Healthcare Policy & Law
WHAT ARE THE 10 ESSENTIAL PUBLIC HEALTH SERVICES?
Table 5-1 outlines the 10 essential public health services and organizes them according to which IOM core function they aim to fulfill. 1 A description of each service is presented in column two and examples of these essential services are listed in column three. We have now looked at the core public health functions and the 10 essential services of public health agencies. Figure 5-1 puts these together to allow you to see the connections.
Public health services are delivered through a complex web of local and federal agencies, as well as via increasing involvement of global organizations. Let us take a look at the work of public health agencies at each of these levels.
Figure 5-2 provides a framework to guide our review of the delivery of public health services. It diagrams the central role of governmental public health agencies and the complicated connections required to accomplish their responsibilities. We will begin by taking a look at the structure and function of governmental public health agencies at the local/state, federal, and global levels. Then we will examine the key connections with other governmental agencies, community organizations, and private organizations, and finally the connections with the healthcare delivery system as a whole.
WHAT ARE THE ROLES OF LOCAL AND STATE PUBLIC HEALTH AGENCIES?
The U.S. Constitution does not mention public health. Because public health is not a delineated federal responsibility, it is an authority retained by the states. States may retain their authority, voluntarily request or accept help from the federal government, or delegate their responsibility and/or authority to local agencies at the city, county, or other local levels.b
Box 5-1 describes a brief history of public health agencies in the United States. It is a complex history and has resulted in more structures than there are states—more because large cities often have their own public health systems.3 In addition, the District of Columbia and several U.S. territories have their own systems and often have the authority to make public health system decisions as if they were states.
To understand the role of local health departments, it is useful to think of two models.4 In the first model, which we will call the home rule or local autonomy model, authority is delegated from the state to the local health department. The local health department, or the local government, has a great deal of autonomy in setting its own structure and function and often raising its own funding.
In the second model, which we will call the branch office model, the local health department can be viewed as a branch office of the state agency with little or no independent authority or funding. There are several thousand local health departments across the country. The majority of these lie somewhere in between these two extreme models; however, these models provide a framework for understanding the many varieties of department structures. Thus, when we speak of local public health, we may be speaking of a state agency with branch offices or a relatively independent local agency. Regardless of which model a state uses, many public health responsibilities of local public health departments are quite similar, and they usually have authority and responsibility for at least the following:4
• Immunizations for those not covered by the private system
• Communicable disease surveillance and initial investigation of outbreaks
• Communicable disease control, often including at a minimum tuberculosis and syphilis case finding and treatment
• Inspection and licensing of restaurants
BOX 5-1 Brief History of Public Health Agencies in the United States
An understanding of the history of U.S. public health institutions requires an understanding of the response of local, state, and federal governments to public health crises and the complex interactions among these levels of government.
The colonial period in the United States saw repeated epidemics of smallpox, cholera, and yellow fever focused in the port cities. These epidemics brought fear and disruption of commerce, along with accompanying disease and death. One epidemic in 1793 in Philadelphia, which was then the nation’s capital, nearly shut down the federal government. These early public health crises brought about the first municipal boards of health, made up of respected citizens authorized to act in the community’s interest to implement quarantine, evacuation, and other public health interventions of the day. The federal government’s early role in combating epidemics led to the establishment in 1798 of what later became known as the U.S. Public Health Service.
Major changes in public health awaited the last half of the 1800s, with the great expansion of understanding of disease and the ability to control it through community actions. The Shattuck Commission in Massachusetts in 1850 outlined the roles of state health departments as responsible for sanitary inspections, communicable disease control, food sanitation, vital statistics, and services for infants and children. Over the next 50 years, the states gradually took the lead in developing public health institutions based upon delivery of these services.
Local health departments outside of the largest cities did not exist until the 1900s. The Rockefeller Foundation stimulated and helped fund early local health departments and campaigns in part to combat specific diseases, such as hookworm. There was no standard model for local health departments. Local health departments developed in at least 50 different ways in the 50 states and were chronically underfunded.
The federal government played a very small role in public health throughout the 1800s and well into the 20th century. An occasional public health crisis stimulated in part by media attention did bring about federal action. The founding of the Food and Drug Administration in 1906 resulted in large part from the journalistic activity known as “muckraking,” which exposed the status of food and drug safety. The early years of the 1900s set the stage for expansion of the federal government’s role in public health through the passage of the 16th Amendment to the Constitution, which authorized federal income tax as a major source of federal government funding.
The Great Depression, in general, and the Social Security Act of 1935, in particular, brought about a new era in which federal funding became a major source of financial resources for state and local public health departments and nongovernmental organizations. The founding of what was then called the Communicable Disease Center (CDC) in 1946 led to a national and eventually international leadership role for the CDC, which attempts to connect and hold together the complex local, state, and federal public health efforts and integrate them into global public health efforts.
The Johnson administration’s War on Poverty, as well as the Medicare and Medicaid programs, brought about greatly expanded funding for healthcare services and led many health departments to provide direct healthcare services, especially for those without other sources of care. The late 1980s and 1990s saw a redefinition of the roles of governmental public health, including the Institute of Medicine’s definition of core functions and the development of the 10 essential public health services. These documents have guided the development of a broad population focus for public health and a move away from the direct provision of healthcare services by health departments.
The terrorism of September 11, 2001, and the subsequent anthrax scare moved public health institutions to the center of efforts to protect the public’s health through emergency response and disaster preparedness. The development of flexible efforts to respond to expected and unexpected hazards is now a central feature of public health institutions’ roles and funding. The success of these efforts has led to new levels of coordination of local, state, federal, and global public health agencies utilizing state-of-the-art surveillance, laboratory technology, and communications systems.
Environmental health surveillance
• Coordinating public health screening programs, including newborn and lead screenings
• Tobacco control programs
• Public health preparedness and response to disasters
Health departments in many parts of the United States have also served as the healthcare provider for those without other sources of health care. This has been called the healthcare safety net. In recent years, many health departments have reduced or discontinued these services, often transferring them to the healthcare system or integrating their efforts into community health centers. The concept of core functions holds that while these activities can be performed by other organizations or agencies, the public health agencies still retain responsibility for ensuring access to and the quality of these services.
The work of local public health agencies cannot be viewed in isolation. The state health department usually retains important roles even in those states where the local departments have home rule authority. These responsibilities often include collecting vital statistics, running a public health laboratory, licensing health professionals, administering nutrition programs, and regulating health facilities, such as nursing homes. In addition, drinking water regulation, administration of the state Medicaid program, and the office of the medical examiner may also fall under the authority of the state health department.
The 2003 IOM report The Future of the Public’s Health in the 21st Century, in conjunction with the Futures Initiative of the Centers for Disease Control and Prevention (CDC), initiated the establishment of a voluntary national accreditation program for state and local health departments to advance quality and performance in health departments. Through these efforts, the Public Health Accreditation Board (PHAB) was formed, and in early 2013, the first set of health departments achieved national accreditation. The accreditation standards and measures address each of the 10 essential public health services to evaluate health department processes and services and their outcomes.5
Today, the federal government has a great deal of involvement in national and global issues of public health and often works closely with local agencies. Let us take a look at the structure and role of the federal government in public health.
WHAT ARE THE ROLES OF FEDERAL PUBLIC HEALTH AGENCIES?
The federal government’s role in public health does not explicitly appear in the U.S. Constitution. It has been justified largely by the Interstate Commerce clause, which provides federal government authority to regulate commerce between the states. Federal public health authority often rests on the voluntary acceptance by the states of funding provided by the federal government. This may come with requirements for state action in order to qualify for the funding.
The Department of Health and Human Services (HHS) is the central public health agency of the federal government. It includes operating agencies, each of which report directly to the cabinet-level secretary of HHS. Table 5-2 outlines most of these agencies, their roles and authority, and their basic public health structure and activities.
The National Institutes of Health (NIH) is far and away the largest agency within the HHS, with a budget of over $30 billion—as much as all the other six agencies’ budgets combined. However, most of its efforts are devoted to basic science research and the translation of research into clinical practice. Some of the federal agencies, such as the Health Resources and Services Administration (HRSA), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Indian Health Service, provide or fund individually oriented health services in addition to population-oriented preventive services. The Indian Health Service is unique because it is responsible for both public health and healthcare services for a defined population.
The Centers for Disease Control and Prevention (CDC) is perhaps the agency most closely identified with public health at the federal level. Box 5-2 describes its first 50 years, from 1946 to 1996, in a reprint of its official history first published in the Morbidity and Mortality Weekly Report (MMWR), a weekly publication of the agency.7 Today, the CDC is a global partner in conducting research and epidemiologic investigations in addition to working closely with states to monitor and prevent disease through health surveillance, taking an action-oriented approach to disease prevention, and maintaining health statistics through the National Center for Health Statistics, which has been a part of the CDC since 1987.
The CDC’s role in connecting federal, state, and local governmental public health efforts is central to the success of the system. Approximately half of the CDC’s over $10 billion total budget is channeled to state and local health departments. A key function of the CDC is to provide national leadership and to coordinate the efforts of local/state and federal public health agencies.
To understand the local/state and federal public health system, it is important to appreciate that less than 5% of all health-related expenditures in the United States goes to governmental public health agencies, and of that, less than half goes to population-based prevention as opposed to providing healthcare services as a safety net for individuals. In addition, the role of governmental public health is limited by social attitudes toward government. For instance, there are constitutional limitations on the authority of public health and other government agencies to impose actions on individuals. These may limit public health agencies’ abilities to address issues ranging from tuberculosis and HIV control to responses to emergencies.
BOX 5-2 History of the CDC
The Communicable Disease Center was organized in Atlanta, Georgia, on July 1, 1946; its founder, Dr. Joseph W. Mountin, was a visionary public health leader who had high hopes for this small and comparatively insignificant branch of the Public Health Service (PHS). It occupied only one floor of the Volunteer Building on Peachtree Street and had fewer than 400 employees, most of whom were engineers and entomologists. Until the previous day, they had worked for Malaria Control in War Areas, the predecessor of CDC, which had successfully kept the southeastern states malaria-free during World War II and, for approximately 1 year, from murine typhus fever. The new institution would expand its interests to include all communicable diseases and would be the servant of the states, providing practical help whenever called.
Distinguished scientists soon filled CDC’s laboratories, and many states and foreign countries sent their public health staffs to Atlanta for training…. Medical epidemiologists were scarce, and it was not until 1949 that Dr. Alexander Langmuir arrived to head the epidemiology branch. Within months, he launched the first-ever disease surveillance program, which confirmed his suspicion that malaria, on which CDC spent the largest portion of its budget, had long since disappeared. Subsequently, disease surveillance became the cornerstone on which CDC’s mission of service to the states was built and, in time, changed the practice of public health.
The outbreak of the Korean War in 1950 was the impetus for creating CDC’s Epidemic Intelligence Service (EIS). The threat of biological warfare loomed, and Dr. Langmuir, the most knowledgeable person in PHS about this arcane subject, saw an opportunity to train epidemiologists who would guard against ordinary threats to public health while watching out for alien germs. The first class of EIS officers arrived in Atlanta for training in 1951 and pledged to go wherever they were called for the next 2 years. These “disease detectives” quickly gained fame for “shoe-leather epidemiology” through which they ferreted out the cause of disease outbreaks.
The survival of CDC as an institution was not at all certain in the 1950s. In 1947, Emory University gave land on Clifton Road for a headquarters, but construction did not begin for more than a decade. PHS was so intent on research and the rapid growth of the National Institutes of Health that it showed little interest in what happened in Atlanta. Congress, despite the long delay in appropriating money for new buildings, was much more receptive to CDC’s pleas for support than either PHS or the Bureau of the Budget.
Two major health crises in the mid-1950s established CDC’s credibility and ensured its survival. In 1955, when poliomyelitis appeared in children who had received the recently approved Salk vaccine, the national inoculation program was stopped. The cases were traced to contaminated vaccine from a laboratory in California; the problem was corrected, and the inoculation program, at least for first and second graders, was resumed. The resistance of these 6 and 7-year-olds to polio, compared with that of older children, proved the effectiveness of the vaccine. Two years later, surveillance was used again to trace the course of a massive influenza epidemic. From the data gathered in 1957 and subsequent years, the national guidelines for influenza vaccine were developed.
CDC grew by acquisition…. When CDC joined the international malaria-eradication program and accepted responsibility for protecting the earth from moon germs and vice versa, CDC’s mission stretched overseas and into space.
CDC played a key role in one of the greatest triumphs of public health, the eradication of smallpox. In 1962 it established a smallpox surveillance unit, and a year later tested a newly developed jet gun and vaccine in the Pacific island nation of Tonga…. CDC also achieved notable success at home tracking new and mysterious disease outbreaks. In the mid-1970s and early 1980s, it found the cause of Legionnaires disease and toxic-shock syndrome. A fatal disease, subsequently named acquired immunodeficiency syndrome (AIDS), was first mentioned in the June 5, 1981, issue of MMWR.
Although CDC succeeded more often than it failed, it did not escape criticism. For example, television and press reports about the Tuskegee study on long-term effects of untreated syphilis in black men created a storm of protest in 1972. This study had been initiated by PHS and other organizations in 1932 and was transferred to CDC in 1957. Although the effectiveness of penicillin as a therapy for syphilis had been established during the late 1940s, participants in this study remained untreated until the study was brought to public attention. CDC was also criticized because of the 1976 effort to vaccinate the U.S. population against swine flu, the infamous killer of 1918–1919. When some recipients of the vaccines developed Guillain-Barre syndrome, the campaign was stopped immediately; the epidemic never occurred.
As the scope of CDC’s activities expanded far beyond communicable diseases, its name had to be changed. In 1970 it became the Center for Disease Control and in 1981, after extensive reorganization, Center became Centers. The words “and Prevention” were added in 1992, but, by law, the well-known three-letter acronym was retained. In health emergencies, CDC means an answer to SoS calls from anywhere in the world, such as the recent one from Zaire where Ebola fever raged.
Fifty years ago, CDC’s agenda was non-controversial (hardly anyone objected to the pursuit of germs), and Atlanta was a backwater. In 1996, CDC’s programs are often tied to economic, political, and social issues, and Atlanta is as near Washington as the tap of a keyboard.
Reproduced from Centers for Disease Control and Prevention, MMWR. 1996;45: 526–528.
The social attitudes of Americans may also limit the authority and resources provided to public health agencies. Americans often favor individual or private efforts over governmental interventions when they believe that individuals and private organizations are capable of success. For instance, some Americans resist active efforts in schools to provide information and access to contraceptives, while others resist the type of case-finding efforts for HIV/AIDS that have been used successfully in investigating and controlling other communicable diseases.
Today, governmental public health is a global enterprise. Let us take a look at the roles of global health organizations and agencies.
WHAT ARE THE ROLES OF GLOBAL HEALTH ORGANIZATIONS AND AGENCIES?
Public health is increasingly becoming a global enterprise. Global governmental efforts have grown dramatically in recent years. The World Health Organization (WHO) was created in 1948. Its impact has become more prominent in the 2000s with the increasing importance of global health issues. The WHO is a part of the United Nations organizations, which also include the United Nations Children’s Fund (UNICEF) and the Joint United Nations Programme on AIDS/HIV (UNAIDS).8
Today, the World Bank and other multilateral financial institutions are the largest funding source for global health efforts.9 National governmental aid programs, including the United States Agency for International Development (USAID), also play an important role in public health. Table 5-3 outlines the structure/governance, roles, and limitations of global public health agencies.
The complexity of local, state, federal, and global public health agencies raises the question of whether or not these agencies can and do work together. It should not surprise you that close collaboration, while the goal, is often difficult to achieve with so many organizations involved. Thus, it is important to ask: How can public health agencies work together?
HOW CAN PUBLIC HEALTH AGENCIES WORK TOGETHER?
Coordination among public health agencies has been a major challenge that is built into our local, state, and federal systems of governance. Increasingly, coordination also requires a global aspect as well. Efforts on all levels have a long way to go. There are signs of hope with progress in such fields as tobacco control, food safety, and the response to SARS. Box 5-3 discusses the dramatic events of the 2003 SARS epidemic, providing an example of what can be done and what needs to be done to address future public health emergencies.10
Collaboration needs to be an everyday effort, and not just a requirement for emergencies or epidemics. Let us look at the relationships and needed collaboration among governmental public health and other governmental agencies, nongovernmental organizations, and the healthcare delivery system.
WHAT OTHER GOVERNMENT AGENCIES ARE INVOLVED IN HEALTH ISSUES?
To address health issues, it is important to recognize the important roles that government agencies not designated as health agencies play in public health. Such agencies exist at the local/state, federal, and global levels. To illustrate the involvement of these agencies in health issues, let us begin with the roles of nonhealth agencies at the federal level.
A number of federal agencies serve public health functions even though they are not defined as health agencies. The roles they play are important, especially when we take the population health perspective, which includes the totality of efforts to promote and protect health and prevent disease, disability, and death.