IOM Report: For the Public's Health
by Sally Pobojewski
A new report from the Institute of Medicine calls for a radical transformation of the entire U.S. public health system. Is anyone listening?
Phyllis Meadows has the firm handshake and no-nonsense attitude of someone who understands the real-world challenges of public health practice. Now a clinical professor and associate dean for public health practice in the School of Public Health, Meadows has 33 years of management, administrative, and nursing experience in community-based public health programs—including for the city of Detroit and the W.K. Kellogg Foundation.
But in spite of her background, she insists she's not an expert in anything. "I think of myself as a learner," says Meadows firmly. "Other people may want to call me an expert, but I don't encourage it."
So Meadows was surprised when a representative from the Institute of Medicine in Washington, D.C., asked her to join a national committee charged with developing strategies to improve and strengthen the U.S. public health system.
"I don't know how I was nominated," says Meadows. "I asked, 'How did you hear about me?' They said, 'We can't tell you, it's confidential.'"
Established in 1970 as a branch of the National Academy of Sciences, the Institute of Medicine "serves as adviser to the nation to improve health," according to its mission statement. That advice comes in the form of in-depth reports from carefully selected experts on issues related to medicine or public health. IOM reports are commissioned by Congress, federal agencies, or nonprofit organizations.
"We turn to IOM because of its reputation as a national group that is objective and analytical," says Paul Kuehnert, senior program officer and public health team director for the Robert Wood Johnson Foundation—the organization that commissioned the IOM reports. "An IOM committee focuses the conversation, and IOM reports can catalyze action within the field and among policymakers at all levels of government."
When the IOM contacted her early in 2009, Meadows was just settling into her new job at SPH. Serving on the IOM committee would mean a three-year commitment, additional travel, and a lot of extra work.
Meadows thought it over and agreed to take the job.
"I did it for my profession and for the good of the field," she says. "The public health infrastructure, particularly government-funded public health, is struggling. If this process could help strengthen and sustain the public health system, it would be worth it to me."
Public health experts in America are in the middle of an ongoing debate about the future of their field. Some support maintaining its traditional focus on monitoring and controlling infectious diseases like whooping cough, measles, and influenza. Others argue for a new emphasis on preventing chronic diseases—especially obesity, heart disease, and diabetes. Both sides agree that too much money is spent on clinical care that benefits individuals, doctors, and hospitals, while not enough is allocated for prevention-based programs that could benefit everyone.
The controversy over the future of public health is part of a larger discussion on the cost-effectiveness of the U.S. health care system. In 2009, the United States spent $2.5 trillion on clinical care (so-called "sick care") provided by doctors and hospitals. No other nation even comes close to spending that much. Yet our average life expectancy is lower than most other developed countries, and infant mortality rates in some states are higher than those of developing countries.
State and local public health departments are caught in a perfect storm of economic, social, and policy changes. The global recession, budget cuts, the H1N1 flu pandemic, and uncertainty about their roles after full implementation of the Affordable Care Act have all contributed to the pressure on community public health programs to do more—but with fewer people and less funding.
To explore how best to resolve these complex issues, leaders of the Robert Wood Johnson Foundation decided to sponsor a new series of IOM reports titled For the Public's Health. Their charge to the committee was daunting: review the latest scientific research on how measurement, laws, and funding affect public health, and develop a comprehensive national strategy with specific recommendations to transform the public health infrastructure of the U.S.
When Meadows walked into the first IOM committee meeting, she saw what she calls "a microcosm of the American public health system." The Robert Wood Johnson Foundation had insisted that the 18 members of the committee include not just academic researchers, but also people from state and community public health departments, physicians, and representatives from the health insurance industry.
"I think it led to a richer product," says Meadows. "I wouldn't want to be in a space with practitioners only, who are locked in discussions about day-to-day issues in public health. But at the same time, I wouldn't want to be in a room with researchers only, whose discussions might be driven by their study interests rather than the real challenges facing public health. The insights from both groups were needed."
The blend of two worlds did generate some lively debate and discussion during committee meetings, however. "It was difficult and challenging, but absolutely worthwhile to hear the different points of view," says Meadows. 'There was a lot of debate, and people stood their ground on issues where there was disagreement.
"We had to learn to listen, take the best ideas, and then shape those ideas into something everyone could buy into and accept as a reasonable recommendation," she explains.
IOM staff members attended the committee meetings to take extensive notes and capture the different ideas under discussion. Professional staff writers synthesized the discussion and recommendations into a draft report, which was reviewed and edited by all members of the committee. Preliminary versions of the report were sent out for external review by experts outside the committee. Their input was included and reviewed by everyone again until a final version of the report was accepted and signed by every member of the committee.
The third and final volume of the IOM report, For the Public's Health, was published in April 2012. All three volumes totaling 580 pages are now posted and available on the IOM website. For the Public's Health describes a new vision of the U.S. public health system and includes specific recommendations on how to achieve that vision (see sidebar, page 33).
The committee has disbanded; its work is done. So what happens next? How do committee recommendations move beyond the pages of an IOM report into the real world? Paul Kuehnert describes the process as "diffuse, dynamic, decentralized, and democratic."
"There's no central organization directing this," he explains. "In national and state public health organizations, people will come together in formal and informal ways to discuss the IOM recommendations and decide whether or how to implement them. It's not going to be resolved in just a year or two."
As an example of how the process works, Kuehnert points to a previous IOM report, The Future of the Public's Health in the 21st Century, which was released in 2003, while he was working as a local health officer in Illinois. This report included a recommendation that all state and local public health departments be accredited based on national standards.
"There was much debate and discussion—in the field and at meetings of various kinds among local, state, and tribal public health practitioners—about accreditation," Kuehnert recalls. "Ultimately, over the years, consensus built that it was a good thing. In 2011, the public health accreditation board launched its formal accreditation program, and we anticipate that the first accredited public health departments will be announced later this year."
Change can't happen soon enough for Meadows, who admits to some impatience with the slow pace of progress in the field.
"Public health has to transform itself; it cannot be what it was 30 years ago," she says. "We haven't even begun to use the knowledge we have about the social determinants of health, which are the major factors that impact health. Public health isn't just for poor people. It's for America."
Sally Pobojewski is a freelance science and medical writer based in Chelsea, Michigan.