A Century Later: Rural Public Health's Enduring Challenges and Opportunities.

The US public health community has demonstrated increasing awareness of rural health disparities in the past several years. Although current interest is high, the topic is not new, and some of the earliest public health literature includes reports on infectious disease and sanitation in rural places. Continuing through the first third of the 20th century, dozens of articles documented rural disparities in infant and maternal mortality, sanitation and water safety, health care access, and among Black, Indigenous, and People of Color communities. Current rural research reveals similar challenges, and strategies suggested for addressing rural-urban health disparities 100 years ago resonate today. This article examines rural public health literature from a century ago and its connections to contemporary rural health disparities. We describe parallels between current and historical rural public health challenges and discuss how strategies proposed in the early 20th century may inform current policy and practice. As we explore the new frontier of rural public health, it is critical to consider enduring rural challenges and how to ensure that proposed solutions translate into actual health improvements. (Am J Public Health. 2020;110:1678-1686. https://doi.org/10.2105/AJPH.2020.305868).

Dr. Abolghasem Bahrami (1894­1950): Physician, Pasteurian, and a Pioneer of Microbiology and Public Health Planning in Iran

Dr. Abolghasem Bahrami was among the generation of Iranian scientists in the early twentieth century who gained most of their knowledge through resources available inside the country. Educated at Dar-ul-Funun Medical School, he was a physician with a great talent in learning, especially self-teaching natural sciences and European languages. He joined the Pasteur Institute of Iran (IPI) at the early days of its foundation and became an integral contributor to this institution during the first twenty-five years of its mission. One of his first assignments at IPI was to help initiating an anti-rabies department by bringing back the rabies vaccine and its manufacturing equipment from Institut Pasteur of Paris. During his IPI years, aside from managerial tasks, he actively participated in upgrading the medical treatments and protocols used for controlling many infectious diseases. He functioned twice as the provisional director of IPI (1925-1926 and 1937-1946) and is considered as the first Iranian director of the Institute. Meanwhile, Dr. Bahrami was a significant contributor to the public health system and assumed several responsibilities such as Chief Quarantine Medical Officer, Chief of Public Health, and the Head of Public Health Administration, in order to improve public health planning throughout the country.

Embedding economic relationships through social learning? The limits of patient and public involvement in healthcare governance in England.

The strategy for NHS modernization in England is privileging individual choice over collective voice in the governance of healthcare. This paper explores the tension between economic and democratic strands in the current reform agenda, drawing on sociological conceptions of embeddedness and on theories of reflexive governance. Building on a Polanyian account of the disembedding effects of the increasing commercialization of health services, we consider the prospects for re-embedding economic relationships in this field. An analysis is provided of the limits of the present legal and regulatory framework of Patient and Public Involvement (PPI) in establishing the democratic and pragmatist conditions of social learning necessary for effective embedding. We show how the attainment of reflexive governance in the public interest is dependent on such conditions, and on the capacities of patients and the public to contribute to debate and deliberation in decision making, including on fundamental policy questions such as how services are provided and by whom.

Decentralization, democratization, and health: the Philippine experiment.

In 1991, the Philippines joined a growing list of countries that reformed health planning through decentralization. Reformers viewed decentralization as a tool that would solve multiple problems, leading to more meaningful democracy and more effective health planning. Today, nearly two decades after the passage of decentralization legislation, questions about the effectiveness of the reforms persist. Inadequate financing, inequity, and a lack of meaningful participation remain challenges, in many ways mirroring broader weaknesses of Philippine democracy. These concerns pose questions regarding the nature of contemporary decentralization, democratization, and health planning and whether these three strategies are indeed mutually enforcing.

Designing HIGH-COST medicine: hospital surveys, health planning, and the paradox of progressive reform.

Inspired by social medicine, some progressive US health reforms have paradoxically reinforced a business model of high-cost medical delivery that does not match social needs. In analyzing the financial status of their areas' hospitals, for example, city-wide hospital surveys of the 1910s through 1930s sought to direct capital investments and, in so doing, control competition and markets. The 2 national health planning programs that ran from the mid-1960s to the mid-1980s continued similar strategies of economic organization and management, as did the so-called market reforms that followed. Consequently, these reforms promoted large, extremely specialized, capital-intensive institutions and systems at the expense of less complex (and less costly) primary and chronic care. The current capital crisis may expose the lack of sustainability of such a model and open up new ideas and new ways to build health care designed to meet people's health needs.

Healthcare reform in Denmark.

The article discusses and describes how healthcare reform from 2007 in Denmark has influenced the health sector. This reform has been labelled the most radical reform of the political administrative system since the first democratic constitution in 1849. Local government reform is the latest step in a process of reforming the welfare state and the health sector. In more concrete terms this article analyzes two key issues that have had top priority in the first period of reform implementation - the new planning of hospital structure and the first generation of health agreements.

Physician resource planning in Canada: the need for a stronger behavioural foundation.

An effective solution to the problem of access to physician services in Canada must extend beyond an over-exclusive focus on the number of providers to consider the behaviour of physicians in greater depth. The amount of labour and associated services supplied by physicians depends importantly on their attitudes regarding work, on practice and non-practice income opportunities, and on the policy environment in which they practise. Hence, the amount of labour supplied by a given stock of physicians can change over time. Only by considering the full range of factors that affect the labour supply of physicians can we effectively plan for physician resources.

The development of American public health, a commentary: three documents that made an impact.

Arguably, three documents epitomize the development of the public health movement in the United States. The 1850 'Report of a General Plan for the Promotion of the Public and Personal Health of Massachusetts,' provided the theoretical and organizational basis for the development of an infrastructure for the American public health movement. The 1932 Report of the Committee on the Costs of Medical Care, 'Medical Care for the American People,' laid out a series of challenges for the humane, effective, and economical delivery of health and medical services to the American people, and the 1964 Report of the Advisory Committee to the Surgeon General on 'Smoking and Health' provided a paradigm of evidence-based public health policy. All three documents justified their conclusions on epidemiological evidence. Some may not agree that these documents are the most important to explain the American public health movement. Few, however, will disagree that they had an important impact.

Civic programmatic participation in public health: the case of Argentina.

Since the Alma Ata World Health Organization Conference in 1978, countries around the world have adopted institutions that promote the participation of citizens in their public health systems. The main objectives of this article are two-fold. First, we describe the origins and implementation of a national-level civic participatory program that was in place in Argentina in the mid-2000s: the Local Participatory Projects (Proyectos Locales Participativos). Second, we analyze the 201 local participatory projects that were carried out in Argentina between 2007 and 2008. We study health and environmental problems that prompt people's participation in the program and the social dynamics through which such participation is executed.

Theodore E. Woodward award: non-pharmaceutical interventions employed by major American cities during the 1918-19 influenza pandemic.

A critical question in pandemic influenza planning is the role that non-pharmaceutical interventions (NPI) such as isolation and quarantine, social distancing, and school closure, might play in delaying the temporal impact of a pandemic, reducing the overall and peak attack rate, and reducing the number of cumulative deaths. Such measures could potentially provide valuable time for pandemic-strain vaccine and antiviral medication production and distribution. Optimally, appropriate NPI implementation would decrease the burden on healthcare services and critical infrastructure. These public health measures, however, are often associated with enormous social and economic costs. Therefore, it is imperative to assess past applications of NPIs in order to better understand how they might (or might not) be employed during future pandemics in an effective, legal, ethical manner that inspires confidence and compliance in the public at large.

Health Planning in 1960s Africa: International Health Organisations and the Post-Colonial State.

This article explores the programme of national health planning carried out in the 1960s in West and Central Africa by the World Health Organization (WHO), in collaboration with the United States Agency for International Development (USAID). Health plans were intended as integral aspects of economic development planning in five newly independent countries: Gabon, Liberia, Mali, Niger and Sierra Leone. We begin by showing that this episode is treated only superficially in the existing WHO historiography, then introduce some relevant critical literature on the history of development planning. Next we outline the context for health planning, noting: the opportunities which independence from colonial control offered to international development agencies; the WHO's limited capacity in Africa; and its preliminary efforts to avoid imposing Western values or partisan views of health system organisation. Our analysis of the plans themselves suggests they lacked the necessary administrative and statistical capacity properly to gauge local needs, while the absence of significant financial resources meant that they proposed little more than augmentation of existing structures. By the late 1960s optimism gave way to disappointment as it became apparent that implementation had been minimal. We describe the ensuing conflict within WHO over programme evaluation and ongoing expenditure, which exposed differences of opinion between African and American officials over approaches to international health aid. We conclude with a discussion of how the plans set in train longer processes of development planning, and, perhaps less desirably, gave bureaucratic shape to the post-colonial state.

Measles and Rubella Global Strategic Plan 2012-2020 midterm review.

KEY HIGHLIGHTS: 1. Measles eradication is the ultimate goal but it is premature to set a date for its accomplishment. Existing regional elimination goals should be vigorously pursued to enable setting a global target by 2020. 2. The basic strategic approaches articulated in the Global Measles and Rubella Strategic Plan 2012-2020 are valid to achieve the goals but have not been fully implemented (or not appropriately adapted to local situations). 3. The report recommends a shift from primary reliance on supplementary immunization activities (SIAs) to assure two doses of measles-containing vaccine (MCV) are delivered to the target population to primary reliance on ongoing services to assure administration of two doses of MCV. Regular high quality SIAs will still be necessary while ongoing services are being strengthened. 4. The report recommends a shift from primary reliance on coverage to measure progress to incorporating disease incidence as a major indicator. 5. The report recommends that the measles/rubella vaccination program be considered an indicator for the quality of the overall immunization program and that measles/rubella incidence and measles and rubella vaccination coverage be considered as primary indicators of immunization program performance. 6. Polio transition presents both risks and opportunities: risks should be minimized and opportunities maximized. 7. A school entry immunization check could contribute significantly to strengthening overall immunization services with assurance that recommended doses of measles and rubella vaccines as well as other vaccines have been delivered and providing those vaccines at that time if the child is un- or under-vaccinated. 8. Program decisions should increasingly be based on good quality data and appropriate analysis. 9. The incorporation of rubella vaccination into the immunization program needs to be accelerated - it should be accorded equivalent emphasis as measles. 10. Outbreak investigation and response are critical but the most important thing is to prevent outbreaks.

Measles and Rubella Global Strategic Plan 2012-2020 midterm review report: Background and summary.

Measles, a vaccine-preventable illness, is one of the most infectious diseases known to man. In 2015, an estimated 134,200 measles deaths occurred globally. Rubella, also vaccine-preventable, is a concern because infection during pregnancy can result in congenital defects in the baby. More than 100,000 babies with congenital rubella syndrome were estimated to have been born globally in 2010. Eradication of both measles and rubella is considered to be feasible, beneficial, and more cost-effective than high-level control. All six World Health Organization (WHO) regions have measles elimination goals by 2020 and two have rubella elimination goals by that year. However, the World Health Assembly has not endorsed a global eradication goal for either disease. In 2012, the Measles and Rubella Initiative published a Global Measles and Rubella Strategic Plan, 2012-2020, referred to hereafter as the Plan, which aimed to achieve measles and rubella elimination in at least five WHO regions by end-2020 through the implementation of five core strategies, with progress evaluated against 2015 milestones. When, by end-2015, none of these milestones had been met, WHO's Strategic Advisory Group of Experts on Immunization (SAGE) recommended a mid-term review of the Plan to evaluate progress toward goals, assess the quality of strategy implementation, and formulate lessons learned. A five-member team reviewed documents and conducted interviews with stakeholders as the basis for the review's conclusions and recommendations. This team concluded that, although significant progress in measles elimination had been made, progress had slowed. It recommended that countries continue to work toward elimination goals with a focus on strengthening ongoing immunization systems. In addition, it concluded that the strategies articulated in the Plan were sound, however full implementation had been impeded by inadequate country ownership and global political will, reflected in inadequate resources. Detailed recommendations for each of the Plan's five strategies as well as the areas of polio transition, governance and resource mobilization are outlined.

Third World experiences in health planning.

In response to an invitation by the American Public Health Association, the author discusses his experiences in health work with particular reference to the Third World. These cover a period of four decades of activities in many countries, the discussion being primarily directed toward the North American audience attending the panel organized by the International Health Committee at the 104th Annual Meeting of the Association in Miami Beach in October 1976. First the paper deals with the legacy of broad social teaching resulting from the years of international collaboration from the time of Franklin D. Roosevelt to that of Richard Nixon. Public health problems, whether new or old, are essentially social in character and can only be solved in terms of social policy. Attention is directed to the current mistake of placing the emphasis on individual behavior, divorced from its social base, in the work of health professionals servings in Third World countries. The weakness of national average values and the consequent need of measuring the differentials between social groups and classes are widely illustrated. Finally, positive and negative lessons learned by experimenting with health technology consistent with the expected development of countries are examined as a basis for a genuinely emancipatory approach to the health problems in the Third World.

PIP: Health planning provided by the U.S. to Latin American countries in the last 4 decades has been culturally imperialistic. 3 periods with different emphases are described; there were mistakes made in all 3. It must be realized that the social function of health services in all dependent countries has been to preserve the status quo, to alleviate but not to cure or prevent diseases of the masses, to perpetuate social domination by the upper classes. Public health problems are basically social rather than merely medical; they can only be solved by revisions in social policy. A U.S. State Dept. directive in 1978 encouraged new emphasis on low-cost primary care, especially for the rural and poor sectors of the population, in developing countries. This new orientation in U.S. health planning policy can be achieved with local community participation and decision-making.

Latin American health policy and additive reform: the case of Guatemala.

Until the mid-1960s, the market-based, dependent-development-conditioned structure of Latin American health systems reflected the skewed distribution of wealth in the region: most (including government) health resources were found in curative care medicine and were concentrated in the capital cities, where they primarily served the needs of the elite. But for many countries of the area, the 1964 PAHO-led efforts to introduce health planning, intended as a first step in rationalizing the health sector, marked a fundamental turning point in the structural development of their delivery systems. Since then, this commitment has been reaffirmed in the Latin American Ministers of Health's 1973 adoption of the primary care approach as the cornerstone of their national health plans, and their ongoing endorsement and pursuit of "Health For All by 2000." Guatemala, however, was and remains an exception. Guatemalan technocrats have proven unable to plan effectively. But, far more fundamentally, the Guatemalan oligarchy has proven unwilling to appropriate the resources necessary to effect change. The reforms that have been made have been the products of bilateral and multilateral agencies, which have conceptualized, promoted, designed, built, and underwritten them. Those changes have not altered the fundamental structure of the system, but instead have been tacked onto it, and exemplify what may be termed "additive reform." Evidence suggests that without the continued sponsorship, support, and guidance of the bilateral and multilateral agencies, even these "reforms" will prove evanescent.

PIP: Until the mid 1960s, Latin American health system reflected the skewed distribution of wealth in the region: most health resources were found in curative care medicine and were concentrated in the capital cities, where they primarily served the needs of the elite. For many countries, however, the 1964 Pan American Health Organization's (PAHO) efforts to introduce health planning, intended as a 1st step in rationalizing the health sector, marked a fundamental turning point in the structural development of their delivery systems. Guatemala, however, was and remains an exception. Its technocrats have proven unable to plan effectively; no single entity is responsible for health sector planning, and the 5-year plans have come to consist of disjointed mini-plans, each reflecting the aims, desires and goals of a particular vested interest group or institution. The Guatemalan oligarchy has proven unwilling to appropriate the resources necessary to effect change. The reforms that have been made have been the products of bilateral and multilateral agencies such as the InterAmerican Development Bank, USAID, UNICEF, Kreditanstaldt and PAHO, which have conceptualized, promoted, designed, built and underwritten them. Those changes have not altered the fundamental structure of the system, but instead have been tacked onto it, and exemplify what may be termed additive reform. The government of Guatemala's own commitment to these outside agency funded projects is reflected in the recurrent shortfall of current or operating funds, and in the rapid depreciation of facilities. Evidence suggests that without the continued sponsorship, support, and guidance of the bilateral and multilateral agencies, even these additive reforms will not last.

Health planning as a regulatory strategy: a discussion of its history and current uses.

Federally mandated health planning is one of the most significant responses to the cost crisis of American medicine. Portrayed as an objective and rational mechanism of determining the future, planning is a socially acceptable means of exerting third-party control over a sector of the economy long able to escape meaningful controls on its growth and development. However, far from being the neutral science which it is heralded to be, the planning process serves the interests that are able to control its use. Health planning agencies must be studied in the context of the current emphasis on cost containment and reorganization of health services. Supported and enfranchised largely by major third-party payors, planning smooths the implementation of changes in the health sector. Despite its progressive potential, planning serves the interests of these third-party payors by masking their attempts to control the future development of the health system.

The supply of dental manpower in the United States.

This description of the supply of dental services in the United States addresses the number, kind, distribution, and training of dentists and dental auxiliaries, and the organizational factors that affect the production of dental services. Beginning with a brief historical review, the paper gives a general overview of the different types of dental personnel including the dentist, dental hygienist, dental assistant, and laboratory technician. The discussion of these categories of providers includes consideration of manpower planning as it has evolved over the past two decades, National manpower legislation is mentioned first as a reaction to the projected dentist shortage and then in response to the issues of geographic maldistribution and the effects of specialization. The second section of the paper discusses the dynamics of the dental care market. The distribution of the supply of services is identified and related to patterns of utilization and productivity. These factors are considered to be part of the set of dynamic relationships that help explain the current manpower problems of geographic and specialty maldistribution. A concluding section superficially discusses policy implications regarding the potential for increasing supply by: (1) increasing the number of dentists, (2) increasing the numbers and functions of auxiliaries, (3) increasing practice efficiency through group practice, and (4) reducing the restrictions that result from current state dental practice acts.