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.


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:

  1. The mission of public health

  2. The government’s role in fulfilling this mission and

  3. The responsibilities unique to each level of government

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