The Future of APHA: Critical Choices The 1978 Presidential Address E. FRANK ELLIS, MD, MPH The term futurism often brings to mind characters from the movie "Star Wars", space shuttles, asexual clothing, and even a slight feeling of weightlessness. Imagining the unknown is heady stuff, although the more credible views of the future are usually those which emerge from a thorough understanding of the present and past. Contrary to the common phrase, we rarely "leap" into the future. Rather, we kind of melt or evolve into it. While certain technological innovations have no doubt accelerated this process in the past century, we nevertheless carry along a lot of emotional and intellectual baggage from other ages as we move forward :n our own time. While I personally find the investigation of the future an important and provocative undertaking, I become concerned when the necessary intermediate steps proceeding any change are overlooked. It is like a cartoon I once saw: Two residents of a severely deteriorated ghetto street are pointing to a sign announcing that a missile site is going to be built in the area. The obvious caption has one of the men saying, "To protect this?" To show how things change and yet do not change, let me quote from an article written in Medical World News nearly ten years ago. This article, by the way, was entitled "New Rival for the AMA?" The first sentence read: "As it nears its 100th birthday, the once-sedate American Public Health Association is girding itself for a radically new role: activist medical spokesman for members of the diverse professions involved in the delivery of health care-and for the 'health consumer' as well."' The article went on to say that APHA was about to provide "an influential new voice in the establishment of national health policies." To that prediction I can only say we are trying, but have not quite arrived.
Past Challenges I think APHA has done quite well in meeting some of its past challenges. Certainly the organization's emphasis on Address reprint requests to Dr. E. Frank Ellis, Regional Health Administrator, DHEW, Region V, 300 S. Wacker Drive, Chicago IL 60606. The Presidential Address was presented at the 106th Annual Meeting of the American Public Health Association, in Los Angeles, California, on October 16, 1978.
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consumer advocacy and involvement has played some role in spreading the concept throughout the health care system. I doubt that this stance diminished APHA's stature in dealing with other national professional organizations, as was predicted at the time. We have also added new sections of professionals and allowed special interest voices to be heard through the caucus mechanism. Some might complain that these interests were co-opted by being brought into the structure. I prefer to view it as a positive expansion on the Association's part to assimilate new attitudes and concepts-in short, to grow. I also think that APHA has maintained its reputation as a resource for technical guidance and knowledge. It is rare for a health organization to blend technical expertise with an action orientation to the extent that we have tried to do. On the other hand, it might also be claimed that our great diversity of opinion and expertise prevents us from becoming identified as a major focus for change in the health system. Abel Wolman once described APHA as a "'multi-discipline rooming house."2 (I suspect that the Housing Bureau for these Annual Meetings would thoroughly agree with that description.) Perhaps our greatest challenge for the future is to get beyond this rooming house image. While it is enjoyable to partake of the communal resources once a year, there must be something we can do after the meal besides going off in our own separate ways. In the next few moments I would like to share some possible directions APHA might take and some of the critical choices it must make along the way.
Directions and Choices One crucial choice APHA must make concerns its role in the health care system. I think we have moved beyond the kind of thinking which wants us to be a rival to the American Medical Association. Not only does such a position dictate a stance which may not always be appropriate, but it also puts us in the position of reacting against something rather than forging our own platform and principles. I personally would like to see APHA become the national focus for public health directions and ideology. I would like us to be actively involved in Congressional and Administration initiatives, whether as an advocate or adversary. To AJPH April 1979, Vol. 69, No. 4
PRESIDENTIAL ADDRESS
do this will require ongoing working relationships with the staffs of these entities. The same must occur at the state, county and local levels. While I realize this requires a certain degree of commitment and willpower, it is certainly not impossible. Many, if not most, of us already possess contacts within the governmental structure. Many of us are involved with Boards of Health, the Health Systems Agencies and other non-official societies and organizations. We probably have the most underused network of health care relationships in the country. At the same time, public health workers have by-and-large backed away from the non-partisan political battles in the health care field. This is not to say we haven't marched for consumer groups, testified at hearings, and made ourselves heard. What I am talking about are longterm strategies to influence legislation, change attitudes, and develop cooperative alliances between professional and voluntary organizations. My experiences during the past year reinforce my belief that many APHA members want to be actively involved in something beyond the Annual Meeting and other organizational responsibilities. This "something" usually boils down to developing a health system based on public health principles. I think many members are genuinely concerned that APHA seems to have many stands, but no identifiable platform. To develop a health platform and strategy will require that APHA consolidate and organize its enormous store of resolutions, policy statements, and position papers. I am sure many members are curious to know what happens to these pronouncements once they are accepted. Do they replace older policies? Are they compared with related statements for consistency? Do they form the basis for APHA actions? In an Executive Committee meeting last winter it was agreed that a codification of APHA policy was needed and should be undertaken. I believe that this is an important first step to developing an effective information system for the Association. Also needed is an ongoing communication system which links affiliates, sections, officers and APHA staff in an ongoing exchange of views and information. We need to get beyond our separate identities as segments of APHA if we intend to carve out a national policymaking role for the organization. In my visits to some of our affiliates, I was exposed to some excellent programming at the state level. In addition, I know that several of the sections have taken a broader, more activist, role in recent months. But how do we harness these separate efforts to energize the national image of APHA? While it is somewhat embarrassing to admit, APHA is characterized by the same fragmentation which we deplore in the broader health system. But we, like some of the most conservative interests in health care, hail our disorganization as diversity. Perhaps this points up some universal trait in health professionals. Maybe we really are slaves to our professional biases and organizational conditioning. Certainly it is easier to see the evolution of the health care system in terms of its effect on one as a health educator, podiatrist, nurse, or environmentalist. But is that an honest view? AJPH April 1979, Vol. 69, No. 4
Health priorities come and go like TV fads. But instead of the competing interests of crime, sex, soap, and outer space, we have prevention, consumerism, environmental pollution, and cost containment. All are legitimate, important concerns. But they are parts of the broader definition of public health, not isolated campaigns. There have been times in my career when I have suspected that these changing emphases were a smoke screen for our inability to handle some very serious problems in our society. For example, environmental causes became vogue as the idealism and innovation of the so-called Great Society years began to crumble. More recently, the overwhelming preoccupation with cost containment obscures the need for drastic changes in the organization and delivery of health care. In short, we are confronted with interactive problems which require interactive solutions and a sophistication in planning which is almost mind-boggling. We must be constantly aware that we are part of the third largest industry in the country. Tinkering with it will not improve it, and may even work against future changes. Closing hospitals without considering how they might be converted to meet other area needs may have serious economic effects on a community. Requiring cost-sharing provisions in health insurance programs may save the plans, but discourage participation of population groups who need health care the most. I do not think APHA will ever be able to substantially influence the directions of the nation's third largest industry unless its members are willing to direct their energies to priorities beyond their professional goals and objectives. This does not mean that all hospital administrators must suddenly become experts in financing a national health plan. It may require, however, that hospitals be analyzed in terms of their future role in a health system based on public health principles, goals, and objectives. Which brings up another question-do we know what APHA's fundamental principles and goals are? Would you know where to find them? I thought maybe they were in our Constitution, so I looked there. There is one short paragraph which reads: "The object of this Association is to protect personal and environmental health. It shall exercise leadership with health professionals and the general public in health policy development and action, with particular focus on the interrelationship between health and the quality of life and on developing a national policy for health care and services and on solving technical problems" (Article II, Object). Well, I guess that is a start. The next paper I examined was the position paper adopted last November entitled "'Criteria for Assessing National Health Service Proposals." This outline is fairly specific about the characteristics of the national program acceptable to APHA. I wonder how many members have read and discussed the provisions of this paper. But what fascinates me most is its title, "Criteria for Assessing National Health Service Proposals." Perhaps I am a bit out of touch with national developments, but I have not seen too many national health service proposals being 365
ELLIS
actively debated lately. Furthermore, the slant of the paper suggests we are waiting to evaluate what Congress or the Administration ultimately develops, rather than actively working to see that the provisions are included in the proposals from the start. From these comments, I do not wish to infer that our Washington staff has not been hard at work trying to infuse legislative developments with APHA positions. They have been doing an excellent job at this; most recently in the area of cost containment. But by our failing to provide them with a platform and strategy, we make their job all the more difficult. As you have probably guessed by now, I am advocating that we devote our energies to developing a national strategy. To do this may require some or all of the following actions: 1. Develop a plan for mobilizing the resources of APHA to develop a national platform. Such a plan should have definite action steps and time frames. If funds are necessary for certain tasks, it should be so noted. Potential outside sources of funding should also be identified. 2. Define the kinds of roles that sections, affiliates, committees, individuals, etc., might play in developing such a platform. While individual sections could handle some aspects, multi-discipline task forces might be more appropriate for other tasks. Responsibilities might include such activities as testifying; writing; gathering and analyzing data; working with Congress and the Administration; working with other health-related associations; involving and informing consumer groups; orienting and interacting with the media; and involving academia. A network of persons active in Health Systems Agencies, Professional Standards Review Organizations, etc., might be developed as well. 3. Set aside a section of "The Nation's Health" to keep the general membership abreast of developmnents. Opportunities for participation or review/comment could also be announced via this mechanism. This effort might help individual members become involved in APHA on a more than annual basis. 4. Declare a moratorium on new policy statements and resolutions until the current and past items have been codified, evaluated, and revised. 5. Strengthen the role of the affiliates by providing a mechanism for innovations at the state and local levels to be communicated among other state and national representatives. There are many exciting developments occurring at
366
the state level. Code revisions are changing the role of state, county, and local health departments. State legislators are becoming interested in health care delivery and financing, and resources are being distributed to local areas through new mechanisms. In some cases, matching arrangements are greatly increasing health care funding at local levels. 6. Develop a structure and mechanism for reviewing and approving portions of the platform. It is possible that elements of such a structure are in place already, so I am not recommending any reorganization unless absolutely necessary. 7. Use the platform and strategy as a basis for APHA's future work plan. This will require us to vastly increase our activities in the broader political arena. We will have to develop time frames and periodically evaluate our progress. We will have to establish priorities and learn to understand how national trends and attitudes may influence our activities. We may have to revise our policies from time to time, and learn how to negotiate productively for the basic principles of our platform. In summary, we will have to leave the comfortable, somewhat abstract shelter of the old APHA and enter the gritty arena of active decision-making.
Summary You may be wondering how my remarks tie into this year's theme of futurism. I admit that the subjects of many of this week's speakers are going to be much more intriguing than what I've been discussing. But many of you have given many years of your lives to the concepts embraced by this Association. Time is running out for us to make APHA the national focus for public health policy making. The only way it will assume such a role is by each one of us reaching beyond the constraints of narrow professionalism and special interests to work together to develop a truly equitable and effective national health system. To this I can only add that I hope "the force" is with us in whatever challenges the future may bring.
REFERENCES 1. New Rival for the AMA?, Medical World News, November 7, 1969, p. 39. 2. Abel Wolman, "APHA in Its First Century," Am J Public Health, 63: 319, 1973.
AJPH April 1979, Vol. 69, No. 4
Past Challenges I think APHA has done quite well in meeting some of its past challenges. Certainly the organization's emphasis on Address reprint requests to Dr. E. Frank Ellis, Regional Health Administrator, DHEW, Region V, 300 S. Wacker Drive, Chicago IL 60606. The Presidential Address was presented at the 106th Annual Meeting of the American Public Health Association, in Los Angeles, California, on October 16, 1978.
364
consumer advocacy and involvement has played some role in spreading the concept throughout the health care system. I doubt that this stance diminished APHA's stature in dealing with other national professional organizations, as was predicted at the time. We have also added new sections of professionals and allowed special interest voices to be heard through the caucus mechanism. Some might complain that these interests were co-opted by being brought into the structure. I prefer to view it as a positive expansion on the Association's part to assimilate new attitudes and concepts-in short, to grow. I also think that APHA has maintained its reputation as a resource for technical guidance and knowledge. It is rare for a health organization to blend technical expertise with an action orientation to the extent that we have tried to do. On the other hand, it might also be claimed that our great diversity of opinion and expertise prevents us from becoming identified as a major focus for change in the health system. Abel Wolman once described APHA as a "'multi-discipline rooming house."2 (I suspect that the Housing Bureau for these Annual Meetings would thoroughly agree with that description.) Perhaps our greatest challenge for the future is to get beyond this rooming house image. While it is enjoyable to partake of the communal resources once a year, there must be something we can do after the meal besides going off in our own separate ways. In the next few moments I would like to share some possible directions APHA might take and some of the critical choices it must make along the way.
Directions and Choices One crucial choice APHA must make concerns its role in the health care system. I think we have moved beyond the kind of thinking which wants us to be a rival to the American Medical Association. Not only does such a position dictate a stance which may not always be appropriate, but it also puts us in the position of reacting against something rather than forging our own platform and principles. I personally would like to see APHA become the national focus for public health directions and ideology. I would like us to be actively involved in Congressional and Administration initiatives, whether as an advocate or adversary. To AJPH April 1979, Vol. 69, No. 4
PRESIDENTIAL ADDRESS
do this will require ongoing working relationships with the staffs of these entities. The same must occur at the state, county and local levels. While I realize this requires a certain degree of commitment and willpower, it is certainly not impossible. Many, if not most, of us already possess contacts within the governmental structure. Many of us are involved with Boards of Health, the Health Systems Agencies and other non-official societies and organizations. We probably have the most underused network of health care relationships in the country. At the same time, public health workers have by-and-large backed away from the non-partisan political battles in the health care field. This is not to say we haven't marched for consumer groups, testified at hearings, and made ourselves heard. What I am talking about are longterm strategies to influence legislation, change attitudes, and develop cooperative alliances between professional and voluntary organizations. My experiences during the past year reinforce my belief that many APHA members want to be actively involved in something beyond the Annual Meeting and other organizational responsibilities. This "something" usually boils down to developing a health system based on public health principles. I think many members are genuinely concerned that APHA seems to have many stands, but no identifiable platform. To develop a health platform and strategy will require that APHA consolidate and organize its enormous store of resolutions, policy statements, and position papers. I am sure many members are curious to know what happens to these pronouncements once they are accepted. Do they replace older policies? Are they compared with related statements for consistency? Do they form the basis for APHA actions? In an Executive Committee meeting last winter it was agreed that a codification of APHA policy was needed and should be undertaken. I believe that this is an important first step to developing an effective information system for the Association. Also needed is an ongoing communication system which links affiliates, sections, officers and APHA staff in an ongoing exchange of views and information. We need to get beyond our separate identities as segments of APHA if we intend to carve out a national policymaking role for the organization. In my visits to some of our affiliates, I was exposed to some excellent programming at the state level. In addition, I know that several of the sections have taken a broader, more activist, role in recent months. But how do we harness these separate efforts to energize the national image of APHA? While it is somewhat embarrassing to admit, APHA is characterized by the same fragmentation which we deplore in the broader health system. But we, like some of the most conservative interests in health care, hail our disorganization as diversity. Perhaps this points up some universal trait in health professionals. Maybe we really are slaves to our professional biases and organizational conditioning. Certainly it is easier to see the evolution of the health care system in terms of its effect on one as a health educator, podiatrist, nurse, or environmentalist. But is that an honest view? AJPH April 1979, Vol. 69, No. 4
Health priorities come and go like TV fads. But instead of the competing interests of crime, sex, soap, and outer space, we have prevention, consumerism, environmental pollution, and cost containment. All are legitimate, important concerns. But they are parts of the broader definition of public health, not isolated campaigns. There have been times in my career when I have suspected that these changing emphases were a smoke screen for our inability to handle some very serious problems in our society. For example, environmental causes became vogue as the idealism and innovation of the so-called Great Society years began to crumble. More recently, the overwhelming preoccupation with cost containment obscures the need for drastic changes in the organization and delivery of health care. In short, we are confronted with interactive problems which require interactive solutions and a sophistication in planning which is almost mind-boggling. We must be constantly aware that we are part of the third largest industry in the country. Tinkering with it will not improve it, and may even work against future changes. Closing hospitals without considering how they might be converted to meet other area needs may have serious economic effects on a community. Requiring cost-sharing provisions in health insurance programs may save the plans, but discourage participation of population groups who need health care the most. I do not think APHA will ever be able to substantially influence the directions of the nation's third largest industry unless its members are willing to direct their energies to priorities beyond their professional goals and objectives. This does not mean that all hospital administrators must suddenly become experts in financing a national health plan. It may require, however, that hospitals be analyzed in terms of their future role in a health system based on public health principles, goals, and objectives. Which brings up another question-do we know what APHA's fundamental principles and goals are? Would you know where to find them? I thought maybe they were in our Constitution, so I looked there. There is one short paragraph which reads: "The object of this Association is to protect personal and environmental health. It shall exercise leadership with health professionals and the general public in health policy development and action, with particular focus on the interrelationship between health and the quality of life and on developing a national policy for health care and services and on solving technical problems" (Article II, Object). Well, I guess that is a start. The next paper I examined was the position paper adopted last November entitled "'Criteria for Assessing National Health Service Proposals." This outline is fairly specific about the characteristics of the national program acceptable to APHA. I wonder how many members have read and discussed the provisions of this paper. But what fascinates me most is its title, "Criteria for Assessing National Health Service Proposals." Perhaps I am a bit out of touch with national developments, but I have not seen too many national health service proposals being 365
ELLIS
actively debated lately. Furthermore, the slant of the paper suggests we are waiting to evaluate what Congress or the Administration ultimately develops, rather than actively working to see that the provisions are included in the proposals from the start. From these comments, I do not wish to infer that our Washington staff has not been hard at work trying to infuse legislative developments with APHA positions. They have been doing an excellent job at this; most recently in the area of cost containment. But by our failing to provide them with a platform and strategy, we make their job all the more difficult. As you have probably guessed by now, I am advocating that we devote our energies to developing a national strategy. To do this may require some or all of the following actions: 1. Develop a plan for mobilizing the resources of APHA to develop a national platform. Such a plan should have definite action steps and time frames. If funds are necessary for certain tasks, it should be so noted. Potential outside sources of funding should also be identified. 2. Define the kinds of roles that sections, affiliates, committees, individuals, etc., might play in developing such a platform. While individual sections could handle some aspects, multi-discipline task forces might be more appropriate for other tasks. Responsibilities might include such activities as testifying; writing; gathering and analyzing data; working with Congress and the Administration; working with other health-related associations; involving and informing consumer groups; orienting and interacting with the media; and involving academia. A network of persons active in Health Systems Agencies, Professional Standards Review Organizations, etc., might be developed as well. 3. Set aside a section of "The Nation's Health" to keep the general membership abreast of developmnents. Opportunities for participation or review/comment could also be announced via this mechanism. This effort might help individual members become involved in APHA on a more than annual basis. 4. Declare a moratorium on new policy statements and resolutions until the current and past items have been codified, evaluated, and revised. 5. Strengthen the role of the affiliates by providing a mechanism for innovations at the state and local levels to be communicated among other state and national representatives. There are many exciting developments occurring at
366
the state level. Code revisions are changing the role of state, county, and local health departments. State legislators are becoming interested in health care delivery and financing, and resources are being distributed to local areas through new mechanisms. In some cases, matching arrangements are greatly increasing health care funding at local levels. 6. Develop a structure and mechanism for reviewing and approving portions of the platform. It is possible that elements of such a structure are in place already, so I am not recommending any reorganization unless absolutely necessary. 7. Use the platform and strategy as a basis for APHA's future work plan. This will require us to vastly increase our activities in the broader political arena. We will have to develop time frames and periodically evaluate our progress. We will have to establish priorities and learn to understand how national trends and attitudes may influence our activities. We may have to revise our policies from time to time, and learn how to negotiate productively for the basic principles of our platform. In summary, we will have to leave the comfortable, somewhat abstract shelter of the old APHA and enter the gritty arena of active decision-making.
Summary You may be wondering how my remarks tie into this year's theme of futurism. I admit that the subjects of many of this week's speakers are going to be much more intriguing than what I've been discussing. But many of you have given many years of your lives to the concepts embraced by this Association. Time is running out for us to make APHA the national focus for public health policy making. The only way it will assume such a role is by each one of us reaching beyond the constraints of narrow professionalism and special interests to work together to develop a truly equitable and effective national health system. To this I can only add that I hope "the force" is with us in whatever challenges the future may bring.
REFERENCES 1. New Rival for the AMA?, Medical World News, November 7, 1969, p. 39. 2. Abel Wolman, "APHA in Its First Century," Am J Public Health, 63: 319, 1973.
AJPH April 1979, Vol. 69, No. 4
