No...there are more important issues that deserve our focus!
Historically, the Ten Essential Public Health Services, promoted by the Centers for Disease Control, [i] have served as a framework to define the scope of the public health profession in the United States, and justify much needed federal funding.[ii] However, while this list of services provides a context for public health as a discipline on many levels (federal, state, county), it provides an incomplete framework for practice. The Ten Essential Services document is a framework that is constrained by the system in which it was developed; one that is primarily oriented towards public health solutions that are focused on the individual. Some public health practitioners have suggested that the Ten Essential Services are outdated - or at best inappropriate - for practical application in the field of public health. At present, a work group of California's public health officers has coalesced to redefine and/or update the existing Ten Essential Services, in the hope that such efforts will engender more relevant public health practice. However, if we believe the fundamental goal of public health practice is to improve population health, it is worth asking whether it necessary for county public health officers to spend their time, energy and resources redefining the Ten Essential Services, or whether there might be a better use of such efforts.
The Ten Essential Services can be relevant to current public health practice, to the extent that this framework reminds practitioners of the fundamentals of the discipline, how broad the scope of work can be, and the importance of a multilateral approach to problem solving at the population level. And yet, the scope of the framework is so broad as to be almost undefined. The first two goals of Healthy People 2010 [iii] offer an example of the applicability (or lack thereof) of the Ten Essential Services. Current California mortality data suggest an overall positive trend - that we are doing better in our efforts to improve years of life (part of HP 2010 goal number one), but illustrates the challenges we face in eliminating health inequities (HP 2010 goal number 2). As public health practitioners, we struggle to describe health inequities beyond their medical definitions, emphasizing that health is attributable in large proportion to environmental, social and economic factors. However, measuring longevity as a proxy for population health may be misguided. Rather than identifying the root cause of a particular health inequity, the use of a mortality rate as a health indicator may in fact limit public health efforts to develop policies that can address this inequity beyond those solutions that are traditionally focused on individuals.
The lack of available morbidity data, the lack of validated measurement tools, and the lack of widespread dissemination of the “place-based” approach to public health solutions suggest that California's county level health officers should shift their focus away from further redefining the Ten Essential Services, and instead focus on development of better measures of population health. Simply measuring longevity, and the use of such data to inform policy decisions, ultimately undermines the community-based approach to public health:
Measurement can, and in this context does, function as a trap. We measure a thing because it can be measured, and then we find our system trying to supply what we measure, not because it is what we want, but because it is what we can measure, and thus disseminate.[iv]
Health policy decisions that allocate resources to address or eliminate a particular health disparity are informed by trends that we can measure. With federal policy that is increasingly focused on measurement as a mechanism to improve quality of care in the US, it may be not only useful but strategic to focus some effort towards developing validated measures of population health. Insofar as public health officers can bring daily practice to bear on health policy discussions, it seems clear that – rather than redefining the Ten Essential Services – their efforts may be better dedicated towards developing measures that reflect more appropriate indicators of “place-based” health, and that will serve to reframe discussions of national health policy.
[i] Centers for Disease Control and Prevention. The Essential Public Health Services. Office of the Director: National Public Health Performance Standards Program. Available at: http://www.cdc.gov/od/ocphp/nphpsp/EssentialPHServices.htm. Accessed March 18, 2008.
[ii] Institute of Medicine (US). The Future of Public Health. Washington: National Academies Press; 1988.
[iii] Healthy People 2010: Fact Sheet. Department of Health and Human Services: Office of Disease Prevention and Health Promotion. Available at: http://www.healthypeople.gov/About/hpfact.htm. Accessed March 18, 2008.
[iv] Fine, M. The Nature of Health: How America Lost, and Can Regain, A Basic Human Value. Radcliffe Publishing Ltd. Oxon, UK: 2007.