Planning for the Future of Cambridge Public Health HKSG MPP masters thesis PAE

VISION 2000:
PLANNING FOR THE FUTURE
OF CAMBRIDGE PUBLIC HEALTH
Policy Analysis Exercise
submitted by:
Steve Gordon and Edward Warburton
Client:
Frank Duehay
Cambridge City Councilor
Advisor:
Henry Solano
Kennedy School of Government
In partial fulfillment of the requirements
for the Master's in Public Policy degree,
John F. Kennedy School of Government
April 13, 1993

Page ii
TABLE OF CONTENTS
Executive Summary.........................................................................................................iii
Introduction......................................................................................................................1
Methodology....................................................................................................................3
Findings ...........................................................................................................................4
Authorizing Environment ....................................................................................4
Organizational Structure......................................................................................5
Environmental health...............................................................................7
Community Health...................................................................................8
Public Health Nursing..............................................................................8
School Health...........................................................................................9
Service Delivery...................................................................................................9
Major Initiatives...................................................................................................12
APEX PH.................................................................................................13
Health of the City.....................................................................................14
Hospital Expansion/Strategic Workplan..................................................17
Literature Review.................................................................................................18
The Future of Local Public Health Departments.....................................18
Medicalization of Social Problems..........................................................22
Analysis............................................................................................................................23
Public Health and Medical Care ..........................................................................23
Future Trends in Public Health............................................................................27
Medicalization of Social Problems..........................................................27
Managed Care/Community Health Networks..........................................28
Recommendations............................................................................................................31
Guiding Principles ...............................................................................................31
Specific Recommendations..................................................................................32
A Model for a New Department of Health ..........................................................35
Conclusion .......................................................................................................................38
Appendix A: List of Meetings and Conversations..........................................................40
Appendix B: Cambridge in Brief....................................................................................41
Appendix C: Massachusetts Public Health Report Card ................................................43

Page iii
Executive Summary
With the health policy debate gaining steam nationally and an evaluation of the
city manager and changes in the Department of Inspectional Services coming up locally,
Cambridge City Councilor Frank Duehay sponsored this Policy Analysis Exercise in
order to get a sense of what form the optimum Cambridge Health Department would look
like in the year 2000. In this document, the authors analyze the public health system
using the strategic triangle of authorizing environment, organizational capabilities, and
clients; review literature on public health; and present recommendations for the short,
medium, and long term.
The city of Cambridge and the city government present a permissive and rich
authorizing environment which enthusiastically encourages initiatives for the public good
and enlists the aid of many volunteer citizen boards. In an effort to properly balance
preventive/public health and acute care, a 1976 ordinance created the current Cambridge
Department of Health and Hospitals.1 A Commissioner of Health oversees The
Cambridge Hospital, Neighborhood Health Centers, Neville Manor, and the Health
Department. Traditional public health functions are under either the direct control of
other city departments (for instance, the Department of Inspectional Services conducts
restaurant inspections) or under the Health Department, which spent less than 2% of the
Department of Health and Hospital budget of $63 million in fiscal year 1991.
Three major findings emerge from a study of the organizational capabilities of the
Health Department: first, some activities do not seem to fit the capabilities of the
department (e.g. hazardous waste collection); second, there is overlap of functions with
many other parts of the Department of Health and Hospitals performing public health
efforts (e.g. The Cambridge Hospital operates the Neighborhood Health Centers which
provide the venue for much Public Health Nursing efforts); and third, increasingly
important public health functions appear to be under-funded and/or under-staffed (e.g.
1The Code of the City of Cambridge. Chapter Eleven: Health, Hospitals and Housing.

Page iv
public health assessment, coordination with other state and local departments, and
coordination of grant applications). These findings are supported by the patterns of
activity characteristic of the subcommittees of the Health Policy Board: the Governing
Board of the Hospital receives staff support and takes an active role in the hospital
accreditation process and is in general much more active than the public health
subcommittee.
Study of the clients focused on three major health initiatives ongoing in
Cambridge: Assessment Protocol for Excellence in Public Health (APEXPH), Health of
the City, and the hospital expansion. APEXPH, The Department's potentially powerful
self assessment vehicle, has been hampered by lack of staff time. Health of the City, a
foundation-funded effort to enhance the relationship of The Cambridge Hospital with its
service community, has sponsored the Men of Color Task Force and the Healthy Children
Task Force. The Hospital's expansion is an attempt to renovate antiquated facilities and
anticipate national changes in health care funding by providing more preventive and
outpatient care.
These three initiatives together suggest unmet client needs in Cambridge. The
Health of the City effort has shown community needs that the Department as it now
stands does not treat -- and hopes to be institutionalized as part of the Department
eventually. The hospital is actively anticipating a health services reimbursement scheme
which rewards preventive health. Such a regime would further blur the division of labor
between public health and medicine.
A literature review of current trends in public health and the medicalization of
social problems indicates that Cambridge is not alone in facing a rapid rate of change. In
fact Cambridge meets already or is taking steps to address all of the recommendations in
a recent Institute of Medicine report on public health. This indicates that Cambridge is
relatively well positioned to meet increased demand for expertise, the movement of social
problems from other realms to health, and the need for more and better health data.

Page v
Specific recommendations for the Department of Health and Hospitals include:
Over the short term
• Complete the APEX PH project as completely as possible.
• Begin talks aimed at merging the Health of the City efforts with those of The
Department.
Over the intermediate term
• Establish a formal reporting process to ensure the flow of information regarding all
health related activities to health policy makers, for example from the Department of
Inspectional Services health inspectors to the Commissioner and the Health Policy
Board.
• Move individual-level, direct treatment services to the direct control of the Hospital.
• Move hazardous waste collection to the Department of Public Works.
• Hire a full time biostatistician in order to incorporate the APEX PH process into the
regular planning efforts of the Health Policy Board.
• Create a new position of revenue coordinator within the Department.
Over the long term
• Design and implement a new model for the Department of Health, building upon
conversations already begun. Key elements of this new Department should include
1. a Health Intelligence Unit;
2. a Community Health Coordination Unit;
3. a Grant Writing/Assistance Unit; and
4. an Emergency Surveillance and Response Unit.

Introduction
Health care systems in Cambridge and the nation face great challenges. Doctors
and the "medical-industrial complex" continually find treatments for problems previously
defined as permanent conditions of life, often at great cost; public budgets for health care
grow faster than inflation as governments define health care concerns as a right, not a
market commodity; and medical and public health officials persuasively address some of
our most difficult and divisive social problems. New voices demonstrate the tenuous
connection between health care spending and health,2 and point out the profound
connections between health and other aspects of life, especially "community," defined in
various ways.3 Heightened sensitivity to the environment regularly turns up new
ecological implications for health (examples include the discovery of radioactivity,
concerns about effects of low level electromagnetic fields, and newly discovered
properties of many foods and drugs). All told, there is today a great challenge for our
public health arrangements to anticipate, define, and in some sense create the texture of
our collective life in the next decade.
This report represents an effort by the authors, working with Cambridge City
Councilor Frank Duehay and an ad hoc committee of Cambridge citizens and civil
servants, to rise to the challenge by answering the question: what will an effective Health
Department look like in the year 2000, and how do we get there from here? Cambridge
would seem to be the perfect place for hammering out a new and workable solution to
this nation's health care dilemma: it has committed citizens, a balanced budget, and a
successful hospital affiliated with Harvard Medical School. The Cambridge system
should be a model for the nation. Is it now? Are the city's relatively abundant resources
2See, e.g., Thurow, Lester C., "Reality and US Health Care," Boston Globe March 23, 1993, p. 40.
3See especially results of Health of the City's Men of Color Task Force; and interview with Dr. Ronald
David in Spring 1993 Harvard Magazine.

coming together in the best way possible to make appropriate and effective investments
in the health of Cambridge? This report investigates the following questions:
• What sort of balance does the current public health structure exhibit among
authorizing environment, organizational capabilities, and the needs of current and
potential clients?
• What structural dynamics underlie the process of setting health policy priorities in
Cambridge, and will they help or hinder movement toward continuous
improvement?
• What "Vision 2000" for public health will make Cambridge a model for the
nation?
For a vision to stand a realistic chance of improving current reality it must grow
out of the demonstrated and expressed values of the people and organizations who will
implement it. Therefore this report does not deal in abstractions or "ideal" visions from
the literature, but in actually expressed and demonstrated needs and capabilities of
diverse groups of deeply committed citizens, providers, elected officials, and civil
servants. As Leland Kaiser put it, "visions are values projected into the future."4
Thus our central question: How can Cambridge master this change? We address
this question in three steps.
• A discussion of the authorizing environment, current organizational structure,
current clients as defined by service delivery, and potential clients as defined by
major current health initiatives in Cambridge and a discussion about the changing
nature of public health.
• Analysis of these findings and systems dynamics in the Cambridge health
community and their implications for the future.
• Recommendations for change in the near, medium, and long terms.
4Quoted in "Bridging the Leadership Gap in Health Care," Healthcare Leadership Forum, p.4.

Methodology
The authors collected information concerning the public health system of the City
of Cambridge from three chief sources: interviews, documents, and public hearings.
Interview sources included key individuals involved with the public health system who
were well-informed about public health efforts in Cambridge and/or held key positions of
influence over the future of public health in Cambridge. Such individuals included the
Commissioner of Health and Hospitals Dr. Melvin Chalfen, the Administrator (CEO) of
The Cambridge Hospital John O'Brien, members of the Health Policy Board, the
Chairperson of the Department of Medicine at The Cambridge Hospital Dr. David Bor,
and the client, Cambridge City Councilor and Chairman of the City Council Sub-
Committee on Health and Hospitals Frank Duehay.5
These individuals provided documents pertaining to the public health system,
including budgets, annual reports, organizational trees, personnel lists, comparative
health data, and supporting materials for ongoing public health efforts. City ordinances
and minutes from public meetings provided a sense of the statutory responsibilities and
day to day concerns of the system, while local newspapers provided a source of detail
regarding programs and public opinion.
Public hearings or meetings in Cambridge average over five a week. During the
period of research the authors attended many to glean a sense of context for the
development of health policy in Cambridge and to observe the venue in which any future
deliberation concerning our recommendations would occur. Many of the individuals
interviewed played key roles in these meetings. Attended hearings included those of the
Health Policy Board, its sub-committees, the City Council, and its subcommittee on
Health and Hospitals.
Using the research tools available through the Harvard library system, the authors
reviewed the academic literature for present trends in public health and health care in
5See Appendix A for a complete list of interviews conducted and meetings attended.

general. This information formed a backdrop for comparison with the efforts in
Cambridge.
Findings
Authorizing Environment
Appendix B provides a demographic summary of Cambridge. Briefly, Cambridge
is an unusual melting pot of New England history, ethnic diversity, higher education,
tolerance of alternative lifestyles, cutting edge technology, and political and social
entrepreneurship. Within the city limits live both an unusually large number of well-
educated, highly motivated individuals with the utmost concern for the public good, and a
population of poor and disenfranchised persons similar to those residing in most
American urban settings. This combination of resources and needs produces in
Cambridge an uncommonly strong and enduring commitment by both citizens and
government toward public health and social welfare. Public servants have tremendous
pride in their historical devotion and wide range of services provided, both municipally
and by private organizations.
Important influences on the health care system come from three sources: the nine
member city council, the city manager and his appointed officials, and a community of
activists and interested parties. According to Cambridge public documents,6 Cambridge
"has a Council-Manager form of government. The legislative and policy making body of
the City is the nine-member City Council, whose members are elected at-large for two-
year terms." City Councilors are elected using a proportional representation system, a
complex means for identifying the nine winners of each biennial election. One by-
product of this election scheme is that a councilor can win a seat with as few as 1,500
"number one choice" votes.
6City of Cambridge, Massachusetts Comprehensive Annual Financial Report July 1, 1990-June 30, 1991.

"The City Manager is the chief administrative officer and carries out the policies
of the City Council. With the assistance of a Deputy City Manager and three Assistant
City Managers, the Manager coordinates the functions of 41 municipal departments and
is responsible for the delivery of services to residents. The City Manager is appointed by
the City Council and serves at the pleasure of the Council."7 This arrangement allows a
dedicated body of public servants to operate free from the day to day influence of
politics. A public performance review of the City Manager by the City Council is
presently underway in preparation for negotiations and consideration of the possibility of
a new Manager when the present City Manager's contract expires June 30 of this year.
The openness of municipal government permits significant influence on policy by
the many vigorous citizen boards, committees, and advocacy groups which populate the
city's political landscape, ranging in interest from rent control to protection of the
stratospheric ozone layer. Acting by earning grant money or through long tenure on
ordinance-established boards, small groups have the opportunity to wield significant
power over the city's policies-in-action. These three facets of the authorizing
environment--citizens, municipal employees, and elected officials, combine to produce to
produce what can be called the "health policy" of the city.
Organizational Structure
In response to perceptions that investments in public health did not balance
investments in acute and chronic care, a 1976 city ordinance created the present
organizational structure for health services.8 Section 11-2(b) states "The Commissioner
shall be responsible for promoting and protecting the health of the citizens of
Cambridge." A new citizen's board, the Health Policy Board, provides a channel for
citizen concerns and sets health policy for the city in consultation with the Commissioner.
7City of Cambridge, Massachusetts Comprehensive Annual Financial Report July 1, 1990-June 30, 1991.
8The Code of the City of Cambridge. Chapter Eleven: Health, Hospitals and Housing.

Specifically, "Although the Commissioner retains full authority for action, the
Commissioner shall discuss major problem areas and proposed policy changes with the
Health Policy Board and is expected to reach agreement with them before making policy
changes."9
The 18-member Health Policy Board (originally 15-member) is comprised of
roughly equal numbers of medical professionals, non-medical professionals, and
consumers. The board members are unpaid appointees of the City Manager. The Health
Policy Board divides itself into three working 12-member sub-committees, with each
member of the full board serving on two committees. These sub-committees are Public
Health, Neville Manor, and The Governing Board of the Hospital.
The Hospital Governing Board receives staff support from The Hospital, and
serves the functions required of all hospital boards under the Joint Commission for the
Accreditation of Health Organizations (JCAHO) guidelines. The Public Health and
Neville Manor sub-committees receive staff support from The Department on an as-
needed basis. The Hospital Governing Board tends to be much more active than the
other two sub-committees, reflecting, among other things, its heightened responsibility
under JCAHO guidelines, its greater staff support provided by the resources of The
Hospital. Whereas the Commissioner reports regularly to the Health Policy Board on
activities of The Department, The Hospital Administrator reports to the Governing Board
on hospital activity and involves its members frequently in strategic planning [see the
section on hospital expansion/strategic workplan, below].
Directing the Department of Health and Hospitals is a Commissioner appointed
by the City Manager. The Department of Health and Hospitals is divided into four
operating units: The Cambridge Hospital [The Hospital], Neighborhood Health Centers,
Neville Manor, and the Health Department [The Department]. The Department of Health
9The Code of the City of Cambridge 11-2(g).

and Hospitals had a budget of $63 million in expenditures in FY 91, $815,000 of which
were incurred by The Department. While the Commissioner is technically in charge of
all four divisions of the full Department of Health and Hospitals, on a daily basis his role
regarding The Hospital, Neville Manor (a municipally operated nursing home), and the
Neighborhood Health Centers resembles more of an oversight capacity, while he retains
daily management responsibility for The Department. The responsibilities and activities
of The Department break down into four general categories: environmental health,
community health, public health nursing, and school health.
Environmental health.
With a projected fiscal year 1993 budget of $85,000, environmental health efforts
include the following:
• Monitoring hazardous material incidents: for instance, Dr. Chalfen provided
expert testimony when several households experienced carbon monoxide
poisonings on Tuesday, January 26 of this year; The Department also responded
to complaints by monitoring fumes emanating from Central Square Printing.10
• Interacting with citizen boards such as the emergency planning and biohazards
committees.
• Household Hazardous Waste Collection Days. Although the Cambridge 1992-93
Annual Budget states that these events, which occurred twice in 1992, "continue
to be popular and well attended,"11 a letter to the Cambridge Chronicle editor
headlined "City gets an 'F' for hazardous waste efforts" states "I have never seen
such an extraordinary public display of incompetence as these two hazardous
waste collections...why was the Department of Health and Hospitals ever put in
charge of this operation?"12
• Oversight of the Department of Inspectional Services in several functions
formerly under the management of The Department, including responding to
complaints by Cambridge residents regarding the health and safety of their
apartments and homes.
10Cambridge Chronicle, November 5, 1992.
11City of Cambridge Annual Budget IV-229.
12Cambridge Chronicle, October 29, 1992, p. 27.

Community Health.
The community health budget is projected to grow from $84,000 in fiscal year
1991 to $157,000 in fiscal year 1993. The staff of two includes the following:
• Community Health Coordinator/Coordination of city-wide AIDS efforts. This
staff member coordinates the citywide response to AIDS and interacts the citizen
boards, especially the AIDS Task Force and Boston and Massachusetts consortia,
to ensure treatment, education, housing, and advocacy for AIDS patients.
• Community Health Social Worker/direct services for elderly. This staff person
interacts with boards and committees to plan and develop programs for "home
visiting, consultation, integration, and coordination of services for elderly living
in Cambridge who have problems related to or arising out of their health needs."13
Public Health Nursing.
The staff, operating largely out of The Hospital's Neighborhood Health Centers,
executes budgetary activities growing from $270,000 in fiscal year 1991 to $330,500 in
FY 93. Activities include:
• Tuberculosis clinics based in the hospital, school visits, and visits in homes and
shelters,
• Homeless health assessment, referral, and advocacy.
• Influenza vaccination clinics and vaccine distribution.
• Investigation of communicable disease occurrence.
• Family health program implementation in coordination with Massachusetts
Department of Public Health and other groups.
School Health
With a budget that is projected to grow 10% from fiscal year 1991 to $383,000 in
fiscal year 1993, school nurses logged 22,000 encounters in 1990-1991 (a 100% increase
13City of Cambridge Annual Budget IV-228.

since 1987). School health practitioners are facing tremendous pressure to keep up with
deepening and broadening problems (social, developmental, and psychological as well as
medical) in the face of increasing state demands and aggressive "mainstreaming." School
nurses are involved with a wide range of teams, non-profit organizations, committees,
and other service agencies.
Service Delivery
Defining the nature and scope of services delivered by The Department is a
challenging task. Most of them interact with other activities of the department, with other
city agencies, and the private and non-profit sectors. Moreover, new demands arise
frequently and old ones fade away. As an attempt to understand this complex picture, the
following discussion "presents a framework for viewing the evolving structure of
the...business, highlighting not only individual components but also the shifting
functional...boundaries between them."14 The essential goal is to illuminate basic forces
and trends as well as strategic positioning and policy relationships.
Figure 1 displays a "map" of the health services. Each entry represents a service
activity and is shown in relation to two axes. The vertical axis roughly tracks the
chronological order in which clients move through the health service system and can be
divided into seven business systems. Entries to the extreme north of the map represent
advocacy, response to technical queries, and other activities with potentially profound but
indirect effect on health. As entries move east along the horizontal axis, they describe
interventions targeted at larger systems: from the individual on the extreme west, through
communities of increasing size, to entire ecosystems on the right. This scheme reflects
the diversity of actions now undertaken by The Department.15 Activities at the extreme
northeast are perhaps the most interesting as they represent a frontier of community based
14McLaughlin, John F., with Antonoff, Anne Louise, Mapping the Information Business (Cambridge,
Mass.: Program on Information Resources Policy, Harvard University: 1).
15See Roszak, Theodore, The Voice of the Earth (New York: Simon & Schuster, 1992).

advocacy or political action (for example, the Ordinance to Protect the Stratospheric
Ozone).
A useful feature of the map lies in its ability to lay out theoretical relationships
and areas of responsibility. For example, Figures 2 and 3 graphically show the contrast
between the fundamental paradigms of medicine and public health, biochemistry and
epidemiology.16 Finally, Figure 4 displays the overlapping areas of responsibility
between The Hospital and The Department. Implications of the health services map are
analyzed in a later section.17
16"The IOM Report and Public Health," JAMA July 25, 1990 vol 264, no. 4.
17On initial review of the map, however, it does appear the Hospital is taking on responsibility for services
(for instance, immunizations and elderly care) which are called "public health" for apparently traditional
reasons. This may have implications for other health services in this part of the map (for instance, school
health).
HEALTH
PROMOTION
QUALITY
ASSESSMENT
TREATMENT
CARE ORDERS
CARE PLANNING
IDENTIFICATION/
DIAGNOSIS
INTERVIEW
EXAMINATION
/
INDIVIDUAL "SUB-COMMUNITY" COMMUNITY ECOSYSTEM
some%school%health
school%health%visits
shelter%visits
Men%of%Color
Healthy%Kids
elderly%care%referrals
restaurant/other%code%enforcement
targetted%immunizations
some%school%health
school%health%statistics%collection
rabies%education
AIDS%efforts%coordiination
advise%on%health%issues
promotion%of%smoking%ordinance
communicable%disease%education
APEX%PH
enforcement%of%smoking%ordinances
communicable%disease%investigation
restaurant%inspections
statistics%collection
monitor%environment
env.%emerg.%planning
hazardous%waste%coll.
enforce%env.%reg.
set%health%policy
ozone%ord.%efforts
Figure 1

HEALTH
PROMOTION
QUALITY
ASSESSMENT
TREATMENT
CARE ORDERS
CARE PLANNING
IDENTIFICATION/
DIAGNOSIS
INTERVIEW
EXAMINATION
/
some%school%health
shelter%visits
Men%of%Color
Healthy%Kids
some%school%health
rabies%education
APEX%PH
monitor%environment
enforce%env.%reg.
set%health%policy
ozone%ord.%efforts
Traditional realm of medicine
Figure 2
HEALTH
PROMOTION
QUALITY
ASSESSMENT
TREATMENT
CARE ORDERS
CARE PLANNING
IDENTIFICATION/
DIAGNOSIS
INTERVIEW
EXAMINATION
/
some%school%health
shelter%visits
Men%of%Color
Healthy%Kids
targetted%immuinizations
some%school%health
rabies%education
APEX%PH
monitor%environment
enforce%env.%reg.
set%health%policy
ozone%ord.%efforts
Traditional realm of epidemiology (public health)
Figure 3

HEALTH
PROMOTION
QUALITY
ASSESSMENT
TREATMENT
CARE ORDERS
CARE PLANNING
IDENTIFICATION/
DIAGNOSIS
INTERVIEW
EXAMINATION
/
some%school%health
shelter%visits
Men%of%Color
Healthy%Kids
rabies%education
APEX%PH
monitor%environment
enforce%env.%reg.
set%health%policy
ozone%ord.%efforts
Hospital services Public Health services
some%school%health
Figure 4
Implications of the health services map are analyzed in a subsequent section, but
it does immediately suggest that The Hospital is both finding incentive for and turning
out to be better equipped to deliver services at the levels of direct treatment and below.
The Hospital is taking on responsibility for services (for instance, immunizations and
elderly care) which are called "public health" for exclusively traditional reasons. This
may have profound implications for other health services in this part of the map (for
instance, school health). It indicates that the core competencies of The Department lie in
health education, promotion, and services targeted at the entire community and city-as-a-
whole.
Major Initiatives
In addition to the daily activities pertaining to service delivery outlined above, at
present there are three major initiatives regarding public health services in Cambridge
which warrant special discussion here. These initiatives represent the fundamental milieu
for individuals intent on improving public health in Cambridge, and constitute the main

vehicles envisioned for change in this area in the coming years. As such they represent
an untapped body of potential clients whose needs the current system does not fully meet.
APEX PH
In early 1992 the Commissioner, in consultation with the Health Policy Board and
the Hospital Administrator, commenced a formal internal review of The Department's
organizational capacity and role in meeting the health needs of the community, using the
Assessment Protocol for Excellence in Public Health (APEX PH) developed by the
National Association of County Health Officials. APEX PH is an instruction workbook
describing in step-by-step fashion how a local health department can continually improve
its performance. The Executive Summary of APEX PH describes the process as follows:
The APEX PH workbook is offered to local health departments as a means of
enhancing their organizational capacity and strengthening their leadership role in
their communities. It is intended for voluntary use by a local health department.
A strong local health department will better enable a community to achieve
locally relevant goals.
The workbook guides health department officials in two principal areas
of activity: (1) assessing and improving the organizational capacity of the
department, and (2) working with the local community to assess and improve
the health status of the citizens. It has three main parts.
Part I, Organizational Capacity Assessment, helps a health department
director and an internal assessment team focus on improving organizational
performance. Included are indicators which focus on authority to operate,
community assessment, policy development, and major administrative areas.
This part of the workbook assists health departments in creating an
organizational action plan, including setting priorities for correcting perceived
weaknesses. When the Organizational Capacity Assessment is made an
ongoing process, it should result in progressive improvement in the performance
of a health department.
Part II, The Community Process, strengthens the partnership between a
local health department and its community in addressing the community's major
public health problems and building a healthier community. It guides the
formation of a community advisory committee, which identifies health problems
requiring priority attention and then sets health status goals and programmatic
objectives. The aim is to mobilize community resources in pursuit of locally
relevant public health objectives. It will lay the groundwork for local adoption of
the Healthy People 2000 objectives and other appropriate national or state
objectives.
Part III, Completing the Cycle, describes activities that are necessary to
ensure that the plans developed for Parts I and II are effectively carried out and
accomplished the desired results. These activities include policy development,
assurance, monitoring, and evaluation.

Efforts to complete APEX PH Parts I and II are continuing. Members of the
Commissioner's staff completed their preliminary internal assessment by the end of
February, 1993. Meanwhile, collection of comparative health data, an important
component of Part II, continues. Efforts have been impeded, according to the
Commissioner,18 because staff must integrate the work to complete APEX PH with their
daily responsibilities to The Department [no funds are earmarked for APEX PH]. An
integral component of APEX PH is the formation of a Community Health Committee,
"the essential mechanism by which consensus on health problems and priorities in the
community health plan is achieved."19 At its January meeting, the existing Public Health
Sub-Committee assigned this capacity to itself.
Health of the City
In 1986 The Pew Charitable Trusts and The Rockefeller Foundation created
"Health of the Public: An Academic Challenge," an effort designed to enhance the
"town/gown" relationship between the nation's leading academic medical centers and the
(often poor and disenfranchised) communities in which they are frequently situated.
Eventually focused in grants to seventeen centers across the United States and Canada,
the Health of the Public initiatives "encompass diverse activities from curriculum reform
in medical schools to working with elected officials on defining health priorities."20
Harvard Medical School, and its affiliate, The Cambridge Hospital, is one of these
centers.
Each center developed a unique agenda for improving the health of its local
community. The Cambridge team expects to meet two specific objectives: "(1) Involve
the academic health center in the social/political process as an advocate of the health of
18Personal communication, January 25, 1993.
19APEX PH p. 88
20Health of the Public: An Academic Challenge Descriptive pamphlet, undated.

the public, and (2) Assume institutional responsibility for maximizing the health of a
defined population within available resources."21
Initially, the Cambridge team focused its efforts on implementing the priorities
established in Healthy People 2000, a list of public health goals produced by the U.S.
Department of Health and Human Services [see literature section]. After creating a
Consortium Board and surveying the community for input, the Cambridge effort, named
The Health of the City Program (HOTC), switched directions.
"The [Consortium] Board explained that the Healthy People 2000 objectives
focused on specific diseases and health problems, whereas they and the survey
respondents tended to think in terms of specific constituencies of people who
may be at risk for many of the problems. Health problems could not be isolated
from their socio-political context or identified independent of groups who
experienced those problems....At this point, the Consortium Board redefined its
role to be an advisory group and mandated two task forces to define the health
needs for two particularly vulnerable constituencies: men of color and
children."22,23
The Healthy Children Task Force blossomed immediately. It divided further into
eight sub-committees functioning as action groups to address eight priority areas24 and
drew heavily from the activities and personnel involved with another Cambridge action
committee, The Cambridge Kids Council. This overlap facilitated the identification of
individuals to participate in the program, the enumeration of priority problem areas, and
program design and implementation. According to their internal assessment, "the action
groups have made significant strides toward meeting the goals of Health of the City:
identifying gaps in health care and inter-agency coordination; devising strategies to
improve health; and engaging medical academics and students in that process."25
21"Progress Report of the Health of the City Program: A Harvard University/City of Cambridge
Collaboration (10/1/90-9/30/92)" Unpublished report.
22 Ibid. p. 2.
23What are termed here "specific constituencies of people" are labeled "sub-communities" on the health
service maps.
24(1) Early Childhood/At-risk Populations, (2) Hunger and Nutrition, (3) Mental Health, (4) Substance
Abuse Prevention, (5) Violence Prevention, (6) Health Education, (7) Sexuality, and (8) Children's Health
Database.
25Op. Cit. # 21 p. 6.

Essentially, the Health Children Task Force faced the task of funding and
coordinating relatively well-defined solutions to the uncontroversial health problems of
readily identifiable at-risk groups with the help of a well established and passionately
committed advocacy community (and all this outside the rigid accountability of
government structures). The Men of Color Task Force, on the other hand, confronted
substantial obstacles from the outset. Not only was the range of workable solutions
unclear, but the problems and even their target community were not well defined. In
order to identify the problems and concerns of this population, the task force would need
to consult and incorporate men of color. its members would need to be Unlike children
and other readily identifiable at-risk groups, there was no pre-existing community
structure representing or organizing men of color. Led by Ken Reeves, first African-
American Mayor of Cambridge, the Task Force conducted a "Saturday Luncheon" on
July 18, 1992, attended by 75 men of color. From this meeting emerged agreement to
pursue efforts to organize men of color through such meetings and use this political
organization as a vehicle for identification of health needs and development and
implementation of programs to meet these needs. Progress in this capacity is continuing.
Funding uncertainties have hampered additional activities of The Health of the
City Program recently. The initial grant expired in the fall of 1992, and efforts are
presently underway to secure additional funding from private philanthropies, local health
institutions, and municipal sources. While past and present activities of the Health of the
City Program have occurred technically as a privately functioning group, many of the key
individuals behind this effort are municipal employees (e.g. the Acting Chairman of the
Department of Medicine at The Hospital), and municipal offices are commonly used for
group activities. The future of this program and the role of the city in this future, both
formal and informal, remains a key question.
Hospital Expansion/Strategic Workplan

The Hospital under the guidance of Administrator John O'Brien is presently
planning a $40 million plant expansion to modernize outdated facilities, expand capacity
for outpatient care, and decrease inpatient capacity. This expansion coincides with a
strategic workplan of The Hospital to develop itself, in conjunction with its multiple
community health centers, into a provider network to function within the "managed care"
environment likely to prevail in Cambridge and the nation within a few years.
The annual City Budget contributes approximately $7 million to The Hospital to
fund uncompensated care. Until recently, despite this supplement the Hospital
continually operated at a deficit. Recent management changes have resulted in an
operating surplus, however, and the Hospital has been able to build up cash reserves in
excess of $20 million while improving quality of care and increasing service volume.
While these cash reserves will partially fund the planned expansion, additional funding
must come from municipally backed loans, requiring the approval of the City Council.
Deliberation on this matter is presently continuing.
There are substantial changes underway in the funding mechanisms for medical
care in Massachusetts and the U.S. The Hospital is developing a strategic plan to reform
itself into an organization optimally situated to continue its mission to serve all the
medical needs of the citizens of Cambridge within this new and increasingly competitive
environment, as well as pursue its more ambitious goal of becoming "the best public
teaching hospital in the United States."26 In developing and implementing this strategic
plan The Hospital has aggressively implemented the continuous quality improvement
philosophy of W. Edwards Deming and required by the Joint Commission for the
Accreditation of Healthcare Organizations (JCAHO).
Literature Review
26The Cambridge Hospital Draft Strategic and Operational Priority Workplan 1993. Unpublished Draft
January 1993.

The Future of Local Public Health Departments
A review of the academic literature for trends and recommendations concerning
local public health efforts revealed that, while most authors comment on efforts for one
or another specific public health problem (i.e. smoking, environment, seatbelts, TB), in
recent years a number of large assessments of and recommendations for the nation's
public health system per se have emerged. Central among these is a 1988 review by the
Institute of Medicine (IOM)27 which, after conducting an exhaustive review of efforts at
the local, state, and national level, concluded the nation's public health system is in
"disarray" and the nation "has lost sight of its public health goals."
The IOM focused its report on identifying weaknesses and redefining the nation's
public health mission. The report declared the mission of public health, "to assure
conditions in which people can be healthy," and the functions of public health,
"assessment, policy development, and assurance." Agencies at all levels of government
are responsible for carrying out these core functions in fulfillment of the mission. The
report delineates numerous guiding principles and concrete recommendations for
improving public health services at all levels of government. The IOM report's findings
have been widely endorsed.28,29,30,31,32 A selection of the report's findings concerning
public health at the local level of government follow:
• Further definitions of the three core functions of public health at the local level:
1. Assessment, monitoring, and surveillance of local health problems and needs
and of resources for dealing with them;
27Institute of Medicine. The Future of Public Health. p. 19.
28Walker, B Jr. The future of public health. American J Public Health 82(1):21-3 1992 Jan.
29Shannon, IS. Public health's promise for the future: 1989 presidential address. American J Public
Health 80(8): 909-12, 1990 Aug.
30"The IOM report and public health." Council on Scientific Affairs. American Medical Association.
JAMA 262(4):503-6, 1990 July 25.
31Ward, D. Public Health Nursing and The Future of Public Health. Public Health Nursing. 6(4):163-8,
1989 Dec.
32APEXPH.

2. Policy development and leadership that foster local involvement and a sense of
ownership, that emphasize local needs, and that advocate equitable distribution
of public resources and complementary private activities commensurate with
community needs; and
3. Assurance that high-quality services, including personal health services, needed
for the protection of public health in the community are available and accessible
to all persons; that the community receives proper consideration in the
allocation of federal and state as well as local resources for public health; and
that the community is informed about how to obtain public health, including
personal health, services, or how to comply with public health requirements.
• Public Health responsibility should be delegated to only one unit of government (e.g.,
municipal or county, but not both).
• Institute mechanisms to promote local accountability and assure the maintenance of
adequate and equitable levels of service and qualified personnel.
• Where the scale of government activity permits, localities should establish public
health councils to report to elected officials on local health needs and on the
performance of the local health agency.
• The committee recommends that state and local health agencies strengthen their
capacities for identification, understanding, and control of environmental problems as
health hazards. The agencies cannot simply be advocates for the health aspects of
environmental issues, but must have direct operational involvement.
• The committee recommends that public health be separated organizationally from
income maintenance, but that public health agencies maintain close working
relationships with social service agencies in order to act as effective advocates for,
and to cooperate with, social service agency provision of social services that have an
impact on health.
• The committee finds that, until adequate federal action is forthcoming, public health
agencies must continue to serve, with quality and respect and to the best of their
ability, the priority personal health care needs of uninsured, underinsured, and
Medicaid clients.
• A uniform national data set should be established that will permit valid comparison of
local and state health data with those of the nation and of other states and localities
and that will facilitate progress toward national health objectives.
• Public health agency leaders should develop relationships with and educate legislators
and other public officials on community health needs, on public health issues, and on
the rationale for strategies advocated and pursued by the health department. These
relationships should be cultivated on an ongoing basis rather than being neglected
until a crisis develops.

• Agencies should seek stronger relationships and common cause with other
professional and citizen groups pursuing interests with health implications, including
voluntary health organizations, groups concerned with improving social services or
the environment, and groups concerned with economic development.
• Agencies should undertake education of the public on community health needs and
public health policy issues.
Attempting to explore the causes of the "disarray" found by the IOM committee,
Koplin33 identified a number of explanations, including disproportionate spending on
medical care versus public health, too numerous and inappropriately sized local health
departments, and the historical ability of the medical profession to impede the expansion
of health departments into their domain. He reports that in 1932 for every dollar spent on
public health in the US, $29 was spent on medical care. In 1988, despite a half-century
of efforts to the contrary, this ratio increased to 1:36. Koplin asserts the combination of
low funding and inappropriate unit size means many local health units cannot afford to
employ adequately trained personnel. For example, he states an
epidemiologist/statistician is employed by only 11% of local health units, and only 27%
utilize a social worker.
Moreover, Koplin describes how while technical expertise at the local level is
often limited, the demands for such expertise are not. Local health units are often
required to advise on water and air quality, sewage disposal, and other environmental
issues, and serve as first-level responder for environmental emergencies, as well as
traditional outbreaks of infectious diseases. Lastly, while pointing out some arguments
against the provision of medical care by local health units (such as it causing a diversion
away from traditional disease prevention and health promotion responsibilities), Koplin
agrees that especially for the indigent population and until definitive federal action is
taken, local health units should, where possible, ensure medical services.
33Koplin, AN The Future of Public Health: A Local Health Department View. Journal of Health Policy
Winter 1990. pp. 420-37.

In 1991 the US Department of Health and Human Services published a mammoth
report, "Healthy People 2000: National Health Promotion and Disease Prevention." This
report identified over 400 public health problems facing the country, discussed causative
factors, developed public health goals relating to improvements in each problem, and
recommended solutions to achieving these goals. This project was designed to give any
and all agencies and institutions interested in public health a thoroughly reviewed list of
priority health areas. This list fits nicely with the IOM recommendations, which
endorsed the development of national health objectives toward which individual goals, on
the local level, could be directed. The Healthy People 2000 list has served as both a
starting point and a yardstick for implementing and improving recent public health
efforts. The NACHO used both the Healthy People 2000 list and the IOM report
guidelines to develop its APEXPH manual. The Health of the Public Program also
endorsed the Healthy People 2000 goals in developing its own agenda for public health
improvement.34 The Healthy People 2000 goals are also reflected in the American Public
Health Association's 1992 Public Health Report Card, which ranked the 50 states by
various measures of public health success.35 The ranking for Massachusetts is
reproduced in Appendix B. Summarizing, Massachusetts ranked in the top quartile for
medical care access, in the second quartile for healthy neighborhoods, healthy behaviors,
and community health services, and in the bottom quartile for a healthy environment.
Medicalization of Social Problems
Thomas Szasz,36 Ivan Illich37 and others have commented extensively on the
historical trend in America toward applying treatments and programs based on the
34Showstack, J. et al. Health of the Public: The Academic Response. JAMA 267(18):2497-2502, May 13,
1992.
35APHA America's Public Health Report Card: A State-by-State Report on the Health of the Public.
November 1992.
36Myth of Mental Illness, New York, Harper and Row, 1961.
37Medical Nemesis: The Expropriation of Health, New York, Pantheon Books, 1976.

medical model, and undertaken by physicians or at their urging, to intervene in what are,
in their essence, social problems. While their approach is highly critical of the medical
establishment (Illich states that "Among murderous institutional torts, only modern
malnutrition injures more people than iatrogenic disease in its various manifestations"38),
others, such as Charles Lawrence III39, have argued that the tools of public health provide
the most appropriate to deal with the social ills of violence and racism.
Whatever particular value one places on the movement of medical analysis and
techniques into previously social realms from mental illness to community ritual, it is
likely that a major component of health outcomes is environmental, and that the effective
environment in question extends beyond the individual's physical interactive domain (that
is, even beyond the food, air, and chemical environment into the network of relationships
and beliefs). As population pressures move us closer together in larger cities and
scientific advances push back the edges of life span, previously insignificant features of
the ecosystem take on new importance. Health care is only one of many possible
responses to these newly important forces, but it is an increasingly central default choice.
Analysis
The previous section presented findings regarding the environment authorizing
public health activities in Cambridge, the organizational structure providing them, and
the clients they serve, both actual and potential. This section will analyze the balance and
scope of these activities, make comparisons with national trends, and test alternative
answers to the question, "To what extent and along what dimensions has Cambridge
realized the promise of the 1976 reorganization of the Department of Health and
Hospitals to emphasize public health and preventive care?"
38Ibid., 26.
39"The Id, the Ego, and Equal Protection: Reckoning with Unconscious Racism" in Stanford Law Review
vol. 39:317.

More has happened to change the face of public health in the past ten years than
in the previous century. This rate of change can only accelerate, given the enormous
health problems at both the national and local levels. The goal of this analysis is to
predict both these changes and the capacity of the system to adapt to these changes, given
the present circumstances. It will provide a basis for recommendations presented in the
subsequent section.
Public Health and Medical Care
The relative investments made by the City of Cambridge in public health and
medical care closely resemble those made on a national level by the federal government
and in state and local governments throughout the country. As discussed previously, over
the past century efforts to improve the health of communities (or, to use the Institute of
Medicine's phrasing, to assure conditions in which people can be healthy) have
increasingly been directed toward providing more medical services, and away from
traditional public health services. In Cambridge, the city makes a direct contribution of
ten dollars to the Hospital for every one dollar to The Department. If however, one
compares the total budget of the Hospital, this expense ratio becomes similar to the
national average of roughly one hundred to one. This contrast in relative budgets extends
to the major health initiatives currently on-going in Cambridge. The City is on the verge
of committing itself to backing financially approximately twenty million dollars in bonds
to cover the hospital expansion. Meanwhile, no public funds have been committed to
either the APEXPH project or The Health of the City program. The availability of
outside funds facilitates this discrepancy. Medical care is paid for by insurers (including
the federal and state governments). Outside funding for public health efforts is available
only through limited grants or private largesse. In Cambridge, the Hospital is also a
revenue source, while The Department is solely an expense.

In comparison to the Hospital, The Department may seem to be a relatively small
and simple organization. If one considers just budget and personnel, this view is true. If
however, one considers overall functions and responsibilities, the comparison is more
difficult. As portrayed earlier on the health services map, in recent times The Department
has become responsible for an enormous range of functions, including but not limited to
school health, environmental quality, hazardous materials collections, infection control,
and public health education. Beyond formal responsibilities, The Department and its
Commissioner serve as a lightning rod which attracts questions, comments, criticisms and
suggestions on any issue or event in Cambridge which can possibly be considered a
health problem. The Department is called, for example, about water safety, indoor air
quality, anti-smoking ordinances, industrial biohazards, AIDS, violence, drug-addiction,
homelessness, and gun control. This range of responsibilities and activities may make
The Hospital's "diversity" seem far narrower than before.
The variety of demands placed on the Commissioner and The Department
represents the magnitude of skills required of the Commissioner and his/her staff. At any
given time they might need to serve as an emergency response team, a health surveillance
unit, a biostatistician, a technical expert on a wide range of topics, an outreach worker,
and an educator. Such an amalgamation of responsibilities does not necessitate a large
organization and budget, because each task is not performed in large volume. However,
maintaining the ability to perform each task does require an unusually large amount of
expertise and management skills.
Finding individuals trained in any one of these capacities is not difficult. Finding
individuals able to perform many of them is much harder. A department with such
responsibilities needs to be staffed by either numerous part-time workers, or a few highly
skilled ones. Unfortunately, the budgetary restraints imposed on most municipal
departments, this one being no exception, instills a tendency toward lower compensated
positions, and therefore hires, on average, lower skilled workers. In other words, under

financial pressures a department tends toward fewer, less skilled workers, exactly the
opposite needed.
At the same time, management of such an organization is not an easy task either.
Maintaining capacity to perform widely varying tasks in a quality fashion with only a
small staff and tight budgetary constraints is difficult. In addition to operations, each task
requires planning and evaluation. When the volume of work done in each category is
small, it is often difficult to justify spending relatively larger amounts of time to these
accessory tasks. The Commissioner and The Department spend significant time "putting
out fires." A new health incident is brought to their attention and a response is expected
immediately. In this atmosphere, activities not requiring immediate attention, such as
planning and evaluation, may receive "back burner" status.
In comparison to national trends, however, the status of the Cambridge
Department of Health seems relatively good. Cambridge already meets many of the
recommendations the IOM report made for local health departments. Additionally, The
Department is poised, through ongoing initiatives, to meet the public health challenges
foreseen for the immediate future. For example, in Cambridge public health
responsibility is delegated to only one unit of government. The Department does not
compete with other municipal agencies or County departments in its role as guarantor of
public health. A citizen public health council already exists which independently
monitors and influences the activities of The Department in relation to the needs of the
community and communicates its activities with the city council. Further, as
recommended in the IOM report, The Department is organizationally separated from
income maintenance (in Cambridge, the Department of Social Services) but maintains a
close working relationship with social service agencies. To the best of its ability, The
Department, through the Hospital, addresses the priority personal health care needs of
uninsured, underinsured, and Medicaid clients. Through the activities of the school
health programs and the Commissioner's relationship with key municipal officials, The

Department engages in many educational activities concerning community health needs
and ongoing activities. Lastly, the amicable relationship between the Commissioner and
the City Council is certainly one of long term cultivation, rather than crisis-based.
The major health initiatives ongoing in Cambridge address the remaining IOM
report recommendations to develop a department which performs adequately the three
core functions of public health: assessment, policy development, and assurance.
APEXPH will provide measures to assess adequacy of personnel and services. All three
initiatives will improve the city's ability to meet the health needs of the poor and
uninsured. APEXPH provides the framework for collecting health data for both local
health assessment over time and comparison with national measures. The Health of the
City Program provides a strong mechanism for improving city relationships with other
non-municipal professional and citizen groups pursuing common health interests, and a
vehicle for outreach to and education of the community.
From a systems perspective, however, one might ask why didn't the needs of this
particular sub-community surface earlier, or perhaps whether the group as defined
actually constitutes a community, or simply a group with particular health services
requirements. One possibility is that an element of the "paradigm shift" in health care
involves moving away from the application of technical (though complex) solutions to
consensus problems to the use of "health" as a wedge for addressing the truly difficult,
adaptive problems of communities and communities within communities.40
In conclusion, while there are substantial obstacles to optimal performance
presently constraining The Department, in comparison with national trends The
Department is actually performing relatively well. This is not to say The Department
cannot be improved, but that recommendations for improvement will have to be
developed from within, since glaring deficiencies cannot be identified when compared
40This type of situation, in which key questions are not asked and paradigm shifts are perhaps unnoticed
could be an unfortunate consequence of a low-turnover board.

with external benchmarks. Fortunately mechanisms for such self-improvement, as
represented by the three on-going initiatives, already exist. What is less clear is whether
sufficient resources exist to utilize these improvement mechanisms to fruition, especially
in consideration of the changes forthcoming in public health. Trends suggest the future
will only place additional burdens on an already stressed department.
Future Trends in Public Health
Medicalization of Social Problems
As discussed elsewhere, societal problems are more and more being described as public
health problems. This tendency has two broad implications for The Department. First,
there will continue to be, as there already has been, increased demand for
Departmental expertise in increasingly diverse areas. This tendency has already been
seen in Cambridge, given the variety of issues which The Department has been forced to
address in recent years. Without additional resources, this tendency will lead to increased
stress on a very small staff as their responsibilities increase. The tendency toward
diversity will also place increased importance on prioritization, as The Department is
increasingly unable to address all issues which confront it.
Second, as more and more social problems are "medicalized," the evaluation
of The Department's success or failure may derive increasingly from factors beyond
The Department's influence. For example, if violence is considered a public health
problem, citizens may wonder what The Department is doing about violence, and blame
The Department when violence occurs for not providing sufficient intervention. Clearly,
other city departments have jurisdiction for violence (e.g. Police, Social Services,
Schools, etc.) and The Department has few resources to address violence itself. Thus
without either additional resources, or the assumption of more control over these other

department's "anti-violence" resources, The Department may be at increased risk of being
perceived as "failing" despite any fault of its own.
The medicalization of social problems presents a perplexing challenge to The
Department. While the increasing diversity of issues confronting The Department
requires renewed prioritization of efforts, at the same time The Department is
increasingly likely to be perceived as having been ineffective at combating an increasing
range of problems. This dilemma suggests that in addition to a more formal prioritization
process, The Department will need to devote more resources to demonstrating success,
and may need to redefine its mission to minimize unrealistic expectations. Specific
recommendations to address these issues are suggested in the next section.
Managed Care/Community Health Networks
No one knows what form our national health care system will assume in the coming
years. A $900 billion health care industry is anxiously awaiting the recommendations of
Hillary Rodham Clinton's task force, expected in May. Some predictions, based on
consensus of leading health policy experts, can be made, however. Our future health
insurance system will incorporate the notion of "managed care" and encourage the
formation of community health networks to provide this care. The Hospital
Administrator, as outlined in strategic plans, is actively pursuing change to adapt to this
altered care environment. This change will have significant impacts on health care
delivery in Cambridge, and on The Department as well. Two major forces derived from
this switch to managed care and community health networks will impact The
Department. First, The Department will need increasing amounts of data concerning
the health of the community. Second, The Department will need improved
information about health services provided to the community, both municipal and
by private agencies, and will need improved ability to coordinate these services.

A fundamental premise of any managed care model is the notion of outcomes-
based assessment. Historically, the benefit of health care interventions has been
determined on a "per intervention" basis. In recent years, as health care budgets have
increased, more focus has been placed on the overall affect of myriad interventions.
Health care planners, key to any future health care system, wonder what combination of
services yields the greatest value for the least cost. While clinical research produces
outcomes data for individual procedures and interventions, new sources of data will be
expected as health care networks assume responsibility for whole communities. The
demonstration of effectiveness requires constant health surveillance data. The
Department, as the agency directly responsible for the health of the community as a
whole, will be expected to provide this data.
The need for more comparative health data on Cambridge cannot be understated.
The three major health initiatives all place paramount importance on good data. Half
(Part II) of the APEXPH project addresses the collection of data to facilitate prioritization
of activities. The Hospital is positioning itself as a health care network, but will face
competition in this regard. Successful competition will be based on demonstrating
effectiveness, solely dependent on good health data. The Health of the City Program has
endorsed as a key objective the assumption of responsibility for community health. This
health must be measured, requiring data.
Unfortunately, the capacity of the present Department is inadequate to meet
present and future data demands. Collection of data for APEXPH is presently done part-
time by one Departmental staff member, and this labor only possible by skillful
rearrangement of responsibilities, since no additional funds were provided for this task.
Furthermore, capacity permits only a one-time collection of data, while evaluating impact
requires at least two collection points over time. Future data needs will require not only
regular collection of similar data to measure change over time, but the capacity to

consider what data is needed (not just what is available) and be able to measure it.
Significant change is therefore in store for The Department if this challenge is to be met.
The Hospital is not the only source of health services for Cambridge citizens.
Other health care organizations (Mt. Auburn Hospital, Harvard Community Health Plan,
University Health Services of Harvard and MIT, other HMO's) provide medical services.
Numerous private charities provide a host of services to Cambridge, which, as all human
services are "medicalized," can increasingly described as health services. As more
emphasis is placed on the health of the community as a whole, through the growth of
managed care networks, The Department will need to have more sophisticated knowledge
of the activities of these various organizations. Direct services provided by The
Department will need to be better balanced against those provided elsewhere, to promote
synergy and reduce duplication in maximizing the overall effect on the community. At
present such knowledge is generated through indirect channels. The Health of the City
program represents a vehicle to improve the relationship between these organizations, but
at present this program is restricted, for logistical reasons, to the health needs of children
and men of color, rather than the community as a whole. In the future, The Department
will better address its responsibility for the health of Cambridge citizens if it had more
formal and regular knowledge of these activities.
Recommendations
In this section recommendations are made based on the observation of the present
system and the analysis of the impact of future trends on the system. In making these
recommendations, the authors maintain that it is the key health representatives of the city,
and not outside observers (including the authors) who are best situated to develop a
visionary document for the future of public health in Cambridge. Therefore the primary
recommendation of the authors is that such a document be created by all invested parties
in Cambridge. Recommendations presented here should be considered suggestions to

facilitate this process. First, a list of imperatives is provided which any "blueprint for the
future" must address, and which health policy makers in the city could use as they
develop such a plan. Second, key recommendations are made within a time frame for
action in the short, intermediate, and long term. Lastly, a model for a future Department
is presented.
Guiding Principles
The following requirements, derived from the observations and analysis
previously presented, pertain to any plans for the future of public health in Cambridge:
• Recommendations must build on the initiatives presently underway (APEXPH,
Health of the City, Hospital Expansion). An enormous amount of thought, energy,
and planning has already been invested in the three ongoing health initiatives. Each
addresses important concerns for the future. Taken together, they represent a far
more thorough approach than could be created de novo.
• Recommendations must build on, and not subvert, the strong commitment made
voluntarily by numerous Cambridge citizens to community health, most notably
through citizen boards and the Health of the City Project. A unique strength of
the Cambridge public health system is the intense devotion paid by so many citizen
volunteers. This devotion provides valuable insight and political support directly
from the consumers of the health care system, not to mention labor which doesn't
require compensation from municipal coffers. In no way should this special asset be
diminished by any health initiative. This recommendation does not imply, however,
that the present citizen board structure is best suited for the task. As part of any
review of departmental structure, effort should be given to considering the best
vehicle to maximize quantity and diversity of citizen input. Mechanisms such as term
limits, rotating assignments, meeting structure and voting policy should be
considered.
• Any recommendations which rely on increased funding must provide a funding
source other than general municipal revenue. While public financial backing is
always a possibility for any effort, a proposal which can use existing resources is far
more likely to be pursued, and a project which generates revenue or attracts outside
funds (such as The Health of the City Program) is even more likely to succeed.
• Recommendations must suggest ways to improve Departmental capacity to
collect and report data concerning the health of the Cambridge Community.
Data management appears to be a leading problem facing all efforts to improve health

services in Cambridge. This hindrance will only grow in coming years, and should be
addressed directly in any "vision for the future."
• Recommendations should reflect the growing medicalization of social problems.
This trend pervades all efforts made under the general category of "public health." As
such it should be explicitly recognized, because it suggests the type of problems The
Department will be expected to address in coming years, in addition to traditional
efforts.
• Recommendations should reflect the expectation of a managed care model for
medical services. While "managed care" traditionally refers to medical services, the
close relationship between the Department and the Hospital, added to the growing
connection between successful medical services and community health, suggests the
Department should plan with this trend in mind.
Specific Recommendations
Current analysis reveals The Department to be functioning reasonably well,
especially in consideration of the many constraints operating. The Department is
involved in several long term initiatives. These initiatives are each well suited to address
some of the future demands expected for The Department. In the short term (1993),
therefore, present service activities and efforts behind these initiatives should
continue. Of the three, The Department is most directly involved with the APEXPH
project, designed to both aid The Department prioritize efforts and to collect comparative
health data about the Cambridge community. The APEXPH protocol appears extremely
appropriate for The Department, and encouragement is especially given for thorough and
rapid completion of the project.
As demands on The Department increase over time, reflecting the medicalization
of social problems, a formal prioritization process, especially one which incorporates
community input, as APEXPH does, has great merit. Not only should APEXPH be
completed, but the methods employed should be incorporated into the regular planning
activities of both The Department and the Health Policy Board. This should be a
relatively simple task, since these bodies will already be familiar with the process after

completing it the first time. Furthermore, the data collection occurring as Part II of the
project can provide a basis for what must become a regular activity of The Department in
the future. The data is presently being collected following detailed instructions in the
protocol. After this collection is completed, experts within the community can review the
information and comment on how the collection process can be modified in the future to
best serve the community.
The Health of the City Program is presently facing the difficult prospect of
finding sufficient funding to continue its activities. It is hoped this search will be
successful, since this program, of the three initiatives, is most specifically designed to
address the health needs of the community. While presently a quasi-independent
organization, the goals it pursues are sufficiently similar to those of The Department to
imply that eventually the two should be merged to avoid chronic duplicity. Discussions
should begin between members of The Department and leaders of the Health of the City
as to the best time course and format for this eventual. It is recognized that future
funding for Health of the City will have significant impact on this merger.
In the intermediate term (one to three years) more specific attention will be
needed to address some of the trends raised in the analysis. Specifically, for The
Department to be viable the task of data collection and distribution will need to be
permanently addressed, as opposed to more of an ad hoc nature. Ideally, this task could
be accomplished by the hiring of a full-time biostatistician. This person would be
responsible for continuing the data collection begun by the APEXPH project, soliciting
input from interested parties, presenting the data in a useful form to these parties, and
adjusting data collection to address changing needs.
In order for such a recommendation to remain budget-neutral, the biostatistician
could also serve as a revenue source for The Department. It is clear that the data
summaries this person produces would be of great value not simply to the Hospital (and
whatever form of a managed care network it becomes), but also to other municipal

departments and private agencies as well. The Department could thus market its data
summaries as a commercial item, charging "clients" for the service on a cost basis which
pays for the position.
The APEXPH protocol suggests data be collected from familiar sources (e.g.
census data). As discussed above, information will also be required about the health
activities of other municipal departments and private health agencies. Collecting this
data will be more difficult. Not only will it entail designing survey instruments and
therefore more manual labor, but it will also rely on the goodwill of the other agencies.
To overcome these obstacles it is proposed that a resources coordinator be positioned
within The Department. This coordinator will serve a number of functions. Primarily,
s/he will assist The Department and any other agency interested in attracting outside
funding for health efforts appeal for such funds. This role is not unique--several
municipal departments, including social services, already have such a position. In this
fashion more funds can be attracted for health efforts without appealing to municipal
coffers. Secondly, the availability of such a resource will encourage other departments
and agencies to share information with The Department, thus generating data concerning
health efforts which can be used to satisfy data requirements. In this fashion, The
Department can facilitate a role as both collector and disseminator of health data, while
attracting additional funds for needed health services.
By the end of the decade, the demands on The Department will quite different
than at present. The Hospital expansion will be complete, operating at the center of a
managed care community health network. Through the APEXPH project The
Department will have become expert at collecting and distributing data. This activity will
provide the Hospital and the community with important evaluative data, promoting
continued improvement. The Health of the City Project will have been incorporated into
the regular activities of The Department. Meanwhile, the traditional functions of The
Department will still have to be served, and additional demands reflecting the

medicalization of social problems will have been made. The Prioritization process of
APEXPH will assist The Department in meeting some of these demands.
However, the optimal structure of such a Department remains question for debate.
On the one hand, The Department is one of the smallest in the City in budget terms. On
the other hand, given the breadth and magnitude of problems which impact on it, the
relative importance for efficient delivery of municipal services will only grow. It is
hoped that the structure of such a small but important agency will be a continued topic of
discussion for key personnel in the years to come. Indeed, as mentioned before, this
document aims to trigger an ongoing dialogue about the future of the public health and
The Department. However, at this time a model example of a new Department of Health
can be outlined.
A Model for a New Department of Health
On April 2, 1993 a meeting was held among key health representatives of the city,
including the client, the Commissioner, the Chief of Medicine of Cambridge Hospital, the
Hospital Administrator, and a representative of the citizen Health Policy Board.
Preliminary results of this Policy Analysis Exercise were presented, and discussion
ensued about the future structure of the Department of Health and Hospitals. The
meeting participants unanimously endorsed, at least in principle, the following model as a
starting point for developing a future Department of Health, and agreed to meet regularly
about this topic in the months ahead.
The forces expected to impact the Department over the next ten years have been
reviewed in the preceding sections (see Analysis and Specific Recommendations). The
analysis of these forces leads one to envision a new Department decreasingly concerned
with direct provision of services and increasingly concerned with oversight and analysis
of services provided elsewhere. The responsibilities of a new Department of Health, with

or without continued oversight of the Hospital, neighborhood health centers, and Neville
Manor, could be divided into four new operating units:
1. A Health Intelligence Unit. Responsible for collecting and disbursing data, this unit
would derive from the APEXPH initiative--the results of the study can be used to
determine what data should be collected on an ongoing basis, while the experience of
the process can be used to design an efficient means of doing this regularly. The unit
would not only collect data, but furnish it, either on a regular basis, to all interested
parties. The Hospital could use this data to better tailor programs to the individual
needs of the community, and assess program effectiveness by improvements in
comparative health data. The Health Policy Board could use the data to monitor the
health of the community and set policy appropriately. The data would be of use to
other municipal departments concerned with health related issues, and private
agencies would benefit from the data to assess their own effectiveness. The
collection and provision of data would better tie the Department to all of these other
"health units," better enabling the central coordination of efforts to avoid duplicity
and measure success or failure. It is conceivable the Department, under this structure,
would become the hub of a wheel of diverse health services, with each reliant on each
other to maximize service delivery.
2. An Outreach/Prevention Unit. This unit would incorporate most of the existing
services provided by The Department--public health nurses, school health, etc. Many
or even most existing services could eventually be merged into other structures if
improved efficiency can be achieved. Therefore this unit could serve as a transition
vehicle as the new Department takes shape. This unit could also become an oversight
and coordination unit, using the data generated by the health intelligence unit to
coordinate multiple efforts by separate agencies striving toward the same goal. New
programs as created by HOTC or elsewhere could be incorporated within this unit as
need arises.
3. A Revenue Enhancement Unit. As discussed previously, health policy in
Cambridge tends to follow dollars, rather than policy being planned and funding
applied. This revenue unit would facilitate the application to outside funding sources
which occurs throughout the city government and beyond, especially in the health
field. By so doing, the Department could improve its ability to prioritize as it
generates its own income, much as the Hospital does now. Individuals interested in
applying for grants or requiring special assistance could request this health from this
unit, rather than constantly reinventing the wheel themselves. Creation of this unit
would not only improve efficiency by concentrating skill in one place for use by all,
but knowledge about the grants would be centralized, thereby adding greatly to the
data collection process and alleviating the feeling of "not knowing what's going on"
commonly expressed by some of the city's leaders in health.

4. An Emergency Surveillance and Response Unit. This Unit would be responsible
for detecting and responding to health issues as they arise, which at present occurs on
an ad hoc basis by the Commissioner and his staff. This Unit represents much of the
"distraction" the present Department often faces while trying to plan and prioritize.
Crises arise which require immediate attention--long term projects, such as APEXPH
are placed on the back burner while limited resources are expended toward
emergencies. Additional funding would be necessary only to the extent the city
wishes The Department to better be able to respond.
In addition to these core units, a number of issues remain to be determined by the
group assembled to plan for the future. The relationship of these units with The Hospital,
the Neighborhood Health Centers, Neville Manor, and other health organizations, public
and private, will need to be accounted for. In addition, any organizational rearrangement
will have to consider whether the present leadership position of Commissioner is still a
viable structure, or whether revision here is needed as well. Some final thoughts
concerning this topic are presented here.
There are enormous and varying demands on the Commissioner in Cambridge. In
a sense, the commissioner is seen to be some sort of health czar, responsible for
everything and everybody, but with little direct budgetary power to effect much
influence. In the presence of these demands and a relatively small budget, the
Commissioner must pick and choose what items receive his attention. Fulfilling all needs
is hard enough--being an entrepreneur is more difficult still. It seems unreasonable to
expect all these skills from the same person, who by statute must also be an MD. In the
future it may be prudent to consider whether the Commissioner's responsibilities be
separated into two positions, or at least a Deputy Commissioner position established to
share the burden. For example, the Deputy could have responsible for day to day
management of The Department, as outlined above. This person would ideally have both
management and health training, perhaps with an MPH, MBA, or MPP degree. The
Commissioner's role, while retaining ultimate authority, would resemble more of a expert
consultant. This person would serve as consultant to various initiatives and programs,

without necessarily being involved every time the phone rings. This person could also
serve on the Health Policy Board and ambassador to the community, serving as direct
link between The Department and the external authorizing environment. This person also
does not have to occupy a full time position. These two roles could alternatively be
labeled Director (managerial responsibilities) and Chief Medical Consultant (technical
responsibilities).
Conclusion
This document began by outlining the present authorizing environment, clients, and
organizational capacity of the present public health system provided by the municipal
government of Cambridge, Massachusetts. After objectively reviewing the data as
collected and adding information collected from the academic literature concerning
municipal public health nationally, analysis was performed to determine the factors
which any future planning for the future of public health in Cambridge must include.
Once done, specific recommendations were made for how such a planning process might
begin, and examples were given to serve as a starting point for deliberation. This process
has already begun, as demonstrated by the enthusiasm and commitment of key "players"
in the Cambridge health community assembled for a meeting in early April, 1993. The
authors fully hope and expect this process continue, and wish this document to serve as a
useful starting point for the process.

Appendix A: List of Meetings and Conversations
DATE WITH
13OCT92 City Councilor Frank Duehay
21OCT92 Duehay
23OCT92 Commissioner of Health and Hospitals Dr. Mel Chalfen
26OCT92 Sacha Rockwell, community health staff member, Department
of Health and Hospitals health division and staff member,
Cambridge Cares about AIDS
26OCT92 Ann Gross, head of public nursing, Department of Health and
Hospitals, public health nursing division
6NOV92 Richard DeFilippi, Ph.D., member, Health Policy Board; John
O'Brien, administrator, The Cambridge Hospital; Chalfen;
Jill Herold, Cambridge assistant city manager for human
services; Duehay
9NOV92 DeFilippi, O'Brien
10NOV92 Public Health Subcommittee of the Health Policy Board
special meeting with Duehay. Barbara Ackerman, former
mayor of Cambridge; Chalfen; DeFilippi; Oliver Farnum,
member, Health Policy Board; Estelle Paris, chairman,
Health Policy Board
13NOV92 Herold
13NOV92 Chalfen
16NOV92 Ann Gardner, staff assistant to Commissioner of Health and
Hospitals
20NOV92 Duehay, O'Brien
25NOV92 Liz Fabel, Health of the City Program
30NOV92 Dr. David Bor, Acting Chairman, Department of Medicine,
Cambridge Hospital
4DEC92 Duehay
11DEC92 Ackerman
17DEC92 Farnum
17DEC92 Meeting of City Council Subcommittee on Health and
Hospitals for discussion of Hospital project
17DEC92 Duehay
5JAN93 Duehay
8JAN93 Chalfen
12JAN93 Paris
19JAN93 O'Brien
19JAN93 Bor
21JAN93 DeFilippi
25JAN93 Chalfen
28JAN93 DeFilippi, O'Brien, Dr. David Bor, chairman, Department of
Medicine, The Cambridge Hospital, Duehay
3FEB93 Public Health Subcommittee of the Health Policy Board
meeting; Health Policy Board Meeting
3FEB93 City Council Subcommittee on Health and Hospitals for
continued discussion of Hospital project
4FEB93 Cambridge School Health Task Force meeting
24MAR93 Duehay
2APR93 Bor, Chalfen, DeFilippi, Duehay, O'Brien

Appendix B: Cambridge in Brief41
Cambridge is widely known as the University City. Harvard, America's oldest university,
was established here in 1636, six years after the city itself was founded. It is also home
to Radcliffe College and the Massachusetts Institute of Technology. Nearly one-fourth of
its residents are students, and over one in six of all jobs are in these institutions. Yet
Cambridge is more than a college town. It features blue collar workers and professionals,
political activists and street musicians, and immigrants from around the world.
• 1990 Population: 95,802, down from a 1950 peak of 120,740.
• Cambridge residents live closely together; only five US cities of population over
75,000 are denser.
• Cambridge is a city of 13 neighborhoods, ranging in population from 582
(Cambridge Highlands) to 13,006 (Mid Cambridge). Most neighborhoods have
their own political and civic organizations. Residents often participate vocally in
city policy debates.
• Cambridge is diverse ethnically. Seventy-five percent of all residents are white;
14% [sic] are black, eight percent are Asian and three percent are other races. Seven
percent of all residents are of Hispanic background. Students from 64 nationalities
attend public schools here; their families speak 46 different languages. Major
nationalities: Irish (17%), English (12%), Italian (9%), Portuguese (9%), German
(4%) and Russian (4%). Since 1980, many newcomers have arrived from Haiti,
Portugal, Cape Verde, Brazil and the countries of Central America and Southeast
Asia.
• 1979 Median Family Income: $17,845. Among the 101 cities in the Boston
metropolitan area, only Chelsea and Boston had lower incomes. Eleven percent of
all Cambridge families have incomes below the poverty line. Median Family
Income in 1989 was estimated to be $33,926.
• The local housing stock contains 41,979 units. Average household size in 1990:
2.08 persons/household.
• Cambridge is a city of renters. Seventy percent of all households are rented; 30%
are owned. Thirteen percent of all homes are single family; 36% contain 2-4
dwelling units; 13% have 5-9 units. The 38% remaining are in apartments of 10 or
more units. Twelve percent of all units are public or subsidized.
• Housing costs have risen locally. The median price for a one-to-three family home
in 1981 was $84,550; in 1989 it was $231,000. Condominium median price was
$173,500 in 1989, up from $37,000 in 1981.
41Annual Report City of Cambridge 1990-91.

• Nearly two thirds of all local jobs are in services (64%). Service employment is
dominated by education, health services and business services, including research
and computer/software services. Fifteen percent of all jobs are in retail and
wholesale trade; 7% are in manufacturing; other major employers: government;
finance, insurance and real estate; transportation. The largest employers in
Cambridge include Harvard University, MIT, Polaroid, Draper Labs, Mt. Auburn
Hospital and Lotus Development.
• The fastest growing sector of the economy is the medical and biotechnical area,
including biotechnology firms, hospitals, medical laboratories and medical
instrument makers. Employers in this group grew by an average rate of 112%
between 1987 and 1990.
• Technicians represent the fastest growing occupation in Cambridge. In a 1991
survey, all firms employing technicians projected stable or growing employment for
this job category.
• Many Cambridge residents work in professional and managerial occupations (40%);
another 31% work in technical, sales and clerical positions; 13% work in service
occupations; 16% work in blue collar trades such as precision production, craft,
repair and machine operation.
• Though famous for education, Cambridge is also an industrial city. The first ladder
factory in America was built here. Other factory "firsts:" piano keys, reversible
collars, waterproof hats, mechanical egg beaters and Fig Newton cookies.
• Cambridge remains an innovator of new industries. Important high technology
industries, many of them aided by MIT, include computer software, artificial
intelligence, optical instruments and biotechnology.

Appendix C: Massachusetts Public Health Report Card

Planning for the Future of Cambridge Public Health HKSG MPP masters thesis PAE

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