3
The Governmental Public Health Infrastructure

The success or failure of any government in the final analysis must be measured by the well-being of its citizens. Nothing can be more important to a state than its public health; the state’s paramount concern should be the health of its people.

Franklin Delano Roosevelt

(quoted in Gostin, 2000)

An effective public health system that can assure the nation’s health requires the collaborative efforts of a complex network of people and organizations in the public and private sectors, as well as an alignment of policy and practice of governmental public health agencies at the national, state, and local levels. In the United States, governments at all levels (federal, state, and local) have a specific responsibility to strive to create the conditions in which people can be as healthy as possible. For governments to play their role within the public health system, policy makers must provide the political and financial support needed for strong and effective governmental public health agencies.

Weaknesses in the nation’s governmental public health infrastructure were clearly demonstrated in the fall of 2001, when the once-hypothetical threat of bioterrorism became all too real with the discovery that many people had been exposed to anthrax from letters sent through the mail. Communication among federal, state, and local health officials and with political leaders, public safety personnel, and the public was often cumbersome, uncoordinated, incomplete, and sometimes inaccurate. Laboratories were overwhelmed with testing of samples, both real and false. Many of these systemic weaknesses were well known to public health professionals, but resources to address them had been insufficient. A strong and effective governmental public health infrastructure is essential not only to respond to crises such as these but also to address ongoing challenges such as preventing or managing chronic illnesses, controlling infectious diseases, and monitoring the safety of food and water.



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The Future of the Public’s Health in the 21st Century 3 The Governmental Public Health Infrastructure The success or failure of any government in the final analysis must be measured by the well-being of its citizens. Nothing can be more important to a state than its public health; the state’s paramount concern should be the health of its people. Franklin Delano Roosevelt (quoted in Gostin, 2000) An effective public health system that can assure the nation’s health requires the collaborative efforts of a complex network of people and organizations in the public and private sectors, as well as an alignment of policy and practice of governmental public health agencies at the national, state, and local levels. In the United States, governments at all levels (federal, state, and local) have a specific responsibility to strive to create the conditions in which people can be as healthy as possible. For governments to play their role within the public health system, policy makers must provide the political and financial support needed for strong and effective governmental public health agencies. Weaknesses in the nation’s governmental public health infrastructure were clearly demonstrated in the fall of 2001, when the once-hypothetical threat of bioterrorism became all too real with the discovery that many people had been exposed to anthrax from letters sent through the mail. Communication among federal, state, and local health officials and with political leaders, public safety personnel, and the public was often cumbersome, uncoordinated, incomplete, and sometimes inaccurate. Laboratories were overwhelmed with testing of samples, both real and false. Many of these systemic weaknesses were well known to public health professionals, but resources to address them had been insufficient. A strong and effective governmental public health infrastructure is essential not only to respond to crises such as these but also to address ongoing challenges such as preventing or managing chronic illnesses, controlling infectious diseases, and monitoring the safety of food and water.

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The Future of the Public’s Health in the 21st Century The fragmentation of the governmental public health infrastructure is in part a direct result of the way in which governmental roles and responsibilities at the federal, state, and local levels have evolved over U.S. history. This history also explains why the nation lacks a comprehensive national health policy that could be used to align health-sector investment, governmental public health agency structure and function, and incentives for the private sector to work more effectively as part of a broader public health system. In this chapter, the committee reviews the organization of governmental public health agencies in the United States. The chapter then examines some of the most critical shortcomings in the public health infrastructure at the federal, state, and local levels: the preparation of the public health workforce, inadequate information systems and public health laboratories, and organizational impediments to effective management of public health activities. The committee recommends steps that must be taken to respond to these challenges so that governmental public health agencies can meet their obligations within the public health system to protect and improve the population’s health. The committee believes that the federal and state governments share a responsibility for assuring the public’s health. From a historical and constitutional perspective, public health is largely a local and state function. The role of the states and localities is a primary and important one. The federal government, however, has the resources, expertise, and the obligation to assess the health of the nation and to make recommendations for its improvement. Ensuring a sound public health infrastructure is an urgent matter, and the committee urges the federal government to engage in planning for national and regional funding to accomplish this. PRIOR ASSESSMENTS OF THE PUBLIC HEALTH INFRASTRUCTURE In 1988, The Future of Public Health (IOM, 1988) reported that the American public health system, particularly its governmental components, was in disarray. In that report, the responsible committee sought to clarify the nature and scope of public health activities and to focus specifically on the roles and responsibilities of governmental agencies. Aiming to provide a set of directions for public health that could attract the support of the broader society, the committee produced findings and made recommendations dealing with three basic issues: The mission of public health The government’s role in fulfilling this mission and The responsibilities unique to each level of government

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The Future of the Public’s Health in the 21st Century The mission of public health was specified as “fulfilling society’s interest in assuring conditions in which people can be healthy” (IOM, 1988:7). The government’s role in fulfilling this mission was described in terms of three core functions of public health practice: assessment of health status and health needs, policy development, and assurance that necessary services are provided. States were considered to have primary public responsibility for health, but it was considered essential that residents of every community have access to public health protections through a local component of the public health system. The public health obligations of the federal government included informing the nation about public health policy issues, aiding states and localities in carrying out their public health functions in a coordinated manner, and setting national health goals and standards. The report also contained recommendations for a review of the statutory basis for public health, the establishment of the governmental public health infrastructure as the clear organizational hub for public health activities, better linkages to other government agencies with health-related responsibilities, and strategies to strengthen the capacities of public health agencies to perform the core functions. A complete listing of the recommendations from that report can be found in Appendix C. Responding to Disarray The Future of Public Health provided the public health community with a common language and a focus for reform, and progress has been made. In Washington, Illinois, and Michigan, for example, revisions of the state public health codes resulted in the inclusion of mandatory provisions for funding and the distribution of services to all communities “no matter how small or remote,” as recommended by the Institute of Medicine (IOM) (1988). In 1994, the Public Health Functions Working Group, a committee convened by the Department of Health and Human Services (DHHS) with representatives from all major public health constituencies, agreed on a list of the essential services of public health. This list of services translates the three core functions into a more concrete set of activities, called the 10 Essential Public Health Services (see Box 3–1). These essential services provide the foundation for the nation’s public health strategy, including the Healthy People 2010 objectives concerning the public health infrastructure (DHHS, 2000) (see Appendix D) and the development of National Public Health Performance Standards (CDC, 1998) for state and local public health systems. At least four subsequent National Academies reports have made a strong case for sustained federal action both domestically and internationally to strengthen the public health infrastructure (IOM, 1992, 1997a, 1997b; NRC, 2002). The federal government has yet to take the initiative to develop a comprehensive, long-term plan to build and sustain the financ-

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The Future of the Public’s Health in the 21st Century BOX 3–1 The 10 Essential Public Health Services Assessment Monitor health status to identify community health problems Diagnose and investigate health problems and health hazards in the community Policy Development Inform, educate, and empower people about health issues Mobilize community partnerships to identify and solve health problems Develop policies and plans that support individual and community health efforts Assurance Enforce laws and regulations that protect health and ensure safety Link people to needed personal health services and assure the provision of health care when otherwise unavailable Assure a competent public health and personal health care workforce Evaluate effectiveness, accessibility, and quality of personal and population-based health services Serving All Functions Research for new insights and innovative solutions to health problems SOURCE: Public Health Functions Steering Committee (1994). ing for this infrastructure at the state and local levels to ensure the availability of the essential health services to all people, and this is a critical concern. The federal government has, however, developed and funded various new programs and organizational units, which, if effectively coordinated, could serve as important components of a more systematic program. The Centers for Disease Control and Prevention (CDC) established (in 1989) the Public Health Practice Program Office and strengthened university-based Centers for Prevention Research (initiated in 1983). CDC also developed Public Health Leadership Institutes (initiated in 1992) at the national and regional levels and the National Public Health Training Network (initiated in 1993). Both programs respond to recommendations to improve the overall leadership competencies of public health practitioners. In 1993, CDC began discussions of a modern and uniform approach to public health surveillance, and it has moved forward with the development of a National Electronic Disease Surveillance Network. More recently, CDC has worked with states to establish the Health Alert Network (initiated in 1999) to improve infor-

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The Future of the Public’s Health in the 21st Century mation and communication systems for both routine and emergency use and the Centers for Public Health Preparedness (launched in 2000) to improve linkages between local health agencies and academic centers. These programs provided important services in the aftermath of September 11, 2001. Many units within CDC have contributed to strengthening the public health infrastructure. The National Center for Chronic Disease Prevention and Health Promotion, for example, has led the effort to develop statewide population-based cancer registries, a tracking system for cardiovascular disease, and a program for the early detection of breast and cervical cancer (CDC, 2002). The National Center for Environmental Health also contributed to the improvement of public health monitoring and assessment functions when it developed a biomonitoring program to measure people’s exposures to 27 different chemicals by analyzing human blood and urine samples. This program offers the first national assessment of people’s exposure to 24 chemicals for which exposures were not previously assessed and 3 for which exposures were previously assessed. In 2002, the center began developing a nationwide environmental public health tracking network in response to a Pew Environmental Health Commission report entitled America’s Environmental Health Gap: Why the Country Needs A National Health Tracking Network (Pew Environmental Health Commission, 2000; www.cdc.gov/nceh/tracking/background.htm). Among CDC initiatives are the development of immunization registries and a guide to community preventive services (www.cdc.gov). Limited Progress Despite this progress, the committee found that in many important ways, the public health system that was in disarray in 1988 remains in disarray today. Many of the recommendations from The Future of Public Health have not been put into action. There has been no fundamental reform of the statutory framework for public health in most of the nation. Funding for the public health infrastructure has recently increased to support the infrastructure that relates to bioterrorism and emergency preparedness but may still be insufficient. Furthermore, governmental and nongovernmental support (both political and financial) and advocacy for the report’s recommendations have been limited. Progress is mixed in strengthening public health agencies’ capacities to address environmental health problems, in building linkages with the mental health field, and in meeting the health care needs of the medically indigent. In addition, new information and technological challenges face the system today. In a recent review of the nation’s public health infrastructure for the U.S. Senate Appropriations Committee, CDC (2001d) pointed to the need for further efforts to

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The Future of the Public’s Health in the 21st Century address gaps in workforce capacity and competency, information and data systems, and the organizational capacities of state and local health departments and laboratories. Finding continued disarray in the public health system is especially disturbing because the nation faces increasingly diverse threats and challenges. The early detection of and the response to these threats will depend on capacity and expertise within the public health system at every level. The gaps in the system warrant urgent remediation. Many of these basic reforms also require actions from agencies that are outside the direct control of governmental public health agencies but whose policies and programs can have important health consequences, such as the Environmental Protection Agency (EPA) (environment) and the Departments of Agriculture (nutrition and food safety), Labor (working conditions), and Treasury (economic development). This support has not been forthcoming from elected or appointed government officials (including those in control of budgets), and stakeholders in the broader public health system—who should have been partners in the vision of creating a healthier nation—have yet to be effectively mobilized in this effort. In the next section, the committee provides an overview of the special role of governmental public health agencies (at the federal, tribal, state, and local levels). The section addresses the legal framework for governmental responsibility and its authorities for protecting the health of the people as well as the organization of the governmental public health infrastructure. THE ROLE OF GOVERNMENTS IN PUBLIC HEALTH: AN OVERVIEW AND LEGAL FRAMEWORK Governments at every level—federal, tribal, state, and local—play important roles in protecting, preserving, and promoting the public’s health and safety (Gostin, 2000, 2002). In the United States, the government’s responsibility for the health of its citizens stems, in part, from the nature of democracy itself. Health officials are either directly elected or appointed by democratically elected officials. To the extent, therefore, that citizens place a high priority on health, these elected officials are held accountable to ensure that the government is able to monitor the population’s health and intervene when necessary through laws, policies, regulations, and expenditure of the resources necessary for the health and safety of the public. The U.S. Constitution provides for a national government, with power divided among the legislative, executive, and judicial branches, each with distinct authority. The states have adopted similar schemes of governance. In health matters, the legislative branch creates health policy and allocates the resources to implement it. In the executive branch, health departments and other agencies must act within the scope of legislative authority by

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The Future of the Public’s Health in the 21st Century implementing legislation and establishing health regulations to enforce health policy. The judiciary’s task is to interpret laws and resolve legal disputes. Increasingly, the courts have exerted substantial control over public health policy by determining the boundaries of government power (Gostin, 2000). The separation of powers provides a system of checks and balances to ensure that no single branch of government can act without some degree of oversight and control by another. Modern public health agencies wield considerable power to make rules to control private behavior, interpret statutes and regulations, and adjudicate disputes about whether an individual or a company has conformed to health and safety standards. In the area of health and safety (which is highly complex and technical), public health agencies are expected to have the expertise and long-range perspective necessary to assemble the facts about health risks and to devise solutions. Role of State and Local Governments in Assuring Population Health States and their local subdivisions retain the primary responsibility for health under the U.S. Constitution.1 To fulfill this responsibility, state and local public health authorities engage in a variety of activities, including monitoring the burden of injury and disease in the population through surveillance systems; identifying individuals and groups that have conditions of public health importance with testing, reporting, and partner notification; providing a broad array of prevention services such as counseling and education; and helping assure access to high-quality health care services for poor and vulnerable populations. State and local governments also engage in a broad array of regulatory activities. They seek to ensure that businesses conduct themselves in ways that are safe and sanitary (through the institution of measures such as inspections, licenses, and nuisance abatements) and that individuals do not engage in unduly risky behavior or pose a danger to others (through the provision of services such as vaccinations, directly observed therapy, and isolation), and they oversee the quality of health care provided in the public and private sectors. Role of Tribal Governments in Assuring Population Health Although their legal status varies, tribal governments have a unique sovereignty and right to self-determination that is often based on treaties with the federal government. Under these treaties, the federal government 1   The 10th Amendment enunciates the plenary power retained by the states: “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.”

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The Future of the Public’s Health in the 21st Century has an obligation to provide tribes with certain services, including health-related services. In addition, American Indians and Alaska Natives are eligible as individual citizens to participate in state health programs. However, in some instances, tribal–state relations are strained, and there are often misunderstandings about the relative responsibilities of states and tribes for the financing of health care and population-based public health services. Until the mid-1970s, the federal government directly provided health care services to American Indians living on reservations and to Alaska Natives living in villages through the Indian Health Service (IHS), an agency within DHHS. In 1975, the Indian Self-Determination and Education Assistance Act (P.L. 93–638) established two other options for obtaining these services: (1) tribal governments can contract with IHS to provide the services or (2) administrative control, operation, and funding for the services can be transferred to a tribal government (IHS, 2001c). In the mid-1970s, legislation also authorized funding health services for American Indians living in urban areas.2 The operation of IHS programs depends on annual discretionary appropriations, which are generally considered inadequate (Noren et al., 1998; IHS, 2001a). Some tribes are able to supplement IHS funding, but many cannot. Many tribes have health directors and operate extensive public health programs that include environmental safety and community health education, as well as direct curative and preventive services. Role of the Federal Government in Assuring Population Health The federal government acts in six main areas related to population health: (1) policy making, (2) financing, (3) public health protection, (4) collecting and disseminating information about U.S. health and health care delivery systems, (5) capacity building for population health, and (6) direct management of services (Boufford and Lee, 2001). For most of its history, the U.S. Supreme Court has granted the federal government broad powers under the Constitution to protect the public’s health and safety. Under the power to “regulate Commerce . . . among several states” and other constitutional powers, the federal government acts in areas such as environmental protection, occupational health and safety, and food and drug purity (Gostin, 2000). The federal government may set conditions on the expenditure of federal funds (e.g., require adoption of a minimum age of 21 for legal consumption of alcoholic beverages to receive Federal-Aid Highway 2   According to 1990 Census Bureau data, about 56 percent of the American Indian and Alaska Native population lived in urban areas (IHS, 2001b). Census data for 2000 show a similar pattern, with 57 percent of individuals who identify themselves solely as Native American or Alaska Native living in metropolitan areas (Forquera, 2001).

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The Future of the Public’s Health in the 21st Century Funds), tax commodities whose use results in risky behavior (e.g., cigarettes), reduce taxes for socially desirable behaviors (e.g., for voluntary employer provision of health care), and regulate persons and businesses whose activities may affect interstate commerce (e.g., manufacturers of pharmaceuticals and vaccines so that they are safe and effective). The judicial branch also can shape federal health policy in many ways. It can interpret public health statutes and determine whether agencies are acting within the scope of their legislative authority. The courts can also decide whether public health statutes and regulations are constitutionally permissible. The Supreme Court has made many decisions of fundamental importance to the public’s health. The court has upheld the government’s power to protect the public’s health (e.g., require vaccinations), set conditions on the receipt of public funds (e.g., set a minimum drinking age), and affirmed a woman’s right to reproductive privacy (e.g., a right to contraception and abortion). Gostin (2000) notes that although the courts generally have been permissive on matters of public health, stricter scrutiny has come when there is any appearance of discrimination against a suspect class or invasion of a fundamental right, such as bodily integrity. Public Health Law: The Need for State Reforms Because primary responsibility for protection of the public’s health rests with the states, their laws and regulations concerning public health matters are critical in determining the appropriateness and effectiveness of the governmental public health infrastructure. At present, however, the law relating to public health is scattered across countless statutes and regulations at the state and local levels and is highly fragmented among the states and territories. Furthermore, public health law is beset by problems of antiquity, inconsistency, redundancy, and ambiguity that make it ineffective, or even counterproductive, in advancing the population’s health. The most striking characteristic of state public health law, and the one that underlies many of its defects, is its overall antiquity. Much of public health law contains elements that are 40 to 100 years old, and old public health statutes are often outmoded in ways that directly reduce their effectiveness and their conformity with modern legal norms in matters such as protection of individual rights.3 These laws often do not reflect contemporary scientific understandings of health risks or the prevention and treat 3   For example, a South Dakota statute passed in the late 1800s and last amended in 1977 makes it a misdemeanor for a person infected with a “contagious disease” to “intentionally [expose] himself . . . in any public place or thoroughfare” (S.D. Codified Laws § 34–22–5). Similarly, an 1895 New Jersey statute forbids common carriers to “accept for transportation

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The Future of the Public’s Health in the 21st Century ment of health problems. For example, laws aimed at preventing casual transmission of airborne diseases such as influenza and measles have little relevance for control of the sexually transmitted and blood-borne pathogens that are major concerns of health authorities today (Gostin et al., 1999). When many of these statutes were written, the science of public health, in fields such as epidemiology and biostatistics, and of behavior and behavioral interventions, such as client-centered counseling, was in its infancy. Related to the problem of antiquity is the problem of multiple layers of law. The law in most states consists of successive layers of statutes and amendments, built up over more than 100 years in some cases, in response to changing perceptions of health threats. This is particularly troublesome in the area of infectious diseases, which forms a substantial part of state health codes. Colorado’s disease control statute, for example, has separate sections for venereal diseases, tuberculosis, and HIV. All three sections authorize compulsory control measures, but they vary significantly in the procedures required and the public health philosophy expressed. Whereas the venereal disease statute simply empowers compulsory examination whenever health officials deem it necessary, the HIV section sets out a list of increasingly intrusive options (requiring use of the least restrictive) and places the burden of proof on the health department to show a danger to public health (Gostin et al., 1999). Because health codes in each state and territory have evolved independently, they show profound variations in their structures, substance, and procedures for detecting, controlling, and preventing injury and disease. In fact, statutes and regulations among American jurisdictions vary so significantly in definitions, methods, age, and scope that they defy orderly categorization. There is, however, good reason for greater uniformity among the states in matters of public health. Health threats are rarely confined to single jurisdictions, instead posing risks across regions or the entire nation. State laws do not have to be identical. There is often a justification for the differences in approaches among the states if there are divergent needs or circumstances. There is also a case for states’ acting as laboratories to determine the best approach. Nevertheless, a certain amount of consistency     within this state any person affected with a communicable disease or any article of clothing, bedding, or other property so infected” without a license from the local board of health (N.J. Stat. Ann. § 26:4–11 9). This might have made some sense in a time when diseases such as influenza, diphtheria, and measles were significant sources of serious illness and death, but it serves little purpose today. Although it may be impolite for people with the flu to walk around in public, it is not a major health threat. Furthermore, efforts to isolate people who do not pose a significant health risk would often violate modern disability discrimination law (it was held that the threat of disease did not justify excessively stringent quarantine of a blind plaintiff’s guide dog) (see Crowder v. Kitagawa, 81 F.3d 1480, 1481, 9th Circuit, 1996).

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The Future of the Public’s Health in the 21st Century is vital in public health. Infectious diseases and other health threats do not confine themselves to state boundaries but pose regional or even national challenges. States must be able to engage in surveillance and respond to health threats in a predictable and consistent fashion, using similar legal structures. Consistent public health statutes would help facilitate surveillance and data sharing, communication, and coordinated responses to health threats among the states. Consider the coordination that would be necessary if a biological attack were to occur in the tristate area of New York, New Jersey, and Connecticut. Laws that complicate or hinder data communication among states and responsible agencies would impede a thorough investigation and response to such a public health emergency. To remedy the problems of antiquity, inconsistency, redundancy, and ambiguity, the Robert Wood Johnson and W. K. Kellogg Foundations’ Turning Point initiative launched a Public Health Statute Modernization Collaborative in 2000 “to transform and strengthen the legal framework for the public health system through a collaborative process to develop a model public health law” (Gostin, 2002). The model public health law focuses on the organization, delivery, and funding of essential public health services, as well as the mission and powers of public health agencies. It is scheduled for completion by October 2003, and current drafts are available on the Turning Point website, at http://www.turningpointprogram.org. The process of law reform took on new urgency after the events of September 11, 2001, and the subsequent intentional dispersal of anthrax through the postal system. In response, the Center for Law and the Public’s Health at Georgetown University and Johns Hopkins University drafted the Model State Emergency Health Powers Act (MSEHPA) at the request of CDC (www.publichealthlaw.net). DHHS recommends that each state review its legislative and regulatory needs and requirements for public health preparedness. MSEHPA offers a guide or checklist for governors and legislatures to review their current laws. As of September 2002, three-quarters of the states had introduced a version of MSEHPA, and 19 states had adopted all or part of the act (Gostin et al., 2002). The model act, under review by federal and state officials, defines the purpose of the legislation as giving the governor and other state and local authorities the powers and ability to prevent, detect, manage, and contain emergency health threats without unduly interfering with civil rights and liberties. The legislation would address matters including reporting requirements, information sharing, access to contaminated facilities, medical examination and testing, and procedures for isolation and quarantine (Center for Law and the Public’s Health, 2001). CDC is facilitating the law reform process through its internal Public Health Law Collaborative. Efforts are in place to improve scientific understanding of the interaction between law and public health and to strengthen

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The Future of the Public’s Health in the 21st Century or the Department of Justice (FBI). Second, no significant gaps in public health protection should exist. This means that at least one level of government should be actively involved in dealing with important health problems. Because the major interactions of the federal and state governments in recent years have related to issues of health care financing through the Medicaid program (or through welfare programs), they have tended to focus on arguments over money and degrees of freedom to spend it. States have often been reduced to being just another interest group. If a mechanism could be developed to engage the states as potential partners in a larger national strategy such as the health agenda that clearly depends on collaborative action for success, it could change these relationships. Direct relationships between the federal government and local governments constitute a complicated issue. In the American system, local governments are the creatures of state governments, from which they get their authority and resources (or the authority to raise revenues). There are more than 90,000 units of local government in the United States; 90 percent have populations of less than 10,000 and 80 percent have populations of less than 5,000 (Cigler, 1998). Their policy-making and managerial capacities are highly variable, as are their capacities and resources in health. It is clear that some units of local government look to the federal government to correct the inequities that they experience at the hands of state governments; others are in tense relations with their state counterparts, and direct federal connections may exacerbate tensions. Ways to manage relationships that engage local governments but that respect the rights of the state governments in terms of their relationships to local governments must be considered in any long-term partnership-building process. The committee believes that a more comprehensive and coordinated approach to health policy is necessary to improve the alignment of federal, state, and local governmental authorities and financial resources to support effective action in improving population health. This kind of coordination is critical to creating a true public health system from the multiple, often disconnected, and somewhat competitive organizations that must work together to promote and protect the health of the public. As one step toward better coordination, DHHS should be looking to new ways to collaborate more effectively with governmental public health agencies at the state and local levels. This is not a new problem for DHHS. In 1960, then Surgeon General Leroy Edgar Burney convened an external expert group to “study the present and future mission of the public health service and design the best possible structure to deal with its multiple new functions.” It found that PHS needed to develop mechanisms to allow it to work “with, rather than through state agencies” (Study Group on the Mission and Organization of the Public Health Service, 1960). During the Nixon administration, there

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The Future of the Public’s Health in the 21st Century was similar recognition of the importance of improving relationships between federal, state, and community organizations to serve the populations in greatest need. This led to strengthening of the regional offices of DHHS and establishing an office on intergovernmental affairs. As discussed earlier, the department’s policy and structures for dealing with state and local governments have varied over the years, but the mechanisms within the department are weak at present. One way to achieve better communication is through formal links with the national organizations representing state and local health officials, ASTHO and NACCHO, which often collaborate with the department in activities such as the Healthy People (2010) initiative and the development of National Public Health Performance Standards. The department could also enhance its efforts to seek state and local perspectives on public health policy through the National Governors Association and the U.S. Conference of Mayors, which have staff who work on health issues. The committee believes that a more formal entity could facilitate the link between the Secretary of DHHS and state public health officers for the purpose of improving communication, coordination, and collaborative action on a national health agenda. In considering the form of such an effort, it is important to recognize that the U.S. health care system is highly devolved, and as noted earlier, historically, the major responsibility for the essential public health services has rested with state governments, but with that responsibility subject to federal regulations and with the public health services partially supported by federal revenues (more revenues are provided for health care delivery than for the public health infrastructure). Because governments have a unique role in assuring the conditions for health of the population and because health is a public good, the high level of interdependence of federal and state governments in achieving national health goals such as those articulated in Healthy People 2010 (DHHS, 2000) requires effective communication and collaboration. In a 1997 report on the principles of state–federal relations, the National Governors Association, while noting the importance of state autonomy and the preservation of the ability of the states to address local circumstances, agreed that there was a need for a federal role in certain domestic issues—when issues are national in scope and the national interest is at risk and to help states meet the needs of special populations. It also reaffirmed its support for a federal role in assuring equality of access, addressing the issues beyond the capacities of individual states, and ensuring that all states have the fiscal capacity to meet the requirements of federal goals. It further cites the critical importance of close working relationships with “our federal partners” (NGA, 1997). Although this discussion did not specifically address collaboration in public health, the principles would seem to apply and call for direct interaction between the

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The Future of the Public’s Health in the 21st Century governmental public health leadership of states and the DHHS rather than through annual meetings of representative organizations or interest groups. Therefore, the committee recommends that Congress mandate the establishment of a National Public Health Council. This National Public Health Council would bring together the Secretary of DHHS and state health commissioners at least annually to Provide a forum for communication and collaboration on action to achieve national health goals as articulated in Healthy People 2010; Advise the Secretary of DHHS on public health issues; Advise the Secretary of DHHS on financing and regulations that affect the governmental public health capacity at the state and local levels; Provide a forum for overseeing the development of an incentive-based federal–state-funded system to sustain a governmental public health infrastructure that can assure the availability of essential public health services to every American community and can monitor progress toward this goal (e.g., through report cards); Review and evaluate the domestic policies of other cabinet agencies for their impacts on national health outcomes (e.g., through health impact reports) and for their impacts on the reduction and elimination of health disparities; and Submit an annual report on their deliberations and recommendations to Congress. The Council should be chaired by the Secretary of DHHS and cochaired by a state public health director on a rotating basis. An appropriately resourced secretariat should be established in the Office of the Secretary to ensure that the council has access to the information and expertise of all DHHS agencies during its deliberations. The committee believes that public health exists within a sphere of political and policy-making activity, from which it cannot and should not be separated. Thus, public health must operate within the boundaries of democracy and must take place in a rational, evidence-based political process. Therefore, the proposed Council may change with changes in administration. CONCLUDING OBSERVATIONS To most effectively protect and promote the health of the population, the nation’s entire governmental public health infrastructure—its human resources, information systems, and organizational capacity—must be revitalized and strengthened. Doing so will require federal, state, and local governmental collaboration to assess the needs in each community and to

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The Future of the Public’s Health in the 21st Century identify national and local strategies to meet those needs. Furthermore, federal, state, and local governments will need to create innovative financing mechanisms that can add new resources (including those from the private sector) to those already committed by all levels of government to infrastructure development and capacity building and ensure that these investments are sustainable over time. Most importantly, it is the responsibility of the federal government to ensure that these actions at the federal, state, and local levels contribute to the creation and maintenance of a comprehensive, intersectoral public health system that serves to protect and promote the health of Americans. REFERENCES Altman LK. 2001. CDC team tackles anthrax. New York Times, October 16. APHL (Association of Public Health Laboratories). 2000. On the front line: protecting the nation’s health. Available online at http://www.phppo.cdc.gov/dls/aphl-ofl.asp. Accessed March 12, 2002. APHL. 2002a. Advancing the National Electronic Disease Surveillance System: An Essential Role for Public Health Laboratories. Report of the Association of Public Health Laboratories. Washington, DC: APHL. APHL. 2002b. Who Will Run America’s Public Health Labs? Educating Future Laboratory Directors. Report prepared by Schoenfeld E, Banfield-Capers SY, and Mays G for the Association of Public Health Laboratories. February. Washington, DC: APHL. ASCP (American Society for Clinical Pathologists). 2000. Laboratory workforce shortage stresses need for health professions funding (last updated on April 6, 2000). Available online at http://www.ascp.org. Accessed March 18, 2002. ASTHO (Association of State and Territorial Health Officials). 1999. Bioterrorism preparedness: medical first response. Testimony of David R. Johnson, MD, MPH, Deputy Director for Public Health and Chief Medical Executive, Michigan Department of Community Health, on behalf of the Association of State and Territorial Health Officials, to the U.S. House of Representatives Subcommittee on National Security, Veterans Affairs, and International Relations, September 22. Available online at http://www.aphl.org/Advocacy/Testimony/index.cfm. Accessed March 12, 2002. ASTHO. 2001a. HIPAA Issue Brief No. 1, February 1. Covered entities under HIPAA. Available online at http://www.astho.org/phiip/documents.html. Accessed March 12, 2002. ASTHO. 2001b. HIPAA policy brief, March 28. Available online at http://www.astho.org/phiip/documents.html. Accessed March 12, 2002. ASTHO. 2001c. Bioterrorism preparedness. Testimony submitted to the U.S. Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, and Education, October 3. Washington, DC: ASTHO. ASTHO. 2001d. Performance assessment and standards, state tool. Available online at http://www.astho.org/phiip/performance.html. Accessed March 12, 2002. ASTHO. 2002. 2002 salary survey of state and territorial health officials. Available online at http://www.astho.org/about/salary.html. Accessed March 12, 2002. Bardach, E. 1998. Getting Agencies to Work Together. Washington, DC: Brookings Institution.

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