(IOM, 1999). The NSC health liaison position was phased out during the early days of the Bush administration.

In America’s Vital Interest in Global Health, IOM (1997a) called for better coordination of global health policy within the U.S. government through the use of a Task Force on Global Health. That report also recommended legislative changes to expand international authorities and funding to DHHS “because of its unique scientific and technical expertise” to lead such an effort across the government and to serve as a focal point for links to nongovernmental organizations and academia. This committee concurs with the need for an effective mechanism for coordination of international health policy making and urges the administration and Congress to consider steps to this end such as the appointment of a permanent NSC liaison for international health, the designation of a lead agency for international health or the formation of a formal cross-cabinet body, and the review of Public Health Service Act authorities for DHHS funding of international health initiatives.

Federalism and a National Public Health Policy

The relationships among various levels of government have always been complex and hotly contested. In most spheres of public health (e.g., injury prevention, clean air and water, and infectious disease surveillance and control), federal, state, and local governments all have a presence. As in all essential government endeavors, good communication and cooperation among the various levels of government are vital. Federalism functions as a sorting device for determining which government, federal or state, may legitimately respond to a public health threat. Often, the national and state governments exercise public health powers concurrently, but the Supremacy Clause gives Congress the authority to preempt state public health regulation, even if the state is acting squarely within its police powers (Gade v. National Solid Waste Management Association, 505 U.S. 88, 98 [1992]). Federal preemption occurs in many areas of public health regulation, including labeling and advertising of cigarettes, self-insured health care plans, and occupational health and safety.

Although there may be debates over the constitutional roles of the federal and state governments, a more fundamental concern is that each level of government operates effectively in assuring the conditions for the public’s health. First, strong public health leadership is essential. This means that where the various levels of government are operating at the same time, clear understanding of who is in charge and who has responsibility for which tasks must exist. During the anthrax outbreak, for example, it was often unclear which level of authority was in charge: the Secretary of DHHS, the local public health commissioners in Florida, New York, and Washington, D.C.,



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