I S S N - 0 9 3 5 - 8 1 3 7
P 9 2 - 2 0 4
Adaptation of the Health System to the Risk Structure of Modern Society in
the Federal Republic of Germany von
Barbara Maria Köhler
B e r l i n , M ä rz 1 9 9 2
Publications series of the research group
"Health Risks and Preventive Policy"
Wissenschaftszentrum Berlin für Sozialforschung D-1000 Berlin 30, Reichpietschufer 50
Tel.: 030/25491-577
Health or rather disease indicators from any source show that the distribution of health risks is changing with the develop
ment of societies and that the actual risk structure might be considered a characteristic of the dangers resulting from so
cial development on the one hand and of the active measures to defeat disease and to maintain health on the other. This paper examines the overall structure of the health system of the Fe
deral Republic of Germany and, for specific areas of this sy
stem, the performance and the conflicts involved in the organi
zational adaptation to new societal risk structures (particu
larly the public health services and the preventive arrange
ments in the area of work and h e a l t h ).
Zusammenfassung
Alle Gesundheits- bzw. Krankheitsindikatoren zeigen, daß die Verteilung der Gesundheitsrisiken sich entsprechend der gesell
schaftlichen Entwicklung ändert und daß dieser die jeweilige Risikostruktur zugeordnet werden kann: sie ergibt sich zum einen aus Gefahren, die im Zusammenhang mit der gesellschaftli
chen Entwicklung stehen und zum anderen aus den präventiven Maßnahmen zur Krankheitsbekämpfung und zur Erhaltung der Ge
sundheit .
In dieser Arbeit werden die organisatorischen Strukturen darge
stellt, die Gesundheitsrisiken in der BRD mindern. Dieses ge
sellschaftliche Gesundheitssystem wird funktional aufgefaßt und ist von daher umfassender als die historisch gewachsenen, klas
sisch als Gesundheitssystem bezeichneten gesellschaftlichen Strukturen der Gesundheitssicherung. A m Beispiel des Öffentli
chen Gesundheitsdienstes und der Präventionsstrukturen im Be
reich Arbeit und Gesundheit werden die Konflikte untersucht, die die Anpassung an veränderte Risikostrukturen begleiten.
1. INTRODUCTION 1
2. THE HEALTH SYSTEM TODAY 6
3. EFFECTIVENESS AND CONFLICTS IN PUBLIC
HEALTH CAMPAIGNS 13
4. ORGANIZATION FOR PREVENTION IN THE HEALTH
FIELD: THE PUBLIC HEALTH SERVICE 18 5. ORGANIZATION FOR PREVENTION OUTSIDE PUBLIC
HEA L T H :HEALTH AND SAFETY IN THE WORK PLACE 27
6. CONCLUSIONS 37
FIGURES AND TABLES
THE CURRENT ORGANIZATION OF PUBLIC HEALTH (FRG) 8 NUMBER OF SICKNESS BENEFIT FUND MEMBERS 1989 9 DEVELOPMENT OF RISK FACTORS 1984-1988 18 DUTIES OF THE PUBLIC HEALTH SERVICE 21
1. Introduction
The achievement of health for all seems to be a goal that all share. However, a look at health or rather disease indicators, be they derived from personal assessments of the health state, from morbidity data supplied by the health care system, from lost days at work or from mortalitiy figures or lost years of life makes one suspect that all can't be well with this shared goal. This is true both in areas where preventive measures are believed to be available and in those areas where this is less obvious as is the case for the control of drugs and their con
sequent health related problems or with back ache.
But looking at health related problems is also a question of perspective. Average life span has risen in all industrialized countries by a considerable number of years including both East and West Germany. Societies have been able to reduce some life shortening risks successfully. At the same time, the spectrum of diseases has changed with modernization of society and con
tinues to do so: New dangers pose problems, for example Aflato
xins, AIDS or legionnaires' disease; known dangers change their frequency such as is obvious from the current rise of salmonel
losis. Looking back over any period of time, lets say a hundred years, we find that infectious diseases, accidents at work have decreased considerably. In the FRG, as no doubt in other indu
strialized countries, the biggest contributors to the disease spectrum today are chronic, noninfectious diseases, ascribed to a large extent to a ) behavioral, b ) environmental and c ) gene
tic causation and to some extent to still existing deficiencies of the medical care system.
These changes in the observed frequency pattern of death and disease can be ascribed to
changes in dangers resulting from social developments
active measures to defeat disease and maintain health, i.e.
prevention.
Prevention has to adapt to the changing risk structure due to modernization of our societies and state strategies to achieve health for all should therefore identify dangers and devise risk lowering socially acceptable strategies followed by an im
plementation of these strategies. This would obviously require a continuous adaptation to the evolving risk structures.
However, the existing societal risk strategies did not come about in this rational fashion. It is not immediately obvious why some health risks are well controlled, down to very low probabilities, while other dangers are just r a m p a n t .
This is not due to the nature of the risk. Even where the spe
cificity of causation is not clear, preventive action can be taken on epidemiological information. Being poor, being out of work and living in a contaminated environment are such dangers Epidemiologically these have been shown to affect the chances to lead a healthy life of long duration. Moreover, joblessness does not only affect the persons who are actually out of work but their dependents as well. Comparing mortality rates across nations, we find good relationships to national wealth as
measured by Gross National Product, comparing mortality and morbidity figures within nations, we find a fairly good
relationship between social class and health^. The grey areas around causation need not prevent health measures being taken, as many a successful public health measure in the past was ta
ken on the basis of what today would be considered unsound s c i ence.
There are other areas of specific health impairments where spe cific causation is better understood but adequate preventive measures are nevertheless not taken. As far as Germany is con
cerned, the most striking examples arise currently from unifi
cation. We actually have a dramatic rise in car accidents in the new Länder. Apart from this, we also permit ourselves the
luxury of millions of persons out of work. Health effects of
the vast social and economic adjustment that is currently ta- king place in East Germany have been estimated-6.
The example of German unification confirms the view that quite extraneous' economic, social and political factors shape risk management strategies and that conflicting interests in society determine the shape of the public health outcome. This is not only true of times of abrupt systems change, these factors also operate during the "normal" functioning of a social system's l i f e .
Risk relationships are not monocausal, in many cases there are proven polycausal models linking health impairments to social and economic conditions or to the arrangements of the man-ma- chine-system. But this knowledge is only partially transferred to prev e n t i o n . T h u s , in preventive activities to lower risk factors for coronary heart disease, attention is more and more reduced to individual behavior variables: lack of exercise, overweight due to unhealthy and unbalanced diets, smoking, an insufficient individual ability to deal with stress. Risk fac
tors such as stress at work are all to frequently reduced to the teaching of individual relaxation techniques.
It is easier to understand the current state of societal risk management if the processes of their development are analysed.
It is not the state of knowledge about a danger and its distri
bution that seems to determine the quality of the risk manage
ment strategy but the power of interests tied in with the v a rious aspects of establishing it.
Certain types of conflict can be identified: There are differ
ent ideas about what dominant goals should be and how they should be realized. None of the conflicting groups would ob
viously be against health, but the decision against health is usually quite implicit in the goals to be pursued. Having a chance for a rise in living standard may thus detract from the real danger of health impairment due to unemployment as was the
case with the general public in East Germany. Here, we might also place the debate about an adequate social risk level. Thus in the conflict over asbestos control, it was argued that m o dernization had to be paid for with health risks and that
people were willing to accept high individual risks anyway, for example in s p o r t s .
A second level of conflict is not over goals but over means: an example is the current debate over social problems and drug use: Should the state take repressive, punitive measures (and thereby foster prostitution, drug related crime by users and above all, criminal associations of drug dealers who thereafter invade other areas of society? Or should we legalize drug use or rather spend money on foreign aid to encourage farmers in drug exporting countries to produce guaranteed crops?
Infectious diseases have provided a rich set of such alterna
tive decisions. To prevent the spread of AIDS, should the state follow a policy to identify and isolate the sick and infected, a model of disease prevention used for the plague and leprosy in not so distant times, or should health policy start cam
paigns in health and sex education, enabling all members of so
ciety to take adequate precautions in their very own sexual behaviour against the risk of being infected? States have taken quite different decisions on this public health question in the very recent past.
At a third level there is conflict over causality, involving both paradigms in science and risk awareness in the public3 . Examples are the familiar ascription of accident risk to risky circumstance or to a particular risk personality.
Another example is the conflict over some basic assumptions underlying the German preventive system against dangerous sub
stances at the work place or in the environment. With very few exceptions, this is based on some simplifying assumptions about reality. The health effects are investigated as if
only one substance is being present at a time in the work environment
with that substance being uncontaminated with any by-pro
duct .
On the other hand, scientists argue that risk awareness of the public is distorted in relation to the danger of substances and to exposure.
This conflictual view of prevention makes one aware that pre
vention is not necessarily of benefit to all and that conflict regulation is a necessary and a continuous part of shaping risk management strategies.
From a practical point of view, the conflict model also
suggests that preventive policies should be organized in such a way that early conflict resolution can be achieved. In con
sequence, health implications of policies should be examined at an early stage and discussed as part of routine decision m a king. Of course, this new policy would have to start within existing structures and their established interest patterns.
The conflict model of prevention might serve as a base or un
derstanding the institutions of any health system, their acti
vities and the effectiveness of their programmes. In this pa
per, the existing health system in the Federal Republic of Ger
many and its linkages to prevention, health maintenance and health care institutions and some public health campaigns
including some of the conflicts they face today will be descri
bed, referring to data up to 1989. Practically all of the fea
tures of the health system described here have been transplan
ted into the new Länder of the Federal Republic after 1990, where the process of transformation from the previous to the newly adopted health system is still underway^.
2. THE HEALTH SYSTEM TODAY
Societal risk management strategies aim at restoring health and, in primary prevention5 , reducing the chance of its initial loss. A wide range of institutions and competing concepts has developed in this area from the conflictual adaptation proces
ses of the p a s t . In a recent Norwegian government publication
"Adding life to years" a distinction is being made between health promotion and prevention, with promotion relating to im
proving all that is good and positive and which improves the quality of life, giving persons a choice among "healthy" alter
natives, while prevention is used in the narrower sense of re
moving, shutting out and hindering factors that lead to ill
ness, injuries or other problems5 . In the FRG, health promotion is all too frequently understood to be directed towards li
festyles and less towards environmental change. In fact, diffe
rent emphasis is placed on the meaning of this concept by different institutions of the health system.
Measures of primary prevention are here understood to be direc
ted towards two of the four complexes of causation of the cur
rent disease spectrum, i.e. towards eliminating or lowering all conditions in the social and physical environment or in beha
viour that lead to a high probability of negative influences on health.
There is a large mix of such programmes and organizations in existence to deal with specific risks including the Public Health Service(PHS). Prevention is fragmented institutionally:
Along conflict lines over political issues, along regional li
nes according to the constitution of the Federal Republic. It is organized both within and without the traditional system of health care and health maintenance. Obviously, road con
struction, driving licences, car safety rules in accident pre
vention, programmes for safer sex in AIDS prevention, provisi
ons for persons to be able to eat enough and well, programmes to avoid contamination of the environment, say with dioxine,
belong into this category. Although all of these public poli
cies have consequences for health, not all of these programmes originated in or are administered by what is known as the
health maintenance system. Public health and healthy public p o licy should really merge here, although they do not do this in a systematic manner as far as the FRG is concerned. There is no systematic procedure today to examine the health impact of
state policies and to resolve the conflicts over dominant goals at an early stage. The examination of the then existing proce
dures to include long term health considerations in state po
licy making led Rolf Rosenbrock of the Group Health Risks and Preventive Policy at the WZB to conclude in 1989:
"A well conceived healthy public policy in the F e deral Republic of Germany simply does not exist?."
Politically, there now is a Ministry of Health at the Federal level, but the responsibility for policies in the area for the environment, work and health and food safety, to give but a few examples, does not rest there. Some aspects, however, have now been drawn together here which were formerly the responsibility of other ministries, ie. health promotion by the sickness bene
fit funds, medical aspects of health promotion safety of phar
maceuticals, and consumer protection.
The currently existing organizations directly involved in p r e vention, health maintenance and the control of environmental and behavioral risks are here considered to constitute the health system, the dominant features of which are shown in fig. 1.
Fig. 1 The current organization of public health (FRG) THE HEALTH SYSTEM
1 r
a)SPECIALISED AGENCIES FOR
b)HEALTH MAINTEN INCE SYSTEM
CONSUMER PROTECTION
+
C )PUBLIC HEALTH d)MEDICAL CARE SYSTEM
SERVICE |
WORK +
f
+ dl)INPATIENT SERVICES
n
d2)OUTPATIENT SERVICES
ENVIRONMENT
e)HEALTH AND
OLD AGE INSURANCE
+ +
ETC.
f)SPECIALIZED SERVICES
(ARMY) (POLICE)
ETC.
The health system in the FRG encompasses
a) specialized preventive agencies in particular fields, also advising the state on policy and
b ) the health maintenance system with several p a r t s : c) the Public Health Services (Öffentlicher Gesund
heitsdienst ),
d) the medical care system. The latter is divided into:
dl) institutions such as hospitals and hospices treating in-pa
tients
d 2 ) the office based family doctors and specialists treating out-patients.
e) a separate system financing the medical care system and part of primary prevention and
f ) medical care services delivered directly to subgroups of the population (police, prisoners, soldiers).
Access to the medical care system ( d) in fig. 1 ) is based on free choice of the treatment relationship by the patient.
Treatment is financed through an insurance system which is m a n datory for most Germans depending on income level and type of employment'. This public insurance system covered 3 7,2 Mio.
(employed plus old age pensioners) and 19,2 Mio dependents in 19898 (c.f. table 1).
TABLE 1 . NUMBER OF SICKNESS BENEFIT FUND MEMBERS 1989 (Average annual membership in M i o .)
21.885 mandatory members(based on employment status and income l e v e l )
4.441 voluntary members, eligible because of previous mandatory membership
10.904 pensioners(membership mandatory) 37.23 SUM 1
19.9 in addition, family members who were covered under these schemes (estimate from Microcensus)
57.13 SUM TOTAL
Thus, in relation to the total population of approximately 62,7 Mio. for the old Federal Republic at the end of 1989, this
amounts to a sickness benefit fund coverage rate in public in
surance schemes of approximately 57,1 : 62,7=90%9 . For the remaining population, there are also private insurance schemes for those not eligible and their dependents (employed with high incomes, self employed, civil servants)^® and an insurance sy
stem providing immediate health care in case of need for per
sons on social assistance and their dependents.
The organization of health care delivery is quite independent of the organization of insurance, inasmuch as every individual has the free choice of his doctor or hospital, except for spe
cial groups of the population such as soldiers, policemen and prisoners, who have their own within-service or within-prison treatment system ( f) in fig. 1 ). The services that are ren
dered to the other patients are remunerated to the medical care system by the sickness benefit funds according to rates fixed between d o c t o r s ' and h o s p i t a l s ' associations on the one hand and the insurance system on the other.
Although the social insurance system does not maintain its own institutions in health care, it does have the obligation and does in fact carry out a wide spectrum of activities in primary prevention (entered in fig. 1 under e), especially in the area of health promotion. These activities include health education directed at risky behaviour and at risk factors in members,
(nutrition, obesity, smoking, addiction, sports), but there are also some examples where harmful conditions at work were iden
tified through the local branch of the insurance company, and changes initiated there. The insured can be sent to health re
sorts for several weeks when they are in danger of falling ill.
Such stays in health resorts are supported and organized by the public pension funds as well (also under e) in fig, 1) to ensure a long and healthful working life to their m e m b e r s . Health edu
cation and individual training in more healthful behaviour is also part of such a stay. Thus, the social security agencies such as sickness benefit funds and old age pension funds do carry out primary prevention, with few exceptions oriented to
wards the individual.
With growing emphasis on primary prevention in recent years, there has been considerable conflict on the meaning and organi
zational locus of preventive activities within this system. E s pecially the office based doctors, working as independent en
trepreneurs , compete for a share of preventive a c t ivities. This competition has implications for the current state of preven
tion carried out by the Public Health Service ( c ) in fig. 1 ), to be discussed in section 4.
Both the Public Health Service and the medical care system deal with illndss and prevention, although in quite different de
grees and with quite different means, their relative invol
vement in these areas has shifted over time. The Public Health Service as it originated in the last century is - and was - d i rected less towards the individual's and more towards the gene
ral public's health (Bevölkerungsmedizin). Their involvement with the treatment of illness has greatly diminished over time, but they are only slowly adjusting to the new risk spectrum of society. Even today, prevention and control of infectious d i seases are at the center of their activities, while prevention
(at least retardation of the onset) of chronic diseases are only slowly gaining entrance on their agenda.
Prevention of diseases and accidents related to work, leisure and traffic are matters of public policies organized in other departments at the Federal and at the Länder level and particu
lar preventive institutions ( a) in fig. 1 ) are funded there (examples will be discussed in sections 2 and 5).
The fairly simple structure presented above is in the reality of the FRG complicated by the Federal structure of the state with a nonhierarchical distribution of responsibilities between Federation, the Länder and the political structure at the com
munity level on the one hand and the preventive work of innume
rable non-governmental organizations on the other-'--*-. All these actors in prevention have tended to develop their own interest profile in relation to goals, means and causality and organiza
tional interests of survival and power.
One possible explanation for the current heterogenous structure within primary prevention is the particular assignment and dis
tribution of political responsibilities within the Federal R e public of Germany. Again, we are led to consider the importance
of extraneous, economic, social and political factors for the shaping of risk management strategies and institutions. Let us just consider state health polic i e s . Responsibilities for the Public Health Services are organized at Länder or community le
vel while responsibilities for health policies are in some
cases with the Länder, in others with the Federation and in yet others shared between all three levels. To reach, within this structure, a joint risk management strategy requires a large amount of coordination and cooperation, and the outcome is fur
ther complicated by the large number of non-governmental orga
nizations with their very own interests. The actual mix of in
struments that is used to implement any particular preventive policy can therefore only be understood by an analysis of its history and current operating conditions. For the Public Health Service and the area of work and health, this will be outlined in the following secti o n s .
Having so far considered the health system with its more perma
nent institutions, there are other forms of preventive poli
cies. One type of state activity is directed by finances, i.e.
taxation or tax exemptions for harmful or for risk lowering goods and services, which will not be considered here. Another type of state supported activities are c a m paigns, often invol
ving the coordinated efforts of many institutions. It is not easily understood why some activities have led to institutiona
lization while others are planned on a limited time basis, al
though the health risks may have an enduring character. Three campaigns will be discussed: information campaigns which are a more or less permanent form of preventive activity carried by most preventive institutions; the seat belt campaign, which can be considered to have been successful (and therefore rightly limited in time) and the healthy heart campaign, where the above does not hold.
Finally attempts are being made to bridge the levels of state and private organizational activities for healthy public poli
cies at community level, for example the healthy cities pro
jects as initiated by the WHO-^.
3. EFFECTIVENESS AND CONFLICTS IN PUBLIC HEALTH CAMPAIGNS.
The factors that went into the success or failure of preventive campaigns 13 are of obvious interest for evaluation.
Information strategies. A large part of primary prevention in relation to chronic diseases is based on information strate
gies, informing the public on current beliefs about the relationship between life style and disease.
Primary prevention in public health as a measure to influence individual lifestyles uses three types of m e t h o d s :
- health education (in kindergarten, schools, for parent g r o u p s )
- health information (usually offered on request:
for example on nutrition, on product safety,
- health guidance usually given to individuals through members of the medical care system.
In the FRG today, much of the actual performance of these
information based strategies is carried by non-governmental or
ganizations (NGOs) of varying type, with the state involved in setting their policy and supporting these NGOs financially. The cooperation taking place in this area may serve as an example for the complex organizational web of cooperation which we find in many areas of the German primary prevention scene. The Fede
ral Institute for Health Enlightenment BZgA and the association of all NGOs in this field, the Federal Association for Health Education (BundesVereinigung für Gesundheitserziehung) play a major role by designing programmes, publishing teaching m a terials and offering courses for communicators. The medical
profession plays a minor role in the actual work, mostly in the area of individual health guidance, for example during preven
tive stays in health resorts or within the medical care system.
The professional medical associations have however, some defi
nite ideas on primary prevention with heavy emphasis on modi
fication of individual behavior as risk lowering strategies, firmly based on the assumption that improving knowledge of a natural science type will improve lifestyles to be healthier.
This primary prevention message emanating from official medical organizations, is in some cases bolstered by suggestions of b e havioral enforcement, for example, that fatter persons and smo
kers should pay higher sickness benefit fund p r e m i u m s ^ 5 .
There is in my view too little discussion on the effectiveness of this strategy in relation to other forms of intervention, for example changes in taxation, developing "healthy" social structures. Investigation of health indicators still show a classrelatedness of disease and risk factors for circulatory d i s e a s e -*-6. At the same time, investigation of information
transfer strategies in health education and health information shows strong links to social status as well. These measures therefore, do not seem to serve the group of persons at the highest epidemiological risk very well, and should therefore be discussed in relation to their efficacy more than is the case t o d a y .
Attempts at behavior modification by information on causal
links cannot be condemned out of hand, however. There are quite successful examples as well: personal hygiene of doctors lowe
red mortality of women from puerperal fever, spitting in public places, quite usual in the last century, was almost eradicated
following an anti-spitting drive as part of tuberculosis pre- vent i o n 4- ; the changes to safer sex practices by homosexual men, although information campaigns are apparently not as suc
cessful among heterosexuals buying sex, another source of AIDS- infection-*-8.
Seat-belts. A recent and successful mix of policies involving behavioral change concerns s e a t b e l t s P u t t i n g on seat-belts is a somewhat clumsy activity which had to be integrated into firmly established habits and which carried a meaning of
distrust into the relevant other (the driver-passenger-
relationship). The risk involved to the person who has to com
ply has a particular structure: The danger of an accident is severe, but the event is nevertheless highly unlikely.
Around 1970, experts generally accepted the view that 3-point passenger seat-belts would reduce personal injury during car accidents considerably. A large number of industrialized coun
tries began to take various measures to increase the wearing of safety belts.
Wearing seat-belts during driving became law in Victoria in 1970, in the entire Federation of Australia and in New Zealand in 1972, and by the end of 1976, it was mandatory in 19 Euro
pean states. Austria, Norway and the FRG abstained at that time from levying f i n e s .
The question whether persons should be forced to wear seat- belts for their own protection raised basic constitutional and legal issues in the FRG. Was it not, it was argued, an intru
sion into the fundamental right to self determination to force someone for his own good? Such an intrusion would only be ju
stified if the good of all demanded it. For this reason, no fine was attached to the ordinance to wear seat-belts origi
nally. Finally, the High Court of the Constitution decided that the common good (of being able to give help after an accident for example) was touched, and fining was deemed admissible.
While the rate of persons wearing seat-belts rose in all coun
tries, it had risen less sharply where no fines were collected.
Germany introduced fines in 1984 for drivers and front seat passengers and in 1986 for back seat passengers. Compliance rate is now between 90 and 100% depending on type of road and
length of drive. This success story did, however, not come
about by law alone but was accompagnied by other m e a s u r e s , most important probably a prevention policy supplying the means to comply. In the FRG, measures were taken so that 100% of cars on the road would be fitted with seat-belts from 1980 onwards.
Technical improvement of the seatbelt also helped to increase c o m pliance.
Safer driving through seat-belts was also supported by publi
city campaigns of NGOs and s t a t e d .
Especially the larger publicity campaigns were evaluated in re
lation to their effectiveness. On the whole, they did not raise the compliance rate. In fact, it was found that compliance and knowledge were not related. Compliance depended on factors re
lated to the specific situation of driving, other factors found are those turning up time and time again in health behavior studies, such as age, social status and level of educational.
An evaluation of the various measures taken led Vieth to the conclusion, that the single most effective measure had been the effect of introducing fines, while changes in the insurance reimbursements according to whether the persons involved in the accident had worn seat-belts or not also had a (minor) influ
ence. The factors leading this campaign to success in such a short time consisted, according to this analysis then in proscribing certain technical norms for industry making it easier to comply and fines as an enforcement for behavior m o dification. Although the information campaigns in their own right had little influence, we cannot judge from the data pre
sented in this study, whether enforcement and technical norms would have been successful without them.
Healthy heart campaign. A story with mixed success is connected with recent efforts to influence risk factors of coronary heart disease at local community level. This program is remarkable because it quantitatively defined its preventive goals in ad
vance; its success can therefore be measured. The healthy heart campaign intends to lower the mortality rate of the diseases in question by 8%22 in the long run and to lower prevalences of risk factors by defined percentages23 (see table 2).
The design of the study binds together a mix of interventions at community level directed at the interaction of individual, behavior related risk factors (smoking, high blood pressure, high concentrations of cholesterol in the blood, adipositas, lack of exercise) and the living conditions of the population.
The objective is to reach, for the populations of the study a r e a s ,
a lowering of the population wide risk factors,
an improvement of the preventive health care system of the area,
a change in individual life styles in a more health maintaining direction ( behavior, attitude),
an increased use of preventive opportunities within the community.
Besides leaning heavily on information strategies, the pro
gramme tries to influence the environmental conditions of life styles as well: the work place in industry and administrations, educational institutions, the health care system and the provi
sion of goods, especially food, and the public arrangements for a healthpromoting leisure time (swimming pools, sports clubs).
The intermediate evaluation (1988) showed an increase in the prevalence of all measured risk factors for coronary heart d i sease for the entire population of the FRG (cf. table 2, last col.) except high blood pressure. By comparison, the develop
ment of risk factors in the study regions is a commendable one, although the goals for 1988 were missed by a long distance.
The reasons for success and failure are currently under debate and the final, conclusive evaluation will not be available for a few y e a r s .
Table 2'. Development of risk factors 1984 - 19882^
relative change in prevalence
Factor goal f.1988 study areas total pop.
pop.blood pressure - 6,0% - 1,2% 0%
total cholesterol - 2.0% + 2,7% + 3,4%
smoking - 3,5% - 1,3% + 1,7%
BMI+20% - 2,0% + 0,6% + 0,25
The study does offer an example of conflict over means of pre
vention and the link to other interests. While originally, it had been planned to organize intervention from specially esta
blished health centers allowing contact between researcher and population, office based doctors claimed a larger share in pre
ventive activities, so that the study design had to be m o d i fied2 5 .
4. ORGANIZATION FOR PREVENTION IN THE HEALTH FIELD: THE PUBLIC HEALTH SERVICE
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 AND SAFETY IN THE WORK PLACE
The general rule that state intervention begins when major state goals are threatened has been true not only in the hi
story of the public health system but for safety and health in the work place as w e l l . T o d a y 's system has a long history going back about 150 years and preceded by an even longer period when the knowledge of the deleterous effects of working conditions on health were known but no prevention was undertaken. The
state began to intervene in labour conditions only when serious threats arose to other goals, i.e. when the health of young men as recruits for the army was threatened.
There has been a large push of legislation at the Federal level in the 1 9 7 0 's to improve working conditions. This is most noti
cable in the area of toxic substances, where a fairly elaborate system of controls has been set up since. Knowledge of health effects formerly available only to a few experts is now begin
ning to be spread through the system of continuous education and thus to the shop floor. Although we have a long way to go yet, at least substances are controlled for their health ef
fects and labelled accordingly before being marketed (in amounts above 1 t per year in the European Commu n i t i e s ).
The improvement of rulemaking and enforcement in relation to dangerous substances in the work place might be considered a late adaptation to a risk structure that had really developed since the end of the century before. Other important areas of policy making, however, set rules that enabled preventive acti
vities in the work place in response to currently changing risk. They included a strengthening of the rights of employees and their representatives both in the enforcement of safety at work rules and in the planning stage of new machines, technolo
gies and procedures in their place of work; the right to conti
nued education for works council members; the provision of ex
pertise to the enterprise who now had to employ safety engi
neers and medical officers in an advisory capacity. These
improvements were not however, based on a thorough analysis of the risk structure of modern production regimes and the design of an appropriate preventive strategy. A thorough analysis re
veals the traces of expansion of the then existing organiza
tions into new areas offered by conflict over changing working cond i t i o n s . The resulting organizational setup between normset
ting and norm controlling agencies, as well as the resulting norms are, to say the least, complex, and show control deficits in relation to various risks. To give but one example, civil servants and public employees are not covered by the same pre
ventive provisions as private employees. Without further refe
rences to the deficiencies of the rule book it may be said^5 however, that the outstanding feature of todays' organization of work and health in the FRG are procedures to anticipate changes in the risk s t r ucture.
Health and safety in the work place as it stands today is an example of the complex cooperation between private, non-govern
mental and state organizations and includes the involvement of the person's whose health is at stake and their representatives.
Going through institutions existing today, the mandatory
workers' compensation funds38 cover almost all employees. They are administered jointly by representatives of workers and entrepreneurs, but financed solely by the entrepreneurs. These funds are important in
setting preventive standards in industry advising on technological innovations
training safety personnel for the companies
to name but a few of their obligations in primary prevention.
In tertiary prevention, the workers' compensation funds reha
bilitate employees who have suffered injury or sickness at w o r k 3 7 . Other than the general sickness benefit fund system, w o r k e r s ' compensation funds employ doctors and maintain hospi
tals and resthomes themselves.
Although the number of accidents in the work-place reported an
nually shows the necessity to improve this situation consi
derably, one should also say that with this system we have had a decrease of accidents per year and thousand workers from 118 in 1961 to 54 in 19893 8 . This is, of course, not only due to the quality of prevention, other reasons which promoted this decrease are changes in the type and risk structure of work.
Major criticism is directed at the Workers Compensation Funds because long-term health effects of working-conditions do not receive sufficient attention in their work. The most obvious problems are the occupational diseases, which are narrowly de
fined: They must be attributable to working-conditions and have to be contained in the catalogue of the w o r k e r s ' compensation fund. For more than 50 work related diseases plus, in theory, other conditions not specifically named, the employee has a
right to be healed, rehabilitated and compensated through the workers' compensation funds. However, this system of com
pensation and prevention does not function too well: Because the direct link between working-conditions and health effects is not as visible as it is in the case of an accident, these conditions are generally diagnosed first in the general medical system and many of the cases are probably ascribed to other causes. It is believed that only a fraction of ill health ac
tually due to working-conditions is ever notified to the
Workers Compensation Fund and a large fraction of these cases are rebutted because of the causality clause: Since the work relatedness of disease has to be shown beyond doubt, cases of litigation are drawn out and frequently end with non-recogni
tion, e.g. in cases of smokers working with chemicals known to cause lung c a n c e r ^ . One of the Workers Compensation Funds estimated in 1979 that only 1:1000 cases of cancer were due to working conditions, while conservative experts arrived at 5%
the same year and trade unions set the figure at 30%40. oi- seases that can also be caused during non-working-life have little chance to be recognized through the instrument of the Workers Compensation Fund, for example stress related diseases resulting from bad work organization.
An unsolved health problem are the so called work related di
seases (arbeitsbedingte Erkrankungen). This is the group of d i seases not contained in the catalogue of the Workers Com
pensation Fund but known to be related to working conditions, for example from occupational morbidity data.
State control over working conditions is organized by the L ä n der (Labour Inspectorate), it is organized on a Länder basis and encompasses both social conditions of work (working hours, protection of young people, women, mothers, disabled persons) and technical organization of work (machine safety, dangerous substances e t c .). This dual system of control by both Workers Compensation Funds and Labour Inspectorates is unique in Europe
(with the exception of Luxemburg). The two control agencies co
operate and cooperate also with the safety personnel and works councils within organizations. If this dual organization con
veys the idea that here a huge control system exists and every
thing therefore should be well in health at the work place, that impression will immediately be revised if one considers the meager staffing of these organizations, leading to few ac
tual control events of places of work.
In creating a healthy environment in the work place the elected body of the employees, the works councils, should also take an active r o l e . W o r k s ' councils are elective bodies of all em
ployees independent of their trade union membership, but to date, trade union representation on works councils is very high. Employee representation was an achievement of the revolu
tion at the end of the First World War; it was abolished during National Socialism but reinstated with added powers after the Second World War. After reforms in 1972 strengthening its rights still further, the works council now has rights which, if used in a proper manner, can influence conditions of work quite considerably. There are some severe limitations, however.
Enforcement can only be carried to the extent of the rule book, and there is the problem of limited resources as to time and knowledge. Works council members have the right to three weeks of further education per year in relation to their duties, but work and health is but one of them. In relation to planning new products and services, production lines, buildings and equip
ment, the rights of the works councils are rather vague and are a field of contest with the employer.
Practically all works councils collaborate with the trade union of their industry, who advise them on specific questions in the health and safety field. The trade unions have also set up an extended net of training for works council members in this area and special technology advisory agencies. These agencies have developed their capacities mostly in the field of information technology, but are getting into other fields, for example dangerous substances. Works councils also have the right to en
gage experts on matters of their concern with the employer ha
ving to pay.
Depending on size of the firm (by number of employees) and risk assessment' of the work places, the employers also have to ap
point qualified safety engineers and medical officers as ad
visers (since 1974) to the employer on matters of safety and health in the work place. Not covered are the smaller firms, where almost 50% of employees work. One full time doctor is generally required for a company of 2000 to 2500 employees, b e low that, time is bought on a part time basis. The system is most effective in large companies with a strong workers repre
sentation and not in the many smaller enterprises, where w o r king conditions deleterious to health may nevertheless exist.
Within the larger companies, which frequently also maintain their own sickness benefit fund for employees and their fami
lies, which have appointed medical officers to their safety staff, and which have active workers councils, activities of health promotion, support of health maintaining activities such as sports or canteens can frequently be found as w e l l .
Evaluations of the health and safety system carried out in the late 1980s found that employees in larger companies with a com
fortable economic situation are
- more likely to have their work conditions controlled by Workers Compensation Funds and Labour Inspectorate
- more likely to have works councils effective in the field of safety and health
- more likely to gain support from the in house safety at work organization
- more likely to enjoy social benefits such as canteens and sports fields supported by the employer, and health promotion pro g r a m m e s .
The whole system of safety and health at work is supported by research activities. There is a series of research institutes
