ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM

[thelivyjr]

"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

As of Thursday afternoon, 26 March 2020, the United States with a population of 327.2 million in 2018 was reporting more than 82,400 cases of COVID-19, above China’s tally of more than 81,700, with China having a population of 1.386 billion as of 2017, and Italy’s count of more than 80,500, with Italy having a population of 60.48 million in 2018, and there should be no mystery as to why that is happening, because compared to China and Italy, the United States of America, and especially New York state, has a broken, slip-shod, fourth-rate public health protection system that one would expect to find in such third-world countries as Haiti, or Somalia, or Iraq, or Afghanistan.

And when I speak of public health, I am not speaking of what is known in America as the "for-profit healthcare industry," an industry that exploits the sickness and un-wellness and un-healthfulness of Americans to the tune of $3.65 trillion in 2018.

For the for-profit corporate healthcare industry to make its profits, it needs sick people to feed off of, plain and simple.

And since it is for profit, it does not deal with making people well, because there is no profit for them to make in people who are well.

Thus, for that industry to grow as it had up into a $3.65 trillion industry in 2018, it was necessary to dismantle and disable and discard our system of public health protection that was supposed to protect and promote the health of people, not exploit them in their sickness for profit.

Contrary to "healthcare," or the exploitation of sickness for profit, which is obscene, but so American, nonetheless, public health is the science of protecting and improving the health of people and their communities.

That is why public health is seen as the "enemy" to be suppressed and defeated by the for-profit corporate healthcare industry, which sector spent a record $594 million on lobbying the federal government last year, up nearly 5 percent from 2018, where "lobbying" is a polite term for bribery.

That is why we have a third-world, fourth-rate public health maintenance system in this country, and that is why we now surpass China and Italy in COVID cases, because our system of keeping people healthy is broken, while the for-profit health care industry that exploits sick people for profit isn't designed to deal with making a mass of sick people well.

Getting back to the broken public health system in America, this work of protecting and improving the health of people and their communities is supposed to be achieved by promoting healthy lifestyles, researching disease and injury prevention, and detecting, preventing and responding to infectious diseases.

And that is supposed to be 24/7/365, if the system was not broken as it clearly is today.

According to the American Public Health Association as to the question "what is public health," besides a broken system in this country, we have:

Public health promotes and protects the health of people and the communities where they live, learn, work and play.

While a doctor treats people who are sick, those of us working in public health try to prevent people from getting sick or injured in the first place.

We also promote wellness by encouraging healthy behaviors.

From conducting scientific research to educating about health, people in the field of public health work to assure the conditions in which people can be healthy.

end quotes

Were that anything more than wishful thinking, we would not be having this COVID health scare crisis right now because we would have had a system in place to deal with it in a rational manner, as opposed to this circus we are now confronted with, with scared and hysterical and totally unqualified "public officials" running around like chickens with their heads cut off, screaming at each other about who is responsible for the failure of our public health system, when in fact they all are, with New York state governor Andrew Cuomo, who personally dismantled New York's public health system along with his father Mario, governor of New York before him, at the head of that list.

As to what the purpose of a public health engineer like myself would be in the system, if the system were not hopelessly corrupt and broken, first of all, my use of the term "public health engineer" comes from the definition of the term from Title 10 of the New York State Public Health Regulations, Part 11 - Qualifications of Public Health Personnel, Section 11.100 - Public health engineer, to wit:

PUBLIC HEALTH ENGINEER

11.100 Definition.

The term public health engineer shall mean a person who applies engineering principles for the detection, evaluation, control and management of those factors in the environment which influence the public's health.

end quotes

Those factors in the environment which influence the public's health are bacteria and viruses and the DUTY of the public health engineer in a non-broken, non-corrupt, fully-functioning system of public health intended to protect and promote public health is to prevent their spread.

As an associate level public health engineer, I was personally responsible for the MANAGEMENT of the health of some 133,000 people in a health district in New York state.

My responsibilities included responsibility the planning, directions and supervision of the environmental health programs of the county health department.

So you can see how a proper public health protection system that was not corrupt or broken would look on paper, my work as an associate public health engineer involved providing advice and guidance to local officials and the general public in regard to environmental health problems related to transmission of diseases, and the measures necessary for improvements and compliance with legal requirements.

It was my responsibility as an associate public health engineer to provide leadership in the promotion of public health through the application of environmental health practices.

In addition, my responsibility also included enforcement of the provisions of the Public Health Law and State Sanitary Code in relation to environmental health matters.

For the record, violation of the Public Health Law in New York State is listed as a class A misdemeanor punishable by a year in jail.

As to the broad scope of my duties, they included supervising enforcement of the provisions of the Public health Law relating to air pollution, x-ray installations, public water supplies, sewerage and wastes disposal, operation of water and sewage treatment plants, swimming pools and bathing beaches, camps, hotels, lodging and boarding houses, restaurants and public eating places, stream pollution, realty subdivisions, qualifications of water and sewage treatment plant operators, public health nuisances and related matters, all related to keeping people safe from bacteria and viruses.

In that regard, it was my duty to make environmental health investigations of outbreaks of disease like COVID, and to perform that duty, I maintained relationships with local, state and federal agencies whose work or policies affect the public health program.

It was also my duty to prepare technical reports including recommendations, and to formulate public health engineering and environmental health policies to prevent the spread of a disease like COVID.

To be an associate level public health engineer, one must possess comprehensive knowledge of the principles, techniques and administration of public health engineering and environmental health programs as related to air pollution, x-ray installations, water supplies and purification, sewerage and sewage disposal, stream pollution, sanitary control of foods, sanitary control of restaurants and public eating places, smoke abatement, sanitary control of camps, hotels, lodging houses, boarding houses, swimming pools, bathing beaches, schools and other places, insect and rodent control, housing, public health nuisances and general sanitation; thorough knowledge of provisions of Public Health Law and State Sanitary Code related to the above subjects; ability to plan, develop, direct, and administer public health engineering and environmental health programs and to project and integrate these into the departmental program; ability to prepare technical reports and correspondence; skill in public health engineering techniques and practices; high degree of initiative and resourcefulness in solving difficult public health engineering problems; ability to deal with the public and other officials; ability to develop and maintain good public relations; and professional judgement.

So, given all of that, why do we now have this public health crisis linked to COVID in this country with its epicenter in New York state?

[thelivyjr]

NCBI

The Future of the Public's Health in the 21st Century.

The Governmental Public Health Infrastructure

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.

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:

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

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 financing 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 information 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 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.

TO BE CONTINUED ...

[thelivyjr]

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The Future of the Public's Health in the 21st Century., continued ...

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 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 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 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.

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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 treatment 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 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 the legal foundation for public health practice.

Through the Public Health Law Collaborative, CDC is joined in its work in public health law by a growing number of partners.

These include public health practice associations, academic institutions and researchers, and public policy organizations (www.phppo.cdc.gov/PhLawNet).

The committee finds that the problems of antiquity, inconsistency, redundancy, and ambiguity render many public health laws ineffective or even counterproductive in improving population health.

A set of standards and procedures would add needed clarity and coherence to legal regulation.

Therefore, the committee recommends that the Secretary of the Department of Health and Human Services, in consultation with states, appoint a national commission to develop a framework and recommendations for state public health law reform.

In particular, the national commission would review all existing public health law as well as the Turning Point 4 Model State Public Health Act and the Model State Emergency Health Powers Act 5 ; provide guidance and technical assistance to help states reform their laws to meet modern scientific and legal standards; and help foster greater consistency within and among states, especially in their approach to different health threats.

It is essential that any reform of public health legislation address the powers needed to deal effectively with bioterrorism and other public health emergencies that pose significant threats across state boundaries.

Each state could adapt the commission's recommendations to its unique legal structures and particular needs for public health preparedness.

Public health is traditionally a state function, so the commission would provide guidance to the states rather than impose standards.

The following section provides a description of the federal, state, and local governmental agencies that are responsible for protecting the health of the public.

Later in the chapter, the committee examines certain aspects of the state and local public health infrastructures that are of special concern.

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The Future of the Public's Health in the 21st Century., continued ...

The State and Local Governmental Public Health Infrastructure

Although the states carry the primary constitutional responsibility and authority for public health activities in the United States, public health administration first began in cities in the late eighteenth century (Rosen, 1993).

The burgeoning social problems of industrial cities convinced legislatures to form more elaborate and professional public health administrations within municipal governments (Duffy, 1990).

City boards of health were established to obtain effective agency supervision and control of health threats facing the population.

Only after the Civil War did states form boards of health.

County and rural health departments emerged in the early twentieth century (Ferrell and Mead, 1936).

Today, there are more than 3,000 local public health agencies, 3,000 local boards of health, and 60 state, territorial, and tribal health departments (CDC, 2001b).

Structure and Governance of State and Local Public Health Agencies

The organization and authority granted to state and local public health agencies vary substantially across the country.

Every state has an agency with responsibility for public health activities.

That agency may be an independent department or a component of a department with broader responsibilities, such as human services programs.

In 31 states, the state health officer is also the head of the larger health and human services agency (Turnock, 2000).

Physicians and nurses often lead state public health agencies.

At the local level, however, general managers with business training rather than formal training in public health or medicine may lead public health agencies.

States differ in terms of the relationship between the state agency and the agencies serving localities within the state.

In some states (e.g., Arkansas, Florida, Georgia, and Missouri), the state public health infrastructure is centralized, meaning that the state agency has direct control and authority for supervision of local public health agencies.

In other states (e.g., California, Illinois, and Ohio), local public health agencies developed independently from the state agency, in that they are run by counties or townships (rather than the state) and report directly to local boards of health or health commissioners or are governed by cooperative agreements.

Still other states (e.g., Iowa and North Dakota) have no local public health agencies and the state public health agency is preeminent (Fraser, 1998).

In a recent report on the local public health agency infrastructure, the National Association of County and City Health Officials (NACCHO) (2001d) identified five types of local public health agencies (see Figure 3–1).

The most common arrangement is a local public health agency (LPHA) serving a single county, ranging from small rural counties (e.g., Issaquena County, Mississippi, with a population less than 1,000) to large metropolitan counties (e.g., Los Angeles County, with a population approaching 10 million).

LPHAs may also serve single cities of various sizes (e.g., Kansas City, Missouri, and New York City).

A combined city–county local public health agency is also found (e.g., Seattle-King County, Washington).

Township local public health agencies are common in states with strong “home-rule” political systems 6 (e.g., Connecticut, Massachusetts, and New Jersey).

City or township health agencies may operate within counties that are also served by county health agencies.

Multicounty local public health agencies often span large geographic areas in the western United States.

For example, the Northeast Colorado Health District serves six counties, an area roughly equivalent in size to that of the state of Vermont.

In these local public health agencies, health directors may be accountable to multiple county boards of health or to a combined board of health whose membership represents the counties or other units covered by the local public health agency.

The multicounty local public health agency category also includes state health department regional offices that act as local public health agencies, an arrangement found in several states (e.g., Alabama, New Mexico, Tennessee, and Vermont).

The governance of state and local public health agencies generally fits one of three models.

In a cabinet model, the head of the agency is appointed by and answers to the governor, mayor, or other executive authority.

Under a board-of-health model, the state or local health director reports to an appointed board representing constituencies served by the department.

In many cases, however, a board of health functions in a strictly advisory capacity, with no oversight authority.

Under an “umbrella” model, the public health agency is part of a larger agency, and the health director either heads the agency or reports to its head.

There are considerable variations within these three models.

Even with this great variability in governance at both the state and local levels, there are no data to suggest what an “ideal” state and local agency governance structure might be.

Thus, it would be important for state agencies to examine their present governance structures and evaluate mechanisms to make these structures more effective.

Doing so should serve to build and strengthen relationships with local public health agencies, coordinate efforts for the delivery of the essential public health services and crisis response services, integrate essential health information, and respond to the changing health needs of the population.

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Scope of Agency Responsibilities and Activities

At both the state and local levels, there are differences among public health agencies in terms of the scope of their authority, responsibilities, and activities.

At the state level, activities such as immunization, infectious disease control and reporting, health education, and health statistics are common to most public health agencies.

States are also responsible for licensing and regulating the institutional and individual providers that deliver health care services.

However, states differ in whether the public health agency has responsibility for programs such as mental health and substance abuse, environmental health, and Medicaid.

These organizational differences make it more complicated to frame and pursue a coherent national agenda concerning changes and improvements in the governmental public health infrastructure.

A recent NACCHO (2001e) survey of local public health agency infrastructures has helped document the variation in services provided at the local level.

Among county health departments, for example, 98 percent provided childhood immunizations (directly or through contract services), 76 percent were responsible for restaurant inspections and licensing, and 31 percent provided dental services.

City and township local public health agencies were often less likely to offer services that other types of local public health agencies provided.

The most common services provided by local public health agencies include those most associated with traditional public health practice: adult and childhood immunizations, communicable disease control, community assessment, community outreach and education, environmental health services, epidemiology and surveillance, food safety, health education, restaurant inspections, and tuberculosis testing.

Services provided by a smaller percentage of local public health agencies included treatment for chronic disease, behavioral and mental health services, programs for the homeless, substance abuse services, and veterinary public health (NACCHO, 2001d).

One widespread change in the scope of local public health agency activities is a reduction in the direct delivery of health care services, especially to Medicaid participants.

This is consistent with a national effort to have governmental public health agencies return their attention to the more population-based public health services that had been weakened by the pressing need to provide safety-net services to uninsured individuals.

Although some have been unable to do so, many state and local public health agencies now have contracts with managed care organizations and other private providers to serve those populations.

A substantial transfer of service delivery from health departments to private providers has also occurred for childhood immunizations under federal and state programs for the purchase and distribution of vaccines (IOM, 2000a).

Some researchers have found the partnership between managed care and local public health agencies to be positively associated with the overall scope and perceived effectiveness of local public health activities in terms of their ability to meet population-based community needs (Mays et al., 2001).

(See Chapter 5 for additional discussion of the role of health care services providers in the public health system.)

However, some local public health agencies have found it difficult to compensate for the loss of revenue that had previously come from the delivery of health care services that have now been transferred to managed care organizations (Wall, 1998; Keane et al., 2001).

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THE FEDERAL PUBLIC HEALTH INFRASTRUCTURE

In contrast to state and local public health agencies, the federal government has a limited role in the direct delivery of essential public health services.

Nevertheless, it plays a crucial role in protecting and improving the health of the population by providing leadership in setting health goals, policies, and standards, especially through its regulatory powers.

It also contributes operational and financial resources: to assure financing of health care for vulnerable populations through Medicare, Medicaid, Community and Migrant Health Centers, and IHS programs; to finance research and higher education; and to support development of the scientific and technological tools needed to improve the effectiveness of the public health infrastructure at all levels.

Organization of the Federal Public Health Infrastructure

At the federal level, the lead entity responsible for public health activities is DHHS.

Several key agencies in DHHS comprise the U.S. Public Health Service (PHS): the Agency for Healthcare Research and Quality, CDC, the Agency for Toxic Substances and Disease Registry (ATSDR), the Food and Drug Administration (FDA), the Health Resources and Services Administration (HRSA), IHS, the National Institutes of Health (NIH), and the Substance Abuse and Mental Health Services Administration (SAMHSA).

In addition, various White House agencies such as the Office of Science and Technology Policy and the Office of National Drug Control Policy, 14 cabinet-level departments and agencies (e.g., Department of Agriculture, Department of Transportation, EPA, Department of Veterans Affairs [VA], and Department of Defense [DOD]), and more than 10 public corporations and commissions and subcabinet agencies are responsible for certain health programs.

The U.S. Congress oversees the activities of federal agencies through committees that review the authorization of programs and the appropriation of funds.

Multiple committees in both the House of Representatives and the Senate have jurisdiction over DHHS programs and health-related activities in other departments.

These multiple authorities and congressional jurisdictions are an important reason for the “disarray” noted in previous IOM reports.

Scope of DHHS Responsibilities and Activities

Although activities and responsibilities related to public health are spread throughout the federal government, the committee focused its attention on DHHS and its agencies as the principal federal component of the nation's governmental public health infrastructure and as the principal point of contact for other federal agencies with health or health-related programs and for state and local public health agencies.

Reviewed briefly here are DHHS activities related to the previously noted functions of policy making, financing of public health activities, public health protection, collection and dissemination of information about U.S. health and health care delivery systems, capacity building for population health, and direct management of services.

Some of these activities are considered in more detail later in this chapter, in conjunction with the discussion of specific concerns regarding weaknesses in the nation's governmental public health infrastructure.

Policy Making

Policy making is a critical function for DHHS and involves the initiation, shaping, and ultimately, implementation of congressional and presidential decisions.

It involves the creation and use of an evidence base, informed by social values, so that public decision makers can shape legislation, regulations, and programs.

The annual budget cycle is routinely the time when lawmakers present new legislation and renew legislation for existing programs and when DHHS defends proposed program budgets to Congress.

Policy making also occurs through program initiatives that do not require legislative action.

One of the leading examples in public health is the Healthy People initiative, which establishes national goals and objectives for health promotion and disease prevention.

The Healthy People initiative is led by the DHHS Office of Disease Prevention and Health Promotion and now involves all DHHS operating divisions, other federal departments, and partnerships with state and local public health officials, as well as more than 350 national membership organizations, nongovernmental organizations, and corporate sponsors.

Although the effort is voluntary, the activity and regular widespread public consultation involved in the initiative have perhaps proved to be the department's most effective nonlegislative policy vehicle for promoting action on population health at the national, state, and local levels (Boufford and Lee, 2001).

Financing of Public Health Activities

Through a variety of mechanisms — grants, contracts, and reimbursements through publicly funded health insurance programs — DHHS is an important financial contributor to the activities of state and local governmental public health agencies, primarily by financing personal health care services through mandatory spending for the entitlement programs of Medicaid.

The fiscal year (FY) 2002 budget for Medicaid amounted to $142 billion (OMB, 2001b); in sharp contrast, the DHHS discretionary budget for PHS agencies in FY 2002 was about $41 billion, of which $23.2 billion was designated for NIH.

Very little of this discretionary money goes directly to states for governmental public health agency infrastructure.

Public Health Protection

Public health protection is perhaps the most classic public health function of the federal government.

In this regard, the federal government uses its surveillance capacity to assess health risks and its standard-setting and regulatory powers to protect the public from health risks: unfair treatment; low-quality services; and unsafe foods, medicines, biologics such as blood and medical devices, as well as environmental and occupational health hazards.

In addition to certain regulatory responsibilities, DHHS also develops and maintains a research base that produces the scientific evidence needed to support the regulations in health-related areas that other federal agencies use.

The principal regulatory agencies of DHHS are FDA for drugs and biologics, medical devices, and certain foods and the Centers for Medicare and Medicaid Services (CMS) for health care providers.

Both CMS and FDA are responsible for regulatory oversight of laboratories (Boufford and Lee, 2001).

Other departments and agencies outside DHHS are also responsible for regulations that protect health. 7

Collection and Dissemination of Information

Timely and reliable data are an essential component of public health assessment, policy development, and assurance at all levels of government.

DHHS, particularly the PHS agencies, sponsors a variety of public health and health care data systems and activities.

These include national vital and health statistics, household surveys on health and nutrition, health care delivery cost and utilization information, and reporting requirements for programs funded by federal grants or assistance.

The National Center for Health Statistics within CDC is the primary agency collecting and reporting health information for the federal government.

CMS collects administrative data on the Medicare and Medicaid programs and conducts beneficiary surveys.

The Administration for Children and Families and the Administration on Aging also collect data on human services.

Other agencies (e.g., the Census Bureau, the Department of Agriculture, and the Department of Labor) also collect data that are important for public health purposes.

In addition, the collection and dissemination of research findings can be considered part of this activity.

Capacity Building for Population Health

The capacity-building function of the federal government centers on ensuring the ability of its own agencies to effectively discharge their responsibilities.

It also centers on ensuring that state and local levels of government have the resources — human, financial, and organizational — they need to carry out the responsibilities delegated to them by the federal government or for which they are responsible by law as they work to assure and promote the health of the communities that they serve.

In terms of the public health infrastructure, this includes striving for effective collaboration within DHHS, between DHHS and other cabinet departments for domestic and international health policy, and between DHHS and state and local public health departments.

With more than 200 categorical public health programs in DHHS and a variety of health-related programs in other federal agencies, the alignment of policies and strategies is challenging.

This also makes it difficult to devise an approach to the systematic and accountable long-term investment of federal funding in governmental public health agencies at the state and local levels.

Direct Management of Services

Federal funding supports the delivery of medical care through a variety of categorical grant programs (e.g., for community health centers and maternal and child health services) and insurance programs (e.g., Medicaid and Medicare).

However, the direct management of clinical or other services delivered to individuals is a small part of DHHS's role.

Under DHHS, direct medical care and public health services are provided primarily by IHS, which serves members of federally recognized American Indian tribes.

As tribal governments assume greater responsibility for managing these services, the role of IHS could evolve into that of a payer or purchaser rather than a provider of services.

In addition, DOD and VA play larger direct management roles in the provision of health care services for their particular constituencies.

The next section highlights the current status of certain critical components of the public health infrastructure that support the public health system in carrying out essential public health functions.

These components include the public health workforce, information and data systems, and public health laboratories.

The section also reviews how these components of the infrastructure are critical to emergency preparedness and response activities.

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CRITICAL COMPONENTS OF THE PUBLIC HEALTH INFRASTRUCTURE

The Public Health Workforce

The governmental public health infrastructure at the federal, state, and local levels consists of physical resources (e.g., laboratories), information networks, and human resources (the public health workforce).

An adequately sized and appropriately trained workforce performing competently is an essential element of the public health infrastructure.

The public health workforce at the federal, state, and local levels must be prepared to respond to an array of needs, such as the assurance of health-related environmental safety, the interpretation of scientific data that can influence health outcomes, or the clarification of vast amounts of highly technical information after a community emergency.

In addition to meeting the scientific and technical requirements of public health practice, state and local public health officials are often expected to provide community leadership, manage community reactions, and communicate about risk, protection, and prevention.

Current estimates indicate that approximately 450,000 individuals are working in salaried public health positions, with many more contributing to this mission through nongovernmental organizations or on a voluntary basis (HRSA, 2000).

Public health practitioners have training in a variety of disciplines, including the biological and health sciences, psychology, education, nutrition, ethics, sociology, epidemiology, biostatistics, business, computer science, political science, law, public affairs, and urban planning.

Recent studies have shown, however, that the current public health workforce is unevenly prepared to meet the challenges that accompany the practice of public health today.

An estimated 80 percent of the current workforce lacks formal training in public health (CDC-ATSDR, 2001).

Moreover, the major changes in technology, biomedical knowledge, informatics, and community expectations will continue to challenge and redefine the practice of public health, requiring that current public health practitioners receive the additional, ongoing training and support they need to update their existing skills (Pew Health Professions Commission, 1998).

Training and Education for the Public Health Workforce

Competency-Based Training

Given that early public health efforts in the United States were aimed at improving sanitation, controlling infectious diseases, assuring the safety of food and water supplies, and immunizing children, it is hardly surprising that public health workers at that time were predominantly graduates of schools of medicine, nursing, and the biological sciences.

Today, however, the public health workforce has broader responsibilities and must be much more diverse.

For example, as part of the performance of essential services, members of the public health workforce must be prepared to engage the community in effective actions to promote mental, physical, environmental, and social health.

Advances in biomedical and genomics research and technologies have the potential to change the way public health practitioners think about population-level disease risk and how disease prevention and health promotion activities might be practiced.

Moreover, rapidly evolving computer and information technologies and the use of mass media and social marketing have the potential to revolutionize health departments' access to up-to-date surveillance information, disease databases, and communications networks as well as to enhance worker productivity.

The need to strengthen the public health workforce was recognized by IOM in 1988 and has been the focus of a variety of efforts since then.

Some of these activities will be discussed in the chapter on the role of academia in the public health system (Chapter 8).

A few key efforts focusing on the current workforce (rather than training new workers) are also covered here.

In particular, the report The Public Health Workforce: An Agenda for the 21st Century (USPHS, 1997) called for greater leadership on workforce issues from national, state, and local public health agencies; use of a standard taxonomy to better assess and monitor workforce composition; competency-based curriculum development; and greater use of new technologies for distance learning.

The Taskforce for Public Health Workforce Development, established in 1999 by CDC and ATSDR, recommended six broad strategies for a national public health workforce development agenda (CDC, 2000e):

1. Monitor current workforce composition and project future needs.

2. Identify competencies and develop curricula.

3. Design integrated learning systems.

4. Use incentives to promote public health practice competencies.

5. Conduct and support evaluation and research.

6. Assure financial support for a lifelong learning system in public health.

An almost universal priority for workforce development is ensuring that all public health practitioners have mastery over a basic set of competencies involving generalizable knowledge, skills, and abilities that allow them to effectively and efficiently function as part of their public health organizations or systems (CDC-ATSDR, 2000; DHHS, 2000; CDC, 2001d) (see Appendix E for an extended list of competencies for public health workers).

Many experienced public health professionals require a variety of cross-cutting competencies to help them meet the routine and emergent challenges of public health, as well as specialized skills and abilities in areas such as maternal and child health, community health, and genomics.

In addition, a recent survey of the local public health infrastructure found that several specific public health occupations are projected to be the most needed in the coming 5 years (NACCHO, 2001e).

These occupations included public health nurses, epidemiologists, and environmental specialists (NACCHO, 2001e) (see Figure 3–2).

The Council on Linkages between Academia and Public Health Practice 8 has developed a list of 68 core public health competencies in eight domains (see Box 3–2), with different levels of competency expectations for frontline public health workers, senior professional staff, program specialists, and leaders (Council on Linkages between Academia and Public Health Practice, 2001).

An expert panel convened by CDC, ATSDR, and HRSA has recommended adoption of this list as the basis for competency-based training of the public health workforce (CDC, 2000e).

Use of this list as the basis for training and continuing education for the public health workforce was recommended, regardless of the programmatic or categorical focus of the training (CDC, 2000e).

Efforts are under way in the various public health training networks to establish models that will contribute to a systematic approach to competency-based training that is linked to the essential services framework and grounded in prior competency validation efforts (CDC, 2000e).

Meeting the Needs for Workforce Development

The issue of workforce training and competency is central to the success of any public health system.

Governmental public health agencies have a responsibility to identify the public health workforce needs within their jurisdictions and to implement policies and programs to fill those needs.

In addition, an assessment of current competency levels and needs is essential to develop and deliver the appropriate competency-based training, as well as to evaluate the impact of that training in practice settings.

Workforce training and education efforts may be conducted in partnership with academia and other relevant and appropriate community partners, and ideally, a percentage of public health employees should be targeted annually for continuing education (DHHS, 2000).

These and other issues are discussed in the 2003 IOM report Who Will Keep the Public Healthy: Educating Public Health Professionals for the 21st Century.

Training resources for the public health workforce are expanding, spurred by modest funding by HRSA for Public Health Training Centers and by CDC for Public Health Preparedness Centers.

By mid-2002, there were 14 Training Centers and 15 Preparedness Centers, which form the backbone of a national public health training network.

Both types of centers promote a variety of general workforce development strategies, although the CDC-funded centers place a heavier emphasis on bioterrorism preparedness.

Given the importance of the workforce in carrying out the mission of public health, the committee finds that education and development of the current workforce must continue to be a fundamental priority within the broader efforts to improve the state and local public health infrastructure.

Therefore, the committee recommends that all federal, state, and local governmental public health agencies develop strategies to ensure that public health workers who are involved in the provision of essential public health services demonstrate mastery of the core public health competencies appropriate to their jobs.

The Council on Linkages between Academia and Public Health Practice should also encourage the competency development of public health professionals working in public health system roles in for-profit and nongovernmental entities.

To facilitate ongoing workforce development, the committee encourages public health agencies to engage in training partnerships with academia to ensure the availability of coordinated, continuous, and accessible systems of education.

These systems should be capable of addressing a variety of workforce training needs, ranging from education on the basic competencies to continuing education for individuals in the specialized professional disciplines of public health science.

Furthermore, the committee recommends that Congress designate funds for CDC and HRSA to periodically assess the preparedness of the public health workforce, to document the training necessary to meet basic competency expectations, and to advise on the funding necessary to provide such training.

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Preparing Public Health Leaders

Senior public health officials must have the preparation not only to manage a government agency but also to provide guidance to the workforce with regard to health goals or priorities, interact with stakeholders and constituency groups, provide policy direction to a governing board, and interact with other agencies at all levels of government whose actions and decisions affect the population whose health they are trying to assure (Turnock, 2000).

These tasks require a unique and demanding set of talents: professional expertise in the specific subject area; substantive expertise in the content and values of public health; and competencies in the core skills of leadership.

Those who have mastery of the skills to mobilize, coordinate, and direct broad collaborative actions within the complex public health system must lead in implementing the actions outlined in this report.

They require the skills for vision, communication, and implementation.

Although many of these skills are innate for most professionals and other leaders, they need constant refinement and honing.

CDC has pioneered the development and funding of a national Public Health Leadership Institute, and in the intervening dozen years, more than 500 leaders in public health have been exposed to leadership training and skill building (described in more detail in the Academia chapter).

Furthermore, a similar network of State and Regional Public Health Leadership Institutes has been funded and, over time, has developed the capacity to work collaboratively through a national network, which permits institutes to benchmark and share best practices and continue the process of learning needed to help with state-of-the art curriculum and educational training efforts.

Equally notable has been the development of the Management Academy for Public Health, a joint effort of the major public health philanthropies.

Although effort is still at an early stage, this academy has already generated graduates who work hand in glove with senior leadership in public health organizations.

Furthermore, the Turning Point Initiative devotes efforts to increasing collaborative leadership across all sectors and at all levels (Larson et al., 2002)

Another key to leadership is continuity in office long enough to exert the leadership and to provide the institutional memory to defend public health agencies and the public health sector from the political winds of the moment.

Yet, the committee finds there has been great difficulty in recruiting, developing, and retaining the leaders so vital to the job.

A state health official's term, if that official is a political appointee, is tied to the governor's term.

Health officials must work with legislators who operate on 2-year terms.

Given that the average tenure of a state health officer is relatively short (an average of 3.9 years and a median of 2.9 years) (ASTHO, 2002), many state health officials find it difficult to create longer-term plans for achieving health goals on shorter-term time frames (Meit, 2001).

Additionally, because state health officers report to many governing bodies, they generally have less direct access to policy makers, and state health officials must prioritize the issues that they think deserve the most attention (Meit, 2001).

Political factors at the state level can also have a significant impact on the abilities of public health leadership to influence policy.

To address the specific issues of discontinuity occasioned by the rapid turnover, particularly of state health officials, the Robert Wood Johnson Foundation has funded a unique State Health Leadership Initiative administered by the National Governors Association to immerse newly appointed officials in a curriculum for political leadership and provide a network of resources and mentors.

Governmental public health leadership is a critical component of the infrastructure that must be strengthened, supported, and held accountable by all of the partners of the public health system and the community at large.

For this reason, the committee recommends that leadership training, support, and development be a high priority for governmental public health agencies and other organizations in the public health system and for schools of public health that supply the public health infrastructure with its professionals and leaders.

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Considering Credentialing as a Tool for Workforce Development

Credentialing is a mechanism that is used to certify specific levels of professional preparation.

There are many different forms of credentials, including academic degrees, professional certifications, and licenses.

For example, medical credentials include medical degrees to certify successful completion of course work, professional testing (e.g., through medical board exams) to provide evidence of qualification to practice medicine, and medical licensing to establish compliance with state standards for medical practice.

An individual credentialed as a Certified Health Education Specialist (CHES) has successfully completed a course of study and passed a competency-based test.

Although some public health workers are credentialed as physicians, nurses, health educators, or environmental health practitioners, few are credentialed within those professions specifically for public health practice.

Most physicians working in public health lack board certification in preventive medicine or public health; most nurses working in public health lack credentials in community public health nursing; and most individuals working as health educators lack the CHES credential.

Furthermore, no single credentialing or certification process has been established to test the various competencies required for the interdisciplinary field of public health; thus, the majority of the public health workforce (80 percent) lacks credentials (HRSA, 2000).

Given the importance of establishing and maintaining a competent public health workforce, CDC and other public health agencies and organizations, including NACCHO, the Association of State and Territorial Health Officials (ASTHO), the Association of Schools of Public Health, and the American Public Health Association (APHA), are examining the feasibility of creating a credentialing system for public health workers based on competencies linked to the essential public health services framework.

CDC (2001d) has recommended the use of credentialing.

Such a process would complement efforts to establish national public health performance standards for state and local public health systems based on the essential public health services framework and the related objectives of Healthy People 2010 (Objective 23–11) (DHHS, 2000).

Although this national effort focuses on experienced public health leaders, support is growing for the concept of credentialing at a basic level all public health workers and at an intermediate level the experienced professionals from many disciplines who share the need for higher-level, cross-cutting competencies in the areas of public health practice, community health assessment, policy development, communication, and program development and evaluation.

Certification or credentialing would help establish that public health practitioners have a demonstrated level of accomplishment in and mastery of the principles of public health practice.

In terms of building the capacity of the public health workforce, the credentialing process could help document the knowledge, skills, and performance of experienced workers who may not have formal academic training and could encourage other workers to seek additional training to meeting credentialing requirements.

An especially important component of this process is that it could play a key role in shaping the training and preparation of future public health practitioners and leaders.

The key challenge is whether and how public health organizations can begin to integrate competency-based credentialing in their hiring, promotion, performance appraisal, and salary structures.

Although the idea of credentialing has considerable support at the federal level, states and particularly localities have voiced concerns that workforce credentialing mandates may become too closely tied to federal funding mechanisms.

In these situations, the fiscal impact could be grave for public health departments that do not or cannot meet credentialing requirements (community informants, personal communications to the committee, 2001).

The committee finds that in the ongoing debate about public health workforce credentialing, what is most needed is a national dialogue that can address the full range of issues and concerns.

Therefore, the committee recommends that a formal national dialogue be initiated to address the issue of public health workforce credentialing.

The Secretary of DHHS should appoint a national commission on public health workforce credentialing to lead this dialogue.

The commission should be charged with determining if a credentialing system would further the goal of creating a competent workforce and, if applicable, the manner and time frame for implementation by governmental public health agencies at all levels.

The dialogue should include representatives from federal, state, and local public health agencies, academia, and public health professional organizations who can represent and discuss the various perspectives on the workforce credentialing debate.

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