With support from The Robert Wood Johnson Foundation, the Institute for the Future, an independent nonprofit research firm that specializes in long-term forecasting, has been conducting individual interviews and focus groups to develop scenarios on the future of public health. Developing alternative future scenarios, in general, has been found to be a useful tool in long-range strategic planning not only for foundations but for public and private organizations alike. In essence, it gives vested parties the opportunity to plan for not only what might occur as well as what they believe should occur.

Issues of Concern

The participants in the focus group in which I recently took part discussed several issues that could potentially have a negative impact upon our current public health system. These issues included toxic pollution, outbreaks of drug-resistant infections, and the  re-emergence of old problems, such as sexually transmitted diseases and epidemics  introduced into this country from abroad. As our current public health infrastructure struggles to contend with these issues, some health departments will also be grappling with how to keep their personal services delivery system alive and functioning for a population whose socio-economic status will probably only grow worse with time. All of this, in addition to strained relationships with a managed care system, makes for an infrastructure in need of some thoughtful planning. As one could well imagine in a group of people trying to map out future scenarios, it was not quite as easy to create solutions as it was to project the issues.

Involving Stakeholders

As a start, our focus group confirmed the shared belief that it will take an investment from many stakeholders to create a system that has the most desirable impact on the health of the entire population. People who work in public health believe that they have always had a vested interest in improving the health of the population for which they were responsible. It is now a question of how to get others involved - to encourage greater understanding of how strengthening the public health system will have an effect on them. Unfortunately, as it was laid out in the "futures manual" from which we worked, "changes in public policy [probably the most critical force for bringing about substantive changes in public health] will be initiated in response to publicized major incidents and growing public awareness of the vulnerability of the entire population, not just of the socio-economically disadvantaged." I would add that significant changes most likely will take place in response to publicized major incidents that are tied to the economics of a particular community. A recent example is the 700-member business alliance formed in New York City that is supporting an effort to identify and reduce the rate of infection  in six major New York City Hospitals. The recent publicity about increased infection rates in New York City caused the business alliance to have concern that patients fearing  infection will shun New York's hospitals, harming an industry that is one of the city's economic mainstays.

Partnerships for the Future

So, how can we plan for a future system that could positively influence the health and behaviors of the populations for which we take responsibility? How can we proactively influence the greater community to support the public health system before being motivated by a critical event? We know that one effective method is to form coalitions and partnerships, because without a value system shared by a very broad spectrum of community stakeholders (in partnership with state leadership) there will be no lasting change. Whether partners buy in because it makes sound economic sense, as in New York City, or because it is in the public good, may matter little. Perhaps it does not even matter if every single public health core function is delivered within the bricks and mortar of a public health department. What matters is that there is a strong, organized coalition of knowledgeable people who have the understanding, the will, and the resources to carry out whatever needs to be done to keep a community healthy. And in the  future these partnerships will have to look differently than they do now.

Turning Point partnerships are already showing us the importance of reaching  out to new and different individuals and groups - ones that none of us had ever imagined the partnerships would be working with even one year ago. They have learned that others outside the typical  public health realm have the talents,  resources, and will needed to ensure a healthy community. And slowly but surely, all of these new stakeholders must be  integrated into what will become a more viable and strengthened infrastructure to meet the demands of the 21st century. We must continue this important work for the sake of us all.

Dr. Hassmiller is the Senior Program  Officer for Turning Point at The Robert Wood Johnson Foundation.