by DOH during the 1974-1977 period, are in-
dications of a real change in the definition of
the role of public health programs as operated by
local government. Traditionally, programs such as
preventive screening, venereal disease, immuni-
zation, child or school health, have been provided
on the basis of "need" rather than "demand."
Thus, they were generally free and targeted to
achieve maximum health impact, rather than to
reach those already demanding such services or
willing to pay for them.
This "needs based" or epidemiologic principle
has long been seen as intrinsic to the effectiveness
of public health programming. It is a key differ-
ence between most public health and most main-
stream medical programs, and it probably rep-
resents a key reason why DOH services are so vul-
nerable in a time of fiscal crisis.
Preventive services are, in general, a low pri-
ority, unglamorous part of the medical system. In
an era of high-technology, "moon-shot" medi-
cine, taking an immunization history from a pre-
school child or tracking down a high-risk preg-
nancy in a ghetto neighborhood may be brushed
aside as mundane compared to the expensive,
glamorous and dominant specialized medicine
of the large teaching and research centers. Further,
the interests and the ideology associated with
mainstream, marketplace medicine often deny
the relevance of such "life enhancing" efforts.
New York's fiscal crisis has pushed such under-
lying tensions-and the article makes clear they
are old tensions-to the point of open conflict.
The crisis in the City's budget and the scramble
to cut spending and programs has created what
Dr. Lowell Bellin, former NYC Commissioner
of Health, calls a "lifeboat mentality." While
Dr. Bellin is correct in his characterization, it
is just such a mentality which allows those who,
like Dr. Bellin himself, believe that the public
sector is inherently weak and trouble-ridden, an
opportunity to advocate their own preference
for marketplace medicine. This position then gets
promoted as a new, more "rational" criterion
for planning. Thus, for example, the answer to
screening programs without adequate follow-
up is to eliminate the screening program, not to
guarantee the follow-up. Services offered by other
providers are jettisoned as "duplicative," whether
or not the poor and working poor using the pro-
grams have access to these other providers.
6 The accompanying article indicates that the
decisions to cut services and/or spending were,
at times, "very painful" for those involved.
However, it would be a mistake to assume that
those who played key policy-making roles during
the fiscal crisis were simply following orders. In
the case of Dr. Bellin, for example, he indicated
in a speech delivered early in his administration,
that his own personal preference for the role of
health departments was, to quote the title of the
speech, "More Quality and Cost Control, Less
Direct Delivery of Health Services." Some pol-
icy makers, in other words, brought an ideology
opposed to public sector services into office
with them.
In fairness, this process did not begin nor will
it end with Dr. Bellin or any of the other recent
DOH Commissioners who share such an approach.
The status of DOH and the public health mission
it shared with many local departments of health
throughout the country have been in trouble
since at least the late 1960s, when the glamour of
"systems analysis," "modern management skills,"
and the growth of the hospital-oriented Medicare
and Medicaid reimbursement systems (and the
revenues they offered) combined to shift virtu-
ally all of the City's health policy attention and
priorities to HHC and the operation of the munici-
pal hospitals.
Thus it is not surprising that even those func-
tions Bellin and his colleagues actually did de-
fend-the quality control and monitoring func-
tions-have also been taken from DOH and trans-
ferred, for the most part, to the New York State
Office of Health Systems Management (OHSM).
Whether the loss of even these minimal public
health functions by DOH is permanent, is not yet
clear. What is however clear is that the conflict
between truly public health services and the
priorities of the medical marketplace is far from
resolved in cities like New York.
If public health sector opponents continue to
hold sway, it will not be long before the poor
and working poor, and eventually all New Yorkers,
will feel the effect. The primary and preventive
services traditionally provided by the DOH have
had a measurable impact on the health status of
many New Yorkers. Without such services, the
current "lifeboat mentality" may rapidly trans-
form New York City into a "sinking ship."
The Editorial Board