One might wonder why efforts for CHD-prevention were set up on a campaign basis covering only a few regions in the Federal R e public rather than as a permanent duty of the existing health system or health maintenance system, for example the Public Health Service.
The Public Health Service is, in spite of its successful hi
story in combating the health risks of the past, only slowly, if at all, answering to the new type of risk structure in the
FRG. This paradoxical development is explained by the conflicts over means of prevention that developed since it was recognized that noncommunicable diseases, especially coronary heart di
sease, can be prevented.
The development of the Public Health Service was an answer to past threats. It originally differentiated from the social sy
stem in response to the accumulating health problems that the industrial revolution carried with it, and as did the in
dustrialization in Europe, it developed later in Germany than in Great Britain. Environmental control with sanitation, pro
pagating food rules to prevent scurvy and increase the resi
stance to tuberculosis and developing publicity campaigns to encourage health maintaining habits, for example, a huge cam
paign against spitting in public p l a c e s ; setting up an advisory system to lower infant mortality, setting up immunisation pro
grammes against infectious diseases; early diagnosis programmes for tooth decay and controlling sources of infection in food, water and in some Länder, the environment, were programmes in
stituted within the Public Health Service even prior to the 1st World War or in the twenties.
Today's responsibilities are shown in Table 3 and will briefly be discussed. Examples of conflicts surrounding the future development of their service in relation to the current risk structure of society will be given.
Although the Länder differ in the organization and duties assi
gned to the Public Health Services, the following five areas are covered more or less thoroughly in all Länder:
Control of professional standards for c a r e . With the ex
ception of medical doctors, who have organized their own pro
fessional standards system, most medical care professions fall under the control of the Public Health Service, especially in relation to certification and performance control. - Hygiene of treatment locations is also controlled by the Public Health Service, who also serve as an advisory resource on community
hygiene. The Public Health Services of the Länder vary in the extent of control they exercise.
Measures of hygiene and health protection. In this area, there are traditional obligations such as protection against epidemics and severe infectious d i s e a s e s , control of public in
stitutions such as schools, cemeteries and the control of food hygiene as well as, in some Länder, new obligations which in
tend to shape the environment in a healthier way. This is how
ever, a politically contested area (cf. discussion below).
Health maintenance activities in specific f i e l d s . Popula
tion wide activities and the care for specific groups, espe
cially children and youths are the main focus here.
Expertise and consultancy for courts and administration.
These duties of the Public Health Service are a contested area, since associations of doctors in private practice claim exper
tise to courts should, as far as legally possible, be taken away from Public Health Service and be carried out by doctors in private practice.
The last set of obligations of the PHS, epidemiology and health planning, is of particular importance for primary prevention since it provides the basic data and allows evaluation of the measures taken. This area is now being developed; which data to collect, which methods to use and which goals to pursue is c u r rently being debated.
Due to the federal structure of the FRG, the Public Health Ser
vice takes a slightly different organizational form in each of the Länder. Duties and strengths, finances and personnel re
flect to a certain extent the past history of political leader
ship of each Land and its preventive p r o grammes.
Table 3. Duties of the Public Health Service^
- CONTROL OF PROFESSIONAL STANDARDS AND QUALIFICATIONS (MEDIZINALAUFSICHT) OF PROFESSIONS AND ORGANIZATIONS IN HEALTH CARE
(with the exception of doctors) Midwives, Healers, physiotherapists, masseurs, nurses, disinfecting personnel and others
health standards in hospitals, dispensaries and other drug dispensing services
- MEASURES AND CONTROL OF HYGIENE AND HEALTH PROTECTION (GESUNDHEITSSCHUTZ),
health standards in new buildings (Mitwirkung bei der Bauleitplanung usw.)
hygiene of living quarters, water, air, refuse hygiene of schools, industry, cemeteries, prevention of epidemics(Seuchen)
prevention and control of sexual disease tuberculosis welfare (Fürsorge)
Inoculation
other responsibilities, such as control of blood donor installations, living quarters for foreign employees, involvement in family planning and pregnancy advising
- HEALTH MAINTENANCE ACTIVITIES IN SPECIFIC FIELDS (GESUNDHEITSPFLEGE)
Care of the disabled (Fürsorge)
preventive activities for children and young persons, for example in schools, dental inspection health care of mothers, children and persons with psychiatric diseases (Fürsorge)
- PROVIDING EXPERTISE AND CONSULTANCY TO COURTS AND ADMINISTRATION ON HEALTH MATTERS (COMMITMENT OF PATIENTS, measures to isolate persons with certain diseases etc.)
occupational health of public employees - EPIDEMIOLOGY AND HEALTH PLANNING.
The reorganization of the Public Health Service after the Se
cond World War had brought decisions about prevention from the state back to the community level, but other ideas of community medicine developed in the twenties and abolished either by the
law of 1934^7 or by the nationalsocialist takeover had no
chance for a new start in the emerging FRG^^. Thus, integrated health services for individual care as well as social medicine were not developed again. Preference was given instead to of
fice based health care of outpatients with only one doctor responsible. The separation of Federal legislation from Länder legislation on health matters plus the diversity of competing prevention programmmes of reigning political parties in the states of the federation had the effect, that although institu
tionalized forms of cooperation between the Public Health Ser
vices 9 of all states exist today, a large number of preventive institutions were created outside the Public Health Service in
stead of adapting their programme to the emerging risk
struc-on . .
ture J . In addition, there are the medical services of the old age insurance, of industry, of the employment agency and of the health care systems within the army, the police, customs and the penal institutions, which serve preventive goals in varying d e g r e e s .
Looking back over the history of the Public Health services since the Second World War shows a gradual weakening of this once successful organization.
Judged by the available resources the Public Health Services are the weakest of the three main stays of the entire health maintenance system (i.e. PHS, Inpatient services, Outpatient s e r v i c e s ). Only 1% of total health expenditures are spent on their work and of the 170 000 medical doctors actively working in the old FRG, only about 3000 were in the public health
f i e l d ^ . The Public Health Service were not very
sue-cessful in recruiting medical staff. Measured against the plan
ned level of 1 Medical officer per 22.500 inhabitants in the Public Health Service, agreed upon by the Länder ministers for health, there was persistent underrecruitment of up to 30% for some years (for the largest of the Länder, NRW, with approxi
mately 16 Mio i n h a b i t a n t s ) ^ .
Critics of the Public Health System also identify an internal source of conflict over goals, in that the Public Health Ser
vice has the fundamental problem of being both an enforcing agency in relation to the state and a counselling agency in re
lation to the public.
Currently, the debate on the reform of the Public Health Ser
vice points in two basic directions:
private d o c t o r s ' associations as well as some Länder are trying to cut even more of the duties of the Public Health Ser
vice and transfer them to the money economy, (i.e. more of pre
vention to office based doctors, more of the quality control of hygiene for example to private enterprises),
in some Länder however, a reversal of the disfunctionali
sation of the Public Health Service is envisaged and the ob
ligations of the Public Health Service are being expanded; an attempt is made to deal more adequately with t o d a y 's health risks as a public obligation of today: More responsibility in prevention, especially towards risk factors of the current
spectrum of chronic d i s e a s e s , more activities in community b a sed preventive medicine, more involvement in health planning and policy decisions at the community level, for example
through the instrument of regular assessments of risk structu
res, community health, preventive activities and level of health care (Gesundheitsberichterstattung), and more invol
vement in environmental control and planning, for example through participation in the legally prescribed procedure of
checking environmental effects of new buildings, enterprises, changes in the landscape and the like (Umweltverträglich
keitsprüfung ).
While it is being claimed that the special relationship between doctor and individual is as beneficial in primary prevention as in the treatment relationship, it is nevertheless true that the shift from community services in prevention to office based outpatient care in private practice changes the impetus of pri
mary and secondary prevention as far as flows of money and the involvement of the public are concerned. The remuneration of doctors is based on a detailed catalogue of well defined single activities (Einzelleistungsverzeichnis), where health coun
selling is but one position. This catalogue honors diagnostics on the whole far better than the hard business of counselling individual persons in relation to their individual living con
ditions, which would have to be explored at length before ade
quate advice could be given. It is hard to see any chance for doctors in private practice to influence the structural condi
tions of work and within the community by counselling indivi
duals .
Another influence favoring measures of secondary prevention in
stead of primary prevention in the office based patient-doctor relationship results from the fact that patients only go there when symptoms are experienced, too late for primary (and in many cases even for secondary) prevention. Only a select sample
is reached this way, not enough for population oriented m e d i cine. The very nature of the relationship between doctor and patient based on non-involvement of the doctor in the social setting of the patient also favors the attempt to induce beha
vioral rather than environmental changes (if changes come about at a l l ).
A closer look at some of the reform ideas in relation to the PHS reveals additional d e t a i l s . One of the basic dilemmas is the conceptual dimension, where important actors in the German
scene differ. How much of the responsibility for a healthy way of living, for individual life style, should or can be the re
sponsibility of the individual or of the primary group or, on the other hand, should or can there be a public responsibility?
That is one of the basic issues underlying much of the discus
sions on the policies in relation to health promotion as well.
If the answer is, that individuals can choose a healthier way of life only if the living and working environments are
healthy, and their improvement should therefore be the prime responsibility of public authorities, this has important struc
tural implications for the PHS: It should then orientate its activities towards advising local authorities on the health im
plications of their policies. This would require the engagement of staff with qualifications pertinent to these policies at the PHS. This kind of expertise is expensive and should probably be more effectively organized on a larger scale than the current one public-health-office-per-community system.
On the other hand, if social medicine and preventive medicine - in the sense of behavioral and secondary prevention - are more at the center of the future activities, then there should be an even stronger integration of PHS-staff within each community and a strengthening of contacts to individuals. Qualifications effective in health promotion, in promoting healthier life styles would then be required.
Other models of reorganization have been proposed or are being practiced. In the state of Berlin, the supervision of environ
mental activities of firms has recently been transferred to the local PHS, leaving only workers' safety and health at the cen
tral authority. The wisdom of this reorganization is being que
stioned on the grounds that both environmental as well as
w o r k e r s ' protection has very much to do with the technology of the enterprise and expertise should better be concentrated in one central agency. In addition, placing environmental protec
tion at the hands of the local PHS would only be sensible if it could develop its own measurement - and technical evaluation
capacities, a costly enterprise which probably strains the fi
nances of the local community too far. A service without such a capacity does not seem to be very effective in the long run.
Other important aspects of the current discussion center around finding optimal forms of organization for the Public Health Service: in relation to size of population served, in relation to the desired degree of specialization and in relation to new types of cooperation with other parts of the health maintenance system such as doctors and the other specialized preventive agencies. Since medical care is taken care of by sickness bene
fit funds and the medical care system, the PHS could con
centrate more on the coordination of preventive activities within the health system at community level and on special pro
grammes . In order to do this effectively however, the PHS would need epidemiological findings about the risk structure and the state of health of the population and about the performance of health services within the community. Both types of informa
tion, although their collection is one of the obligations of the PHS (see Table 3), is sadly lacking for most communities.
Some Lander have only recently started to set up regular health reporting (Gesundheitsberichterstattung), including both regio
nal health statistics and information on the medical care sy
stem.
Another field of activity of the Public Health Service is
health maintenance for children and youths. However, there are two developments impeding the activity of the PHS here: Abso
lute numbers of persons in this age group have decreased, and a change in the sickness benefit fund system now allows paedia
tricians in private practice to take an active part in preven
tion, such as performing the regular health checks for young
sters and the childhood inoculations. What is left to the PHS today is the responsibility to identify groups not having re
ceived this protection, a rest category. Thus, health promotion and prevention for children and youths cannot be a point of departure for population wide activities in relation to the m o
dern risks. Nevertheless, there could be and probably needs to be a shift to other activities: Acting as an advisor on pre
ventive aspects to schools and other organizations concerned with children and y o u t h s .
The most contested area between the PHS and the medical pro
fession is that of treatment. It is only in social psychiatry that there are some possibilities for an active engagement of the PHS. In some Länder there are model projects to explore appropriate forms of delivery.
The many issues currently under debate in relation to the Pu
blic Health Service probably makes it easier to comprehend the goals which the healthy heart campaign set itself in furthering the growth of preventive structures at community level3 4 t which after all, should have been the obligation proper of the Public Health Service all along. At any rate, there are demands to im
prove the work of the PHS in life style related health promo
tion in regard to smoking, nutrition and excercise.
5. ORGANIZATION FOR PREVENTION OUTSIDE PUBLIC HEALTH: HEALTH