Authors

  1. Linder, Stephen H. PhD

Article Content

With generous grants and leadership from two of the country's wealthiest foundations, Turning Point launched more than 60 experiments intended to rebuild the infrastructure of public health. The literal turning point for public health came, however, not so much with the infusion of external funds to a chronically underfunded system but with a change in the models for organizing and implementing its basic activities. Infrastructure, in this instance, had little to do with physical installations but still conveyed a sense of urgency normally reserved for failing dams and crumbling highways. Through their national program offices, The Robert Wood Johnson Foundation (RWJF) and W.K. Kellogg Foundation (Kellogg) brokered new models of planning as "infrastructure" based on new ways of talking and thinking about policy development for community health. These were not "new" in the technical sense of innovation. Most were borrowed and adapted from practices seldom associated with public health and typically found more at home in corporate settings and commercial enterprises. Such transplantations invariably come with strings attached. Assumptions and practices that work well in the instrumental world of economic calculation and self-interest come along with the models. Too often, they remain hidden as subtle but steady sources of bias.

 

In these borrowings, the two foundations reflected a general shift to the right in our political culture since the early 1980s, favoring private over public provision of services and market virtues over government responsibilities. Rather than challenging the prevailing neo-liberal confidence in profit motives and market strategies that had reshaped health care delivery in the prior decade, these efforts at overhauling "infrastructure" actually built on it. After production was privatized in business-like partnerships, public health would be "branded," like laundry soap and promoted to communities of customers. The Institute of Medicine's (IOM's) injunction to local health departments a decade earlier to mobilize politically to resist the tides of fiscal austerity was co-opted by well-funded strategies to go with the flow and become more entrepreneurial. Turning Point ultimately promised less government (and lower taxes) by building more efficient and effective external networks of support for accomplishing traditional public health functions. Public infrastructure, the argument goes, would be better off privatized. Health departments could do more with less and few asked, "why should they?" In effect, government's roles would be divvied up among numerous private partners, each willing to contribute time or money (in lieu of tax support) in exchange for more control. Many of the partners would be service providers with a financial stake in certain initiatives, now able to ascend from contractor status to active involvement in policy development. Others would be businesses able to blunt regulatory impulses before they got out of hand. At the core of these efforts were the stalwart principles of the free market's moral order-self help, voluntarism, and mutual advantage-and a close alignment with pro-business, small-town republicanism in its aversion to welfarism, "hand outs," and the undeserving poor.

 

Yet, if that were the end of the story, not much would be gained from taking a more careful look. The Turning Point picture is made far more complex by the presence of several central tensions. Public health professionals, typically sympathetic to the powerless and vulnerable in their jurisdictions, could not be expected to entrust their responsibilities to private partners without lots of resistance. Community activists rightly would be skeptical of the motives of various stakeholders in any planning exercise steeped in corporate norms and practices. As a result, the political movement among the Turning Point participants was anything but clear even though the models and concepts subtly pressured them to the right. In making public planning more business-like, one effectively privileges economic interests and arguments at the expense of notions like public trust that serve as a moral basis for public health. Even within the foundations, the partisans of partnering and privatization were not the only voices to be heard. Some departed from the infrastructure issues to address health disparities and community involvement, key issues in the federal government's Healthy People 2010. This conflict was played out partly in a fascinating semantic dance of contradictory language. Highly political terms from the grass-roots movements of the 1970s were coupled with the depoliticized technical language of corporate strategic planning in a bewildering "TurningPointSpeak". Community "voice" and "empowerment" were juxtaposed with "vision," "leverage," and "joint ventures." This language appears throughout the profiles submitted by each project, likely following lexical leads offered in the sponsor's many briefings and conferences.

 

A second tension arises between the foundations themselves and is manifested in their very different styles. The RWJF work with the states appeared distinctly directive. When RWJF had a model it liked, say, of a statute or of a public relations campaign, it gave the model to the states and then showed them what to do with it. The struggle for the states involved figuring out how to make it fit their circumstances. Alaska, for example, never could interest anyone in its legislature in the RWJF model statute, even though it was the lead state in that initiative. In dramatic contrast, Kellogg's dealings with communities (through the city and county health officers' professional association) underwrote a wide variety of self-styled planning activities, some giving a prominent role to community organizations, others to local governments, and still others to partnering "stakeholders." In some instances, the only features linking the project descriptions with Kellogg money are the rhetoric of infrastructure, a self-congratulatory tone and TurningPointSpeak.

 

The three articles in this section assume sharply contrasting perspectives on the Turning Point experience. The Alaska and Chaves County accounts offer enthusiastic endorsements for Turning Point models and premises. New partnerships are successful, new planning strategies are making a difference, recent collaborative events are significant, and most everything seems to be going right. Turning Point is featured as the main catalyst in the Kellogg-funded Chaves County case and as the guiding hand in RWJF's Alaska-led Collaborative. The authors seem intent on crafting highly supportive statements that reproduce the promotional tone of the foundations' own materials. The skeptical reader may find a hint or two of possible frictions (one author talks of "hard work"), but insufficient careful scrutiny to be persuaded that there were no negatives. Without an acknowledgement of trial and error, any lessons must be taken on faith. In short, these accounts lack balance and pay scant attention to either documentation or corroboration for their one-sided claims.

 

When an argument is put forward, as on the merits of a model statute in the Alaska case, the reasons are provided by RWJF's outside expert, Gostin, and taken on his authority. Gostin has designed model statutes in other areas and his claims are documented in several articles in law journals. As it turns out, however, Gostin's reasons are not very compelling; three of his five reasons relate to the age of the statute, that is, being obsolete or out of date-a factor that Gebbie (a source cited by Gostin) found was irrelevant to whether statutes accommodated essential public health services. More importantly, Gostin offers no connection to the consequences or effects on health department performance of doing without so trim and standardized a statute as the "modernized" version he prescribes. Fixing the form doesn't necessarily alter or improve the function, but it can alter the balance of power across levels of government and among political interests. Gostin's legal formalism and appeals to modernization offer cover for a political agenda linked to the reform of federalism. Here, we also get a taste of RWJF's commitment to transform the current system of health care financing and its efforts to link public and private systems of health care. A uniform statute would commit all states equally to a few centralized objectives. These would include greater reliance on private sources of funding and greater use of market forces for regulation instead of governmental processes. If any of the participants in the collaborative raised concerns about these issues, these have been omitted.

 

In contrast, the Kellogg-funded Gila River case puts Turning Point and its politics in the background. Reasons are offered for each of the major problems ("challenges") faced in developing a rapprochement between tribal authorities and local government. There is no self-congratulation here. The proposed remedies, although at times vague and procedural, convey a guarded and cautious tone. There is a good deal of skepticism in the narrative, but none of it is unreasonable given the context and record of conflict. The roles of the Turning Point administrators in Phoenix and Washington, D.C. are omitted. Although the role of tribal "partnerships" is not developed fully either, in the end, this is less a story about Turning Point and putting a business face onto public health than it is about organizational growing pains and the slow tedious work of interjurisdictional bridge building.

 

The authors themselves draw few conclusions beyond a restatement of their commitment and, in some instances, faith in the process and its participants. It may be some time before we can fully judge whether any of these initiatives has made a lasting, manifest difference in community health. From these reports alone, we have no basis for questioning claims or interpretations and no record to turn to for corroboration. One thing that has been accomplished by Turning Point is to give "voice"-not necessarily to communities themselves-but to the people whose avocation is to make them better. It is a heartening sound to hear.