Summary of Public Health Organizational Structure Primary
responsibility and authority for public health in the U.S. is
assigned to federal, state and local public health agenciesFederal
agencies set policy and standards and provide guidance and funding;
State agencies define policies and establish and help fund local or
regional public health initiatives; and Local/regional health
departments implement public health programs.
*1. Vaccination Resulted in eradication of smallpox, elimination
of poliomyelitis in the Americas and control of measles, rubella,
tetanus, diphtheria and Haemophilus influenzae type b in the U.S.
and other parts of the world.2. Motor-vehicle safety Resulted in
large reductions in motor-vehicle-related deaths due to safer
vehicles and highways and efforts to change personal behavior
(e.g., increased use of safety belts, child safety seats and
motorcycle helmets, as well as decreased drinking and driving).3.
Safer workplaces Resulted in reduction of approximately 40 percent
in the rate of fatal occupational injuries.4. Control of infectious
diseases Resulted in dramatic reduction of infections, such as
typhoid and cholera, through clean water and improved sanitation,
and greater control of infections, such as tuberculosis and
sexually transmitted diseases, through the discovery of
anti-microbial therapy.5. Decline in deaths from coronary heart
disease and stroke Resulted in 51 percent decrease in the death
rate from coronary heart disease through efforts to modify
behaviors and reduce risk factors, such as smoking and high blood
pressure, and to provide better access to early detection and
treatment. 6. Safer and healthier foods Resulted in near
elimination of major nutritional deficiency diseases, such as
rickets, goiter and pellagra, in the U.S. through the
identification of essential micronutrients and establishment of
food-fortification programs.7. Healthier mothers and babies
Resulted in 90 percent decrease in infant mortality and 99 percent
decrease in maternal mortality through better hygiene and
nutrition, availability of antibiotics, greater access to health
care and technologic advances in maternal and neonatal medicine.8.
Family planning Resulted in altered social and economic roles of
women, made possible by: family planning and contraceptive
services; smaller family sizes and longer intervals between the
birth of children; increased opportunities for pre-conceptional
counseling and screening; fewer infant, child and maternal deaths;
and use of barrier contraceptives to prevent pregnancy and spread
of sexually. transmitted diseases9. Fluoridation of drinking water
Resulted in reductions in tooth decay (40 to 70 percent in
children) and of tooth loss in adults (40 to 60 percent);
contributed to effectively preventing tooth decay, regardless of
socioeconomic status or access to care. 10. Recognition of tobacco
use as a health hazard Resulted in prevention of millions of
smoking-related deaths, changes in social norms to prevent
initiation of tobacco use, promote cessation of use and reduce
exposure to environmental tobacco smoke.
*Age of Industrialization In the 1700s, as people left farms and
small villages for towns and cities, to make a living in the newly
emerging industrial economy, conditions became ripe for the spread
of infectious diseases.Crowded, unsanitary conditions and long
hours of work in unsafe and often exploitative industries
contributed to waves of disease, such as cholera, smallpox,
typhoid, tuberculosis and yellow fever. As the diseases took their
toll, however, several key discoveries that would eventually lead
to the reduction and control of infectious disease occurred.
Following are some of the highlights: Lady Mary Wortley Montagu, In
1717, introduced to England the Turkish practice of inoculating
children with smallpox. In 1796, Edward Jenner further developed
smallpox vaccine. In 1848, Dr. John Snow traced an outbreak of
cholera to well water drawn from the pump at Londons Broad Street.
Snow found the source by pinpointing on a map where cholera deaths
occurred. The evidence led Snow to water drawn from the pump as the
disease source. By identifying the source and persuading the city
to close the pump, Snow helped prevent hundreds of cholera cases.
His use of data was one of the earliest recorded examples of
epidemiology (the use of statistics to study disease transmission),
a key strategy of population-based public health practice.In the
1850s, Louis Pasteur discovered that most infectious diseases are
caused by germs. (His discovery is referred to as the "germ theory
of disease.") This discovery is considered among the most important
in medical history. Jenners smallpox vaccine and Snows
epidemiological discovery of one source of cholera in England were
milestones achieved through deductive logic and common sense. But
in 1884, Robert Koch developed four postulates that further guided
understanding of infectious agents and disease. While Kochs study
focused on the etiology (origin) of tuberculosis, his postulates
were applied to other diseases as well. They held that:The organism
must be found in all animals suffering from the disease, but not in
healthy animals. The organism must be isolated from a diseased
animal and grown in pure culture. The cultured organism should
cause disease when introduced into a healthy animal. The organism
must be re-isolated from the experimentally infected animal. In the
late 1800s, in the United States, the tenements of New York City,
brimming with newly arrived immigrants, led to poor public health
conditions similar to those found in European cities earlier.
Epidemics of smallpox, yellow fever, cholera, typhoid and typhus
were not uncommon. Tuberculosis and malaria killed thousands of
people each year. Children worked 12- to 14-hour days in
sweatshops. Lillian Wald, viewed as one of the nations early public
health nursing pioneers, devoted her life to addressing health
needs of tenement populations. Read more about Lillian Wald at the
Jewish Womens Archives. As nurses such as Lillian Wald and others
sponsored by church and womens groups, hospitals, charitable
services and, eventually, cities began caring for the sick in the
tenements, the seeds for a more comprehensive government-sponsored
public health service were sown. *What became of Snow and his
theories?
Compelling as they are to modern readers who know the end of the
story, Snow's exhaustive books, articles, and presentations
immediately influenced the opinion of very few scientific or
medical authorities of his day in England or in Europe. Snow's
work, when it was read, was largely rejected as "untenable" and
inconclusive. Those who did value Snow's work thought that
contaminated water might predispose persons to cholera, but unlike
Snow, they did not believe that it was a sufficient single
cause.His now famous 1855 edition of On the Communication of
Cholera had sold only 56 copies by the time Snow, a lifelong
bachelor, died in 1858 at the age of 45 (Chave, 1958, p. 347).
Virtually all authorities continued to hold complex airborne miasma
theories of cholera transmission for several more decades.
Recognition and acceptance of Snow's work would gradually increase
for the next several decades, until the more foundational work of
Koch and Pasteur cleared the way for contagion theory and
documented the existence and disease-causing abilities of the
"animalcules" (bacteria) hypothesized by Snow and others. Snow
himself was not widely known in epidemiology or medicine until more
than 75 years after his death, when epidemiologist Wade Hampton
Frost republished Snow's work in Snow on Cholera in 1936. In short,
Snow labored in public health for about ten years for no pay and in
relative obscurity. He died unrecognized for having come very close
to understanding the nature of cholera and its transmission. What
became of the Broad Street Pump?
Astounding as it seems to modern readers, so few people of
influence accepted Snow's waterborne theory of cholera that within
several weeks after the outbreak, the Broad Street pump was back in
service (Chave, 1958). Records show that throughout London, shallow
street pumps like that in Broad Street continued to be used for
more than twenty years, but their existence was increasingly fought
by medical and sanitary reformers who warned of the danger they
posed. Even when cholera was present, the pumps often remained in
service.
What became of cholera?
In the 20th Century, sanitary improvements have largely
eliminated cholera from industrialized countries. Cholera remains
endemic in many areas of the world, however. The seventh cholera
pandemic that began in Indonesia in 1961 continues. After a
Peruvian outbreak in 1991, Central and South America saw more than
one million cases and eleven thousand deaths through 1995, and the
disease also continues to produce significant morbidity and
mortality in Africa and Asia.*1900s to Today In 1918, an influenza
pandemic killed an estimated 20 to 40 million people around the
world, far more than had died during World War I, which ended the
same year. In the world of public health, the pandemic established
epidemiology as a key strategy for fighting disease. Read more
about the flu pandemic of 1918 at
http://www.stanford.edu/group/virus/uda/ *In 1964, the U.S. Surgeon
General issued the first (of many) reports on cigarette smoking and
its connection with cancer. The report was an early volley in what
has grown to be a major public health emphasis: preventing
smoking-related cancer deaths through public education, policy and
promotion of the negative health impact of smoking and the benefits
of not smoking. * In 1981, the HIV-AIDS virus was first recognized.
Public health responded with initiatives to educate the public
about the disease, its cause, how it is transmitted and how it can
be prevented, as well as initiatives to provide treatment to AIDs
patients.* In 1990, as awareness of the relationship between diet
and disease increased, Congress passed the Nutrition Labeling and
Education Act, requiring that all packaged foods have nutritional
labeling and that health claims for foods meet standards set by
Secretary of Health and Human Services. The goal: provide consumers
with information on the nutrients in the foods they buy as a means
of reducing the incidence of heart disease, cancer and other
illnesses.* In 2001, the threat of bioterrorism in the U.S. became
real when mail containing deadly anthrax spores was sent to several
members of the U.S. Congress and other individuals. The incident,
along with the Sept. 11 terrorist attacks on the U.S., led public
health to consider and implement bioterrorism preparedness
measures.*
*1798. The U.S. Public Health Service. The first marine hospital
owned by the Federal Government was purchased from the State of
Virginia in 1801 and was located at Washington Point in Norfolk
County.The origins of a government public health infrastructure
dates to the nations early days and its reliance on sea merchants,
men vital to the transport of goods to and from the country.
Seamen, as you can imagine, frequently fell victim to disease and
injury. To provide care for sick or injured seamen, the federal
government, in 1798, established a Marine Hospital Service, charged
with building and administering marine hospitals at a number of
port cities. *1798: First local public health board. With each
advance in knowledge, from greater understanding of environmental
controls for water sanitation and sewage treatment to measures for
controlling the spread of diseases (quarantine, isolation and
vaccination), some localities began creating health agencies to
implement the controls.Baltimore is cited as one of the first to do
so, in 1798.1850: Growth of local and state public health
activities. Lemuel Shattucks Report of the Sanitary Commission of
Massachusetts in 1850 outlined existing and future public health
needs for that state. The report became Americas blueprint for
development of a public health system. Shattuck called for the
establishment of state and local health departments to organize
public efforts aimed at sanitary inspections, communicable disease
control, food sanitation, vital statistics and services for infants
and children. 1870s: State boards of health created. Recognizing
that infectious and environmental hazards do not respect local
boundaries, the states began to develop their own public health
boards and agencies after 1870. These agencies often had broad
powers to protect the health and lives of state residents, although
the clear intent at the time was that these powers be used to
battle epidemics of infectious diseases.Late-1800s: Shift to social
reform as strategy for public health. During the late 1800s, the
focus of public health shifted from problems related to
individuals, such as poor hygiene, to broad social reform. Poverty
and disease came to be recognized as consequences of
industrialization. Thus, it was believed that public health
problems could be addressed through social reform in such areas as
labor, employment, housing, education and the environment.
1930s-1960s: Shift from personal responsibility to social
responsibility. The Great Depression of the 1930s created vast
social insecurity that was beyond the capacity of individuals or
local communities to adequately address.The federal government was
permitted indeed, expected to intervene. This led to a shift from a
non-interventionist federal government approach to a more active
federal government role in the nations public health. This shift
increased the influence of the federal government over public
health in general and public health activities of state and local
governments in particular. Later, in the 1940s and 1950s, polio
epidemics led to federal funding for polio vaccine development and
delivery. A nationwide program of vaccination was coordinated by
federal, state and local agencies. Beginning in the 1960s, federal
grant-in-aid programs designed to fill gaps in the medical care
system nudged state and local governments further into providing
public health services.The 1965 enactment of Medicare legislation
under the Social Security Act marked a significant public health
milestone. For the first time, people ages 65 and older were
provided a publicly financed health insurance program. 1970s 1990s:
Public healths responsibilities broaden. With infectious diseases
largely abated through improved social conditions and disease
prevention programs, public health increasingly began to focus on
preventing chronic diseases, such as cancer, diabetes, stroke,
heart disease and emphysema. Also, public health increasingly
promoted healthy lifestyles, including improved diets, more
exercise and reduced tobacco use.During this time, public health
agencies provided a vast array of services, including early
periodic screening, school nursing, immunization clinics,
tuberculosis follow-up, prenatal and postnatal assessments and
education, child development instructions, cardiovascular disease
prevention and vision and hearing screenings. Home care services
increased as payment sources grew through Medicare, Medicaid and
veterans health services, insurance reimbursement and sliding fee
charges. *What Are the Leading Health Indicators?The Leading Health
Indicators will be used to measure the health of the Nation over
the next 10 years. Each of the 10 Leading Health Indicators has one
or more objectives from Healthy People 2010 associated with it. As
a group, the Leading Health Indicators reflect the major health
concerns in the United States at the beginning of the 21st century.
The Leading Health Indicators were selected on the basis of their
ability to motivate action, the availability of data to measure
progress, and their importance as public health issues.The Leading
Health Indicators are
*A description of how public health is structured in the U.S. is
found in the introduction to Public Health: What It Is and How it
Works, 3rd Ed. (2004), by B. J. Turnock. It reads: The public
health infrastructure may be described as a complex network of
people, systems, and organizations working at local, state, and
national levels to protect the health of populations Promoting the
health and safety of the local community requires the interaction
of many health agencies and organizations in the private and public
sectors. It has been estimated that the U.S. currently has more
than 3,000 health departments in cities and counties and at least
3,000 Local Boards of Health. In addition, there are 59 state and
territorial health departments that have varying interactions with
local health authorities. The public health infrastructure also
includes a number of other organizations, such as tribal health
departments, laboratories, and community health
organizations.*Within the federal government, the Department of
Health and Human Services (HHS) is responsible for protecting the
health of Americans and providing essential human services,
especially for citizens least able to help themselves. As such, it
is charged with most (but not all) public health activities. The
Secretary of Health and Human Services serves as a member of the
President's Cabinet. The Secretary is appointed by the President
and must be approved by the U.S. Senate.
Office of the Surgeon General, one of the most visible positions
in government from which to advocate healthy behaviors. National
Institutes of Health (NIH). NIH is the steward of medical and
behavioral research for the nation. Health Resources and Services
Administration, the mission of which is to improve and expand
access to quality health care for all. Centers of Disease Control
and Prevention (CDC). The CDC is recognized as the lead federal
agency for protecting the health and safety of people at home and
abroad, providing credible information to enhance health decisions
and promoting health through strong partnerships. The CDC serves as
the national focus for developing and applying disease prevention
and control, environmental health, and health promotion and
education activities designed to improve the health of the people
of the United States. Indian Health Service (IHS) provides
comprehensive health services (medical, dental and environmental
health programs) through IHS and tribally contracted hospitals,
health centers, school health centers and health stations. Special
program concentrations are in disease prevention and health
promotion, alcoholism, substance abuse, suicide, accidents,
maternal and child health, nutrition and public health services.
Substance Abuse and Mental Health Services Administration. SAMHSA
works to build resilience and facilitate recovery for people with
or at risk for substance abuse and mental illness. Agency for
Health Policy Research and Analysis, which conducts research on
health care systems; Agency for Healthcare Research and Quality
Food and Drug Administration assures safety of food, drugs and
medical devices.
*American Public Health Association. The American Public Health
Association (APHA) is the oldest and largest organization of public
health professionals in the world, representing more than 50,000
members from over 50 occupations of public health. Association of
State and Territorial Health Officials. The Association of State
and Territorial Health Officials (ASTHO) is the national nonprofit
organization representing the state and territorial public health
agencies of the United States, the U.S. Territories, and the
District of Columbia. ASTHO's members, the chief health officials
of these jurisdictions, are dedicated to formulating and
influencing sound public health policy, and to assuring excellence
in state-based public health practice. National Association of City
and County Health Officers. NACCHO is the national organization
representing local public health agencies. NACCHO works to support
efforts that protect and improve the health of all people and all
communities by promoting national policy, developing resources and
programs, seeking health equity and supporting effective local
public health practice and systems. HRSA Public Health Training
Centers Network. This national network of centers funded by the
Health Resources and Services Administration develops a range of
academic and continuing education programming in core public health
competencies.
*Most states recognized their responsibility for the welfare of
citizens. Thus, the more complete and coordinated structure for
public health activities is at the state and local levels.The
various states have taken different approaches to organizing and
administering public health. Some have a centralized public health
structure; others have a de-centralized approach. For example, if
your state has a centralized approach, you and other public health
employees are state (not county) employees and the funding for
programs and program direction comes from the state. If your state
takes a decentralized approach, you and your fellow public health
co-workers are probably employees of a county or region. Under a
de-centralized approach, funding may come from the state, but
decision-making is local. *Each community has its own unique local
public health system made up of multiple and diverse public and
private entities (such as non-profit organizations). Generally,
however, public health decisions at the local level are made by
professionals at regional or county health departments and by their
boards of health.Public health practitioners at these departments
are responsible for ensuring that all members of the community are
served. Generally, a local board of health has primary
responsibility and legal authority for public health decisions. (In
contrast, some boards may serve an advisory role to the ultimate
local public health governing body.) Implementation of local public
health policy decisions is the responsibility of the local public
health department staff. *In addition to federal, state and local
public health agencies, organizations that are not part of the
government also play a vital role in the U.S. public health
infrastructure. These organizations include hospitals, health care
providers in private practice, health plans and others that work
independently of but alongside public agencies, to promote
population health and prevent disease. Private, non-profit
organizations, too, contribute to public healths mission. Among
them are the United Way, American Red Cross and American Cancer
Association.*Primary responsibility and authority for public health
in the U.S. is assigned to federal, state and local public health
agencies, each of which has distinct roles and responsibilities.
Generally,Federal agencies set policy and standards and provide
guidance and funding; State agencies define policies and establish
and help fund local or regional public health initiatives; and
Local/regional health departments implement public health programs.
Responsibility for public health is shared broadly among
governmental agencies and non-governmental organizations, such as
hospitals, private clinics and health plans. Such non-governmental
organizations, which also include private, non-profit agencies
dedicated to addressing community health issues, play an important
role in helping build healthy communities. Although the
authorities, responsibilities and activities may vary across the
various public health agencies, they have in common the core
functions of public health: assessment, policy development and
assurance. Youll learn about these in Unit 2: Principles and
Practices.
