The magazine of the UW School of Public Health

Letters to the Editor

System Change vs. Specific Issues

It was challenging to compare the governance and decision-making implications for community health improvement in Berkowitz and Thompson's article "Responding to Challenges in Public Health" and Krieger and Ciske's article "The Community as a Full Partner in Public Health Initiatives" [Fall 2000]. Both articles advocate for greater community connection and collaboration in public health actions. Each speaks to the need to incorporate "community values and beliefs" and "felt needs and community assets" as fundamental to the public health system working collaboratively with the community. And both conclude that increasing the sense of true partnership between community interests and health professionals is necessary to achieve health status improvement.

However, the articles appear to differ over decision making and governance structure for community collaborative work. Berkowitz and Thompson call for a "structure with clear decision-making processes" and talk about representative steering committees, but Krieger and Ciske speak to "flexible and fluid" decision making with more "open, inclusive, self-selected" participants.

Perhaps these differences are reflective of the scope of the work envisioned. The former addresses more system-wide change of an ongoing nature, and the latter appears to focus more on issue-specific interventions. It may be that the broader scope and ongoing nature of the one requires more formal structure and process to sustain the effort; and the immediacy and issue focus of the other is better served in the moment by a more organic approach. I would welcome the authors' thoughts on whether elements of these approaches can be combined in ways that support system change and issue-specific work concurrently.

Patrick M. Libbey, Director
Thurston County Public Health & Social Services

Public Health Challenges

Lance Heineccius's recent article, "Continuing Market Turmoil Bodes Ill for Health Care System" [Fall 2000] was on target in explaining the challenges facing our state's health system. As legislators and other policymakers struggle to balance budget demands against conflicting needs, it becomes increasingly questionable whether we will be able to maintain services to our most vulnerable populations.

Our experience at the Washington Health Foundation verifies Vickie Ybarra's accompanying conclusions ("Strains on the Rural Health Care Safety Net") that some of the toughest, most intractable problems can be found in our rural areas. These areas have the largest proportion of government-sponsored patients, and face additional challenges of distance and economies of scale. It is crucial that we maintain our ability to deliver services to all people throughout the state, across the full continuum of care, no matter where they live.

Remember, though, that all challenges hold the potential to bring about dramatic change. One day we may be able to look back at this time of turmoil and see it as the catalyst that forced us toward a more rational way to structure and manage health care for the people of Washington.

Greg Vigdor, President
Washington Health Foundation