Book Review:

Cahill, Kevin M.. Imminent Peril: Public Health in a Declining Economy. The Twentieth Century Fund Press, New York. 1991.

The health care system of the United States is heading towards disaster. As more americans lose find themselves without health insurance (and the difference in health between insured and uninsured increases), the economy is weakened. The unpaid bills of the uninsured are charged to the insured, the sick are unable to work, and a tremendous amount of money is used just trying to make up for the gap in basic services. The situation has continued to the point that something must be done. Unfortunately, the majority of americans do not realize the seriousness of the situation.

The book Imminent Peril is an attempt to make sure that americans do know. Edited by Kevin Cahill, the Senior Member of the New York Board of Health, it collects a number of essays written by professionals and policy makers concerned with New York City's health care system. Although primarily a response to New York's specific problems (primarily budget cuts to the New York Department of Health at a time when need for its services was increasing), the general issues it addresses are true for most, if not all, the United States. Imminent Peril is in effect a case study of one city health system in an advanced state of disrepair, and the damage poor public health can do to the economy. Its various authors hope to gain support for both the New York Department of Health and some sorely needed reform of the U.S. health care system, even if they disagree on exactly what that reform should be.

The book is organized into three basic sections. Part I: The Foundation, discusses the history of public health in the United States, from the founding of New York's Department of Health to the 1991 budget crisis that precipitated the book. Part II: The Economics of Public Health, discusses the state of public health today, emphasizing the ties between economy and public health. art III: New Approaches suggests new policies for more efficient public health in the United States, as well as setting some goals for New York.

Part I is by far the most accessible to the layman. "Assuring Public Health in a Democracy: A Historical Perspective" By John Duffy is a straightforward history of public health in New York (emphasizing its successes, of course). Thomas Dowling's "The Role of the Law in Public Health" discusses the precedents for public health set by early opposition to required immunizations. Both essays serve to define the original mission and scope of public health organizations in the United States accurately, covering the incidents and issues that lead to the system today.

"Suffer the Little Children" by Margaret Heagarty is a more difficult piece to judge. Written for a large part from her experiences at the Harlem Hospital Center, it is certainly the most factually driven of the medical essays in the book. Heagarty cites statistic after statistic showing the decreasing health of the lower socioeconomic classes in New York, and points out that New York's budget cuts (to the hospital and the Health Department) are just the opposite of what one should do in a developing medical crisis such as this. I can argue with none of her facts or convictions, but I must point out that she does get a little emotional at times (as with "I write to bear witness, to tell the sorry tale of the lives of children of many parts of this grand city.").

While I applaud her rhetorical skill (and I hardly mean to advocate the ill-thought orthodoxy of value-free science), it's possible that Heagarty goes a little overboard when she starts comparing the health crisis to the Persian Gulf War. While I have no doubt she is correct in the severity of the situation, I can't help but believe that many people would be put off by such liberal use of simile and metaphor. It would defeat the purpose of the essay if the rational point was drowned out by an emotional reaction in the reader. Again, that's not to say I disagree with Heagarty's facts or opinions, just her style.

Cahill himself contributes "Averting Disaster: A New York City Case Study", detailing the drastic budget cuts proposed by New York for its Health Department. Here Cahill explains the effects that poor priorities, mismanagement, and complacency can have on public health organizations. In doing so, Cahill illustrates how important it is for such health organizations to make sure the government in charge of their funds knows how important public health is, and illustrates the New York Board of Health and Health Department reaffirmed the importance of their mission in 1991 and was able to maintain at least a functional level of service despite financial hardships on the city.

Following this example of how a poor economy can affect public health follow three essays dealing with how public health can affect the economy. Comprising Part II: The Economies of Public Health, these essays all seek to illustrate the damage done to an economy when large portions of a nation's populace are medically incapable of working. They each, however, take slightly different approaches.

"The Special Case of AIDS in Public Health" by David Rogers is a short essay that succinctly explains the ultimate economic hazard of AIDS. Rapidly spreading, incurable, and taking several years to kill, every AIDS infection represents a net drain of approximately 85,000 dollars. Rogers rightly points out that virtually any form of AIDS prevention (be it education, condom distribution, etc) would cost less and help more, but have not been put in effective practice by New York or any other government. For one reason or another, however, the american concept of preventive medicine begins and ends with immunizations, leading to preventable death and economic ripples that affect everyone. Rogers' short paper is perhaps one of the best modern examples of the need for public health agencies in the United States.

The other essays of Part II, "Economic Consequences of Inaction" by Marianne C. Fahs, and "The Private Sector: Good Partners in Hard Times" by James Jones and Deborah Steelman, both spell out problems that could overwhelm current health systems in the future (AIDS is the main example in Fahs' essay, demographic change in Jones and Steelman's) and suggest revisions of the system. They do propose different forms of revisions, however. While Fahs seems sure that the private sector cannot be counted on to help, Jones and Steelman argue that there are certain sectors of public health where only the private and public sector working in unison can accomplish their goals.

These different attitudes partially seem to stem from a disagreement about what to do with the national GNP. Fahs (p 72-73) hold that there is nothing dangerous in the fact that health care accounts for 12% (and rising) of the GNP, claiming that a level up to 20% is acceptable. Jones and Steelman on the other hand (p 82) see this as excessive in comparison to other industrialized nations, and point that health care could consume 31.5% of the GNP by the year 2020.

The basic nature of this disagreement probably stems from the fact that Fahs is a professional economist while Jones and Steelman aren't. In any event, both essays appear to agree that 31.5% is too high a number, which would make the question moot, except that its questionable wisdom to include two essays in a policy-driven book when they disagree on such a fundamental issue.

Part III: New Approaches, written mostly by politicians, focuses on a more philosophical and moral discussion of the public health situation, while managing to sneak in some of the more radical proposals for public health. "A War Room for Health" by Stephen Thacker points out that policy makers often lack the data to properly define their health priorities, and advocates the extensive use of computer driven situation models (similar to those used by the U.S. military) to weigh the consequences of policy decisions and if necessary, choose the lesser evil when budget cuts are necessary.

Congressman Charles Rangel uses his essay, "A Federal Response" to point out that the half-hearted and badly managed health policies of the federal government have not accomplished their goals. He further points out the short-term views often taken when making budgets ignore the long term consequences of even the least neglect for public health (such as the shortage of doctors caused by cutting the National Health Service Corps), and deftly turns it into a plea for national reform and national health care, which would encourage preventive medicine and long-term planning.

"Crisis and Cooperation" by David Dinkins (Mayor of New York City) and "Public Health: Old Truths and New Realities" by Governor Mario Cuomo of New York are definitely the most philosophical pieces in Imminent Peril. They are written by policy makers who feel trapped into making budget concessions on public health policy and are now trying everything possible to correct it. Being members of the proverbial system, however, their changes can only go so far; for the most part they praise increased cooperation between existing health agencies and providers (as opposed to Congressman Rangel's relatively "radical" proposal for national health care) and blast the federal government (rightly so) for its poor policy decisions.

On the other hand, it may be better to separate philosophy and moral appeals from a body of hard statistics (unlike Heagarty's essay). The Dinkins and Cuomo essays come across as more focused and though out (even though Cuomo's is actually one of his infamous semi-extemporaneous speeches transcribed). Both are fairly eloquent pleas for better public health and higher ideals in policy making.

Overall, Imminent Peril itself is a fairly eloquent book, covering multiple aspects of the public health crisis facing New York and the nation. The book is a fine example of a book written to bring a message to the public clearly and concisely with neither confusing technicalities nor bad generalizations. Cahill has collected a well-focused attack on the current weakened public health system and shown that change is supported by a spectrum of health professionals and policy makers. If the book can succeed in its purpose, it will win the support of others as well.

Filed at 02:10:34 PM EDT on 22 October 1992 from Toledo, OH