advantage. The nature of the national medical care system that will emerge in the 1990s cannot be forecast at this time. It will be molded not only by the respective strengths of the various contending forces in the health arena, but to a large extent by the general factors discussed at the beginning of this paper: the course of the arms race and the cold war, the rate of growth of the US economy, and the rapidity of development of independent political action to challenge the conservative political leadership of the nation.

CONCLUSION Public health policy in the 1990s will be determined not only by factors intrinsic to the health field but by external circumstances related to in­ ternational and domestic political and economic changes. The prospects for positive action vary with the specific areas of public health policy, since in each instance there are somewhat different sets of interacting factors. In all instances, however, the dominant role of conservative political forces in the United States is a major limiting condition. Gains in specific areas of public health will undoubtedly be made in the coming decade, but fundamental changes in public health policy will require far-reaching changes in the nation's ideology and politics.

Literature Cited 1. Am. Public Health Assoc. 1989. Action alert: Administration slashes NIOSH budget. APHA Govern. Relat. High­ lights (Mar. 1989): 3 2. Assoc. State Territorial Health Officials. 1989. The National Health Objectives Act: A proposal by the Association of State and Territorial Health Officials. J. Public Health Policy 10:246--58 3. Editorial. 1988. For rational, national health care. New York Times, Aug. 9 4. Epp, J. 1986. National strategies for health promotion. Can. J. Public Health 77:243-48 5. Manning, W. G., Leibowitz, A., Gold­ berg, G. A., Rogers, W. H., Newhouse, 1. P. 1984. A controlled trial of the

effect of a prepaid group practice on use of services. New Engl. J. Med. 310:1505-10 6. McDonald, L. 1987. The Party that Changed Canada: The New Democratic Party, Then and Now. Toronto: Mac­ Millan 7. Natl. Assoc. for Public Health Policy. 1988. A Progressive Proposal for a National Medical Care System. South Burlington, VT: NAPHP 8. Ottawa Charter for Health Promotion. 1986. Ottawa: Can. Public Health

Assoc.

9. Sivard, R. L. 1986. World Military and Social Expenditures, 1986. Washington, DC: World Priorities. 11th ed.

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PUBLIC HEALTH POLICY

10. US Dept. Health Human Serv., Public Health Servo 1979. H ealthy People: The Surgeon General's Report on Health Promotion and Disease Prevention, Ch. 10. Washington. DC: US GPO 11. US Dept. Health Human Serv., Public Health Servo 1980. Promoting Health/ Preventing Disease: Ohjectives for the Nation. Washington, DC: US GPO 12. Wagner, M. G. 1988. Infant mortality in Europe: Implications for the United States. Statement to the National Com­ mission to Prevent Infant Mortality. 1. Public Health Policy 9:473-84 13. Wegman, D. H., Robbins, A., et al.

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1988. Symposium: A new OSHA: The tasks for the first 100 days . 1. Public Health Policy 9:319-45 14. Wilkins, R., Adams, O. B. 1983. Health expectancy in Canada, late 1970s: Demographic, regional and so­ cial dimensions. Am. J. Public Health 73:\073-80 15. Wilkinson, R. G., ed. 1986. Class and Health: Research and Longitudinal Data, p. 14. London/New York: Tavis­ tock. 16. Winslow, R. 1989. National health plan wins unlikely backer: Business. Wall Street J April 5 .•

Public health policy for the 1990s.

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