Public Health System: Structure and function CHAPTER OUTLINE ADMINISTRATION OF U.S ADMINISTRATION OF U. S PUBLIC HEALTH 309 PUBLIC HEALTH A. Responsibilities of the Federal G Commerce 309 A. Responsibilities of the Federal Government 2. Taxation for the General Welfare 309 3. Provision of Care for Special Groups 310 The public health responsibility of the U.S. Federal Govern 4. Funding Federal Legislation 310 ment is based on two clauses from article 1, section 8 of the 5. Coordination of Federal Agencies 3I0 U.S. Constitution. First, the Interstate Commerce Clause B. Responsibilities of States 312 gives the federal government the right" to regulate Com- C. Responsibilities of Municipalities and Counties 33 merce with foreign Nations, and among the several States and with the Indian Tribes Second, the general welfare Basic six " to 10 essential services 314 Clause states that the Congress shall have Power to lay and 2. Health Director's Duties 314 collect Taxes.. for the common Defense and general Welfare 3. Environmental Protection 315 of the United States, Federal responsibility also is inferred II, BROADER DEFINITIONS OF PUBLIC HEALTH POLICY 315 from statements that Congress has the authority to creat and support a military and the authority to negotiate with Ill. INTERSECTORAL APPROACH TO PUBLIC HEALTH 315 Indian tribes and other special groups IV, ORGANIZATIONS IN PREVENTIVE MEDICINE 316 V. ASSESSMENT AND FUTURE TRENDS 316 . Regulation of Commerce VI. SUMMARY 316 The regulation of commerce involves controlling the entry REVIEW QUESTIONS, ANSWERS, AND EXPLANATIONS of people and products into the United States and regulating commercial relationships among the states. People may be excluded from entry to the United States if they have infec- tious health problems, such as active tuberculosis. Products The U.S. Institute of Medicine(IOM)describes the chal- may also be excluded from entry, such as fruits and vegeta- lenges inherent in organizing the public health system for bles if infested with certain organisms (e. g, Mediterranean the 2lst century as follows fruit fly) or treated with prohibited insecticides or fungi cides In the past, similar prohibitions have been extended to The systems and entities that protect and promote the publics the importation of animal products from cattle that might health, already challenged by problems like obesity, toxic envi- contain the prions of bovine spongiform ronments, a large uninsured population, and health disparities, and, as recently in 2011, produce that might be contami- must also confront emerging threats, such as antimicrobial nated with Escherichia coli resistance and bioterrorism. The social, cultural, and global cor The regulation of commercial relationships between texts of the nations health are also undergoing rapid and dra- states has increased over time. Contaminated food products matic change. Scientific and technological advances, such as hat cross state lines are considered to be "interstate com- genomics and informatics, extend the limits of knowledge and merce"; what crosses state lines are harmful microorganisn human potential more rapidly than their implications can be The federal government takes the responsibility for inspect- absorbed and acted upon. At the same time, people, products ing all milk, meat, and other food products at their site of d germs migrate and the nations demographics are shifting production and processing.(In contrast, the state or local in ways that challenge public and private resources government is responsible for inspecting restaurants and food stores. Likewise, polluted air and water flowing from The U.S. public health system was designed at a time state to state are deemed to be "interstate commerce"in pol when most threats to health were infectious, before com lution and come under federal regulation puter information systems, and when local autonomy pi vailed. This chapter describes the structure of the U.S. health 2. Taxation for the General Welfare challenges. Public health systems in other countries are likely The power to "tax for the general welfare"is the constitu- structured very differently but still need to adapt to the same tional basis for the federal government,'s development of challenges most of its public health programs and agencies, including 309
SECTION 4 Public Health the Centers for Disease Control and Prevention(part Social Security Act. Medicare is covered under Title 18 of Department of Health and Human Services)and the the Social Security Act and pays for medical care for the pational Safety and Health Administration(OSHA, lderly population. Medicaid is covered under Title 19 and the Department of Labor); for research programs, such as pays for medical and nursing home care in cooperation with those of the National Institutes of Health(NIH); and for the the states(see Chapter 29). CMS duties include setting stan- payment for medical care, such as Medicare and Medicaid dards for programs and institutions that provide medical (see Chapter 29) care, developing payment policies, contracting for third party payers to cover the bills, and monitoring the quality of 3. Provision of Care for Special Groups care provided. CMS also supports graduate medical educa- tion, residency, and fellowship programs that provide care The federal government has taken special responsibility for individuals covered by Medicare or Medicaid for providing health services to active military personnel, through military hospitals; families of military personnel, through military hospitals or the Civilian Health and Medical PUBLIC HEALTH SERVICE Program of the Uniformed Services; veterans, through the The U.S. Public Health Service(PHS) comprises the follow Veterans Administration hospital system; and Native Ameri ans and Alaska Natives, through the Indian Health Service of the u.s. public health service he Agency for Healthcare Research and Quality (AHRQ) is the main federal agency for research and 4. Funding Federal Legislation policy development in the areas of medical care organiza- tion,financing, and quality assessment. Since 2000, the Funding of federal legislation requires a two-step process The initial bill provides an authorization of funds. An authorization bill only sets an upper limit to the amount of 2. The Agency for Toxic Substances and Disease Registry funds that can be spent No monies can be spent, however ATSDR) provides leadership and direction to programs until they have been specifically appropriated for that bill designed to protect workers and the public from exposure purposes in a subsequent appropriations bill. The authoriza to and adverse health effects of hazardous substances that tion is a political fiction for which members of Congress can are kept in storage sites or are released by fire, explosion, or accident tends to be about half the amounts authorized in the bills, 3. The Centers for Disease Control and Prevention(CDC) and the amounts are usually appropriated for only one fiscal has the responsibility for"protecting the public health of ear at a time. It is in the funding bills that fiscal(and politi the[United States] by providing leadership and direction al)reality must be faced. Because a funding bill covers many in the prevention and control of diseases and other pre ems,the voters usually are unaware that the amount actu ventable conditions and responding to public health ally appropriated is much smaller than the amount promised emergencies. The CDC directs and enforces federal quar- he authorization bill antine activities: works with states on disease surveillance and control activities; develops programs for prevention 5. Coordination of Federal Agenci and immunization; is involved in research and training; makes recommendations on how to promote occupa In the United States the federal department most concerned tional health and safety through the National Institute with health is the Department of Health and Human Ser on Occupational Safety and Health(NIOSH); provides consultation to other nations in the control of prevent described next(Fig. 25-1) able diseases; and participates with international agencies the eradication and control of diseases around the ADMINISTRATION ON AGING world. The CDC has a complex organizational structure The Administration on Aging provides advice to the Secre- 4. Th825-2) ood and Drug Administration(FDA)is the primary tary of the dhHS on issues and policies regarding elderly gency for regulating the safety and effectiveness of drug persons. It also administers certain grant programs for the for use in humans and animals vaccines and other bio benefit of the aging population products including ionizing and nonionizing radiation-emitting ADMINISTRATION FOR CHILDREN AND FAMILIES electronic products. The FDA is also responsible for the fety, quality, and labeling of cosmetics, foods, and food The Administration for Children and Families is additives and colorings for administering child welfare programs through the stat 5. The Health Resources and Services Administration Head Start programs, child abuse prevention and treatment (HRSA)is responsible for developing human resources programs, foster care, adoption assistance, developmental and methods to improve health care access, equity, and disabilities programs, and child support enforceme uality, with an emphasis on promoting primary care HRSA also supports training grants and training pro- CENTERS FOR MEDICARE AND MEDICAID SERVICES grams in preventive medicine and public health. 6. The Indian Health Service promotes the health of and The Centers for Medicare and Medicaid Services(CMS)is rovides medical care for Native Americans and Alaska esponsible for administering two major programs of the Natives
CH ER 25 Public Health System: Structure and Function The Executive Secretariat Secretary Deputy Secretary Office Office of Health Reform and Extemal Affairs (EA (OHR) Chief of staff Office on Disability Strategic Information (osSI Administration for Children Centers for medicare d Neighborhood (ASA) (ACF) (CFBNP) Program Support Office for Civil Rights Administration on Agin Food and Drug (FDA) fice of the Assistant Secretary for Financial ASFR gency for Healthcare Research and Quality Services Administration AHR (HRSA Office of the assistant Secretary for Health Office of the general nd Disease Registry ind an Health Office of the assistant ecretary for Legislation Office of Global Affairs Centers for Disease Control National Institutes of health* (OGA) and Prevention Secretary for Planning (ASPE) Health Services Office of the Assistant SAMHSA Preparedness and gs and Appeals (ASPR OMHA Office of the Assistant heesigpates a emp sent ce Secretary for Public (ASPA) Information Technology Figure25-iu.s.dEpartmentofhEalthandHumanServices(dhhs)organizatIonalchart.(fromhttp://www.hhs.gov/about/orgchart.) 7. The National Institutes of Health(NIH) consists of 2 8. The Substance Abuse and mental health institutes, which perform intramural (in-house)research Administration(SAMHSA) provides national l on their particular diseases, organ systems, or topics(e.g in preventing and treating addiction and othe National Cancer Institute; National Heart, Lung, and disorders based d Blood Institute: National human genome research insti has four major operating divisions: Center for Mental tute: National Center for Advancing Translational Health Services, Center for Substance Abuse Prevention Science). The institutes also review and sponsor extramu Center for Substance Abuse Treatment, and Center for ral research at universities and research organizations Behavioral Health Statistics and Quality. through competitive grant programs. Some of the inst tutes also undertake disease control programs and public The PHS is not the only important agency in public and professional education in their area(e.g, National health. The other major federal organization is the Office of Library of Medicine, National Institute for Neurological Public Health and Science(OPHS), which leads the Healthy People initiative through its Office of Disease Prevention and
312 SECTION 4 Public Health Office of the Chief of Stafl caT Office of the Office of Diversity Management Director Office of the Assoc ate D recor Office of Minority Health and Office of the Assoc ate direc ce of Public Health Office for State, Tribal, Lccal and redness and ResponsecG Ofice of Surveillance, Epidemiology and Laboratory Services in u oy and emyrmnicanta hsa abes. Office of Infectious Diseases National Institute for National Center for Heath National Center on Birth Statistics Center for Global Heal Safety and Health NDiseas e preer otion hon ractce Program Office and Zoonotic Infectious Iseases cVL Technology Program Office Environmental Health/A ral Hepatitis, STD and TB Toxic Substances and Public Health Surveillance Professional Develoment Approved 7/27/20 Figure 25-2 u.S. Centers for Disease Control and Prevention( CDC)organizational chart. STD, Sexually transmitted disease; TB, tuberculos (frOmhttp://www.cdc.gov/maso/pdf/cdc-offcial.pdf) Promotion(see Chapter 26)and oversees the U.S. Surgeon 2. The policy development role requires that"every public General's office President's Council on bioethics U.S. Public health agency exercise its responsibility to serve the Health Service Commissioned Corps, and Office of Minority lbic interest in the development of comprehensive Health(Fig. 25-3) public health policies by promoting the use of the scien tific knowledge base in decision-making about public developing public health policy, B. Responsibilities of States nd by taking a strategic approach, developed on the basis f a positive appreciation for the democratic political In the United States the fundamental responsibility for the process health of the public lies with the states. This authority derives 3. The assurance role requires that"public health agencies from the 10th Amendment to the Constitution: The powers assure their constituents that services necessary to achieve not delegated to the United States by the Constitution, nor agreed upon goals are provided, either by encouraging prohibited by it to the States, are reserved to the States action by other entities(private or public sector), by respectively, or to the people quiring such action through regulation, or by providing In 1988 the IOM stated that"the mission of public health services directly. 3 to ensure conditions in which people can be healthy",and that the three core functions of public health agencies at all within these three core functions, 10 essential public levels of government are assessment, policy development, health services have been defined(Box 25-1). Administrators and assurance and others involved in public health have been struggling to define how the mission and three core functions can best be 1. The assessment role requires that" every public health fulfilled. As indicated by the assurance role, public health agency regularly and systematically collect, assemble, agencies enjoy considerable latitude. Although not required analyze, and make available information on the health of to provide all (or even most of)the services themselves, the the community, including statistics on health status, com- agencies are expected to use all their authority and resources munity health needs, and epidemiologic and other studies to ensure that needed policies, laws, regulations, and services of health problems eXIs
CH ER 25 Public Health System: Structure and Function Office of Public Health and Science(OPHS) USPHS Office of disease Administrators Corps Office Division 兰 Medical HIVAIDS Office of Office of Office Physical Fitness Figure 25-3 u.S. Offce of Public Health and Science(OPHS)organizational structure. HIV/AIDS, Human immunodeficiency virus and acquired Each state has a health department to perform or overse the performance of the 10 essential public health services Governmental Public Health The state health department oversees the implementation of Infrastructure: The I0 Essential Publi the public health code, a compilation of the state laws and Ith Services regarding public health and safe ules passed by a legislature. In contrast, regulations are technical rules added later by an empowered body with spe- 1. Monitor health status to identify community health cific expertise, such as a state or local board of health. In some states, responsibility for mental health services falls to 2. Diagnose and investigate health problems and health the health department, whereas other states have separate departments of mental health services. Every state also licenses medical and other health-related practitioners and Public Development medical care institutions, such as hospitals, nursing homes 3. Inform, educate, and empower people about health issues. nd home care programs. 4. Mobilize community partnerships to identify and solve health problems ans t C. Responsibilities of Municipalities ommunity health efforts and counties Assurance 6. Enforce laws and regulations that protect health and ensure Although the states hold the fundamental police power to protect health, they delegate much of this authority to cha 7. Link people to needed personal health services, and assure tered municipalities, such as cities, or other incorporated the provision of health care when otherwise unavailable. areas. These municipalities accept public health responsibili- 8. Ensure a competent public health and personal health care ties in return for a considerable degree of independence from the state in running their affairs, including property 9. Evaluate effectiveness, accessibility, and quality of personal ownership and tax levies. In this respect, they differ from and population-based health services counties(called parishes"in Louisiana). Counties Serving All Functions bureaucratic subdivisions of the state created to administer 10. Research for new insights, and innovate solutions to ilities(with rying degrees of local cor health problems uch as health services, as well as courts of law, educational programs, highway construction and maintenance, and Modified from Public Health Functions Steering Committee, 1994; police and fire protection American Public health Association. Association of Schools of the Local public health departments usually are administra Public Health Association of State and Territorial Health Officials, tive divisions of municipalities or counties, and their policies Environmental Council of the States, National Association of are established by a city or county board of health. These County and City Health Officials, National Association of State boards of health have the right to establish public health laws Alcohol and Drug Abuse Directors, National Association of State and regulations, provided that they are at least as strict as ental Health Program Directors, Public Health Foundation, US similar laws and regulations in the state public health code, Public Health Service. and provided that they are reasonable. Anything that is too
SECTION 4 Public Health strict risks being overturned by the courts on the grounds that it is unreasonable Box 25-2 Ten Greatest Public Health The courts have generally upheld local and state health Ach ents of 20th Ct encu department laws and regulations when they pertain to the control of communicable diseases. The courts have also upheld laws relating to safe water and subsurface sewage 2. Motor vehicle safe disposal, immunization, regulation of restaurants and food 3. Improvements in workplace safety stores, quarantine or treatment of persons with an infectious 4. Control of infectious diseases disease, investigation and control of acute disease outbreak 5. Decline in deaths from coronary heart disease and stroke 6. Safer and healthier foods and abatement of complaints relating to the spread of infec 7. Healthier mothers and infan tious disease(e. g, rabid animals Outside the area of communicable diseases 9. Fluoridation of drinking water legislatures nor courts have been as supportive 0. Recognition of tobacco use as a health hazard and regulations. Laws yclists and b o wear helmets sometimes have not been enacted or have FromUsCentersforDiseaseControlandPreventionhttp:/ been repealed, despite abundant evidence of their benefits If an individual risk factor for disease can be she a negative public impact, however, such as passive inhalation, legislatures usually support controls, pro the direct fiscal impact is minimal(see Chapter 26) system to be in"disarray, and the "basic six"functions have reappeare important functions of local health D. Responsibilities of Local Public departments ublic health agencies perennially struggle to garn Health Department enough popular and government support to promote health 1.“ Basic six”to0 Essential services and prevent disease effectively. Nonetheless, Americans have benefited greatly from the many achievements of public The best-known description of the responsibilities of local health efforts, in conjunction with laboratory research, clini- health departments emerged in 1940, when six primary areas cal medicine, and sanitary and safety engineering. Box 25 of responsibilities were defined as follows provides the CDC's list of the 10 leading public health achieve- 1. Collecting vital statistics ments of the 20th century. For the 21st century, the following 2. Controlling communicable diseases domains have been defined as "winnable battles, " the public 3. Protecting maternal and child health health priorities areas with proven effective interventions 4. Monitoring and protecting environmental health 5. Promoting health education a Global immunization against polio, measles, rubella, 6. Maintaining public health laboratorie meningitis, pneumococci, and rotaviruses These functions of local health departments, later known as Health care-associated infections the"basic six continue to influence the direction of local a Human immunodeficiency virus(HIV) infection itic filari departments, despite the many changes in the nature of blic health problems over time. However these six func a Mother-to-child transmission of Hiv and congenital tions are not fully adequate to deal with some more recent yphilis public health problems, such as environmental pollution n Motor vehicle injuries rossing state lines and the increased incidence of chronic Nutrition, physical activity, and obesity degenerative diseases. For a time,public health leader Teen pregnancy debated the proper functions and responsibilities of Tobacco use(especially smoking) health departments at the local and state level. To help health departments in evaluating their work, the CDC has 2. Health Director's Dutie created a National Public Health Performance Standards The programs run by a local health department vary by Public health departments cannot carry out their respo region or county and depend on available funding, state and sibilities without funding by legislative bodies. From the local priorities, and availability of other providers and insti- 1950s to the early 1970s, the danger of infectious diseases tutions. Some local health departments manage a complex seemed to be waning. Consequently, and despite occasional set of services, including mental health and primary care for warnings that communicable diseases were still major underserved populations, which involves managing tea threats, legislatures saw infectious diseases as a diminishing and human resources, analyzing organizational perfor threat, and funding for public health agencies decreased mance,and overseeing budgeting analysis. Health directors The emergence of legionnaires disease and Lyme disease in must adhere to applicable federal and state rules when they the mid-1970s was soon followed by toxic shock syndrome, hire, evaluate, and fire employees. Directors must also ensure AIDS, multidrug-resistant tuberculosis, and the resurgence that employees are supervised appropriately, including of other infectious diseases . By the time society began to regular performance evaluation, pay equity to comparable awaken to the problem of the emerging public health dis- jobs, and compliance with grievance process(see Chapter eases,the IOM and others considered the public health 28). Particular challenges arise if different staff members
CH AP T ER 25 Public Health System: Structure and Function with similar responsibilities are paid from different payrolls ll. BROADER DEFINITIONS OF PUBLIC e.g.,county, city, state, grant funders). In addition to running these services, the health director HEALTH POLICY serves as the chief health policy advisor to local elected offi cials for public health, community assessment, access to The current view of public health policy in the United medical care, and financing of health and medical care. The States is narrower than that in the world public health director also serves as the chief public health educator for ene. According to the Ottawa Charter for Health Pro- politicians and the public, to ensure ongoing funding, grass- motion, which guides much of the international work in roots support, and collaboration with community groups this area, health promotion requires that all policies be and health care institutions reviewed for their health impact and adjusted to strengthen rather than hinder, the effort to achieve good health, as 3. Environmental protection follow Among the functions of local health det,d inspecting septic Health promotion goes beyond health care. It puts health on the akers in all sectors and at all levels, di systems are among the most important them to be aware of the health consequences of their decisions and to accept their responsibilities for health RESTAURANT INSPECTION Health promotion policy combines diverse but complemen tary approaches including legislation, fiscal measures, taxation Most contamination occurs through just a few breakdowns: and organizational change. It is coordinated action that leads to unwashed hands, improper cooking, improper storage, health, income and social policies that foster greater equity Joint unclean utensils, and contact between food and nonfood ributes ing safer and healthier goods and surfaces. Local food regulations vary by county and district services, healthier public services, and cleaner, more enjoyable However, most local health departments inspect restaurants environments episodically, assign points for violations of code depending Health promotion policy requi on the gravity of violations, and provide grades to restau in non-health sectors rants as a summary assessment (A-F or colors ). Health and ways of removing them. The aim must be to make the nspectors particularly look at five critical items(sometimes healthier choice the easier choice for policy makers as well. called"red items") that pose an immediate health hazard, The switch from public health policy to healthy public poli a Improper hand hygiene ies is subtle but important. The point of this app Food is not kept at temperatures high enough or low that all public policies must be evaluated and, if necessary enough to inhibit bacterial growth modified for their impact on public health a Incorrect sanitizer concentrations of dishwasher or clean ing solutions a Cross-contamination between raw and cooked products l. INTERSECTORAL APPROACH TO ■ Plumbing hazards PUBLIC HEALTH If an establishment is found to pose an immediate hazare or if it has a history of persistent failure to comply with So far, this chapter has emphasized the role of specific recommendations, health inspectors can shut it down. In . S. public health agencies at the federal, state, and local those cases, the establishment usually cannot reopen until vever, as the Ottawa Charter emphasizes, many the health inspector has returned to confirm that the viola- duties with public health implications are carried out tions have been corrected. Some departments also perform by government agencies that are not usually considered compliance inspections for restaurants with borderline"health agencies. Departments of agriculture are respon scores to document improvement sible for monitoring the safety of milk, meat, and other agri cultural products and controlling zoonoses(animal diseases WASTEWATER DISPOSAL that can be spread to humans). The U.S. Department of Agriculture (USDA)also administers the program for Many rural areas have no central sewage system. Every new Women, Infants, and Children(WIC), which supports low building needs a septic tank and a drain field, the size of income women and children up to age 5 who are at nutri- which varies with the drainage pattern and depth of the tional risk by providing foods to supplement diets and topsoil. Otherwise, raw sewage may contaminate an aquifer financial support. This program has a substantial impact on and pollute everybodys drinking water. Given the amount food choices, childhood obesity, and oral health. Depart- of money involved in developing land and the potential for ments of parks and recreation must monitor the safety of damage, the health director and environmental staff need to water and sewage disposal in their facilities. Highway depart- coordinate closely with local and county officials in planning ments are responsible for the safe design and maintenance and zoning and the granting of building permits. of roads and highways. Education departments are charged In an age of vanishing rain forests, receding polar ice caps, with overseeing health education and providing a safe and and progressive climate change, environmental protection healthful environment in which to learn. Government has taken on new meaning, Such issues as conservation and departments that promote a healthy economy are crucial biopreservation intersect meaningfully with public health, as well, because when an economy falters, the people's health addressed in Chapter 30
SECTION 4 Public Health Because health is the result of the entire fabric of training programs. Chapter 15 provides more details on environment and life of a population, a true public health training for physicians pproach must be intersectoral; that is, it must consider the health impact of policies in every sector of a society and government, not just in the health sector or medical ca V. ASSESSMENT AND FUTURE TRENDS sector. Moreover, a true public health approach must also consider the health impact of policies on the planet more In its 2002 report the IOM assessed the state of the U.S broadly, being mindful of the health of entire ecosystems public health system as follows see Chapter 30). The perspectives of the Ottawa Charter and intersectoral policy analysis are foundations for the broader, The governmental public health infrastructure has more community action-oriented approach to public health from political neglect and from the pressure of political agendas currently emphasized in Europe and elsewhere. This and public opinion that frequently override em approach is sometimes called"the new public health" Under the glare of a national crisis [attacks of 9/11/2001], policy the"healthy communities"approach. The healthy com makers and the public became aware of vulnerable and outdated munities movement is also active in the United States"(see health information systems and technologies, an insufficient and inadequately trained public health workforce, antiquated The United States is fortunate to be home to many vol laboratory capacity, a lack of real-time surveillance and epide untary health agencies and other nongovernmental organi zations(NGOs)whose focus is to prevent or control diseases tions gical systems, ineffective and fragmented communica- networks, incomplete domestic preparedness and and promote health. Some focus on certain diseases(e. g emergency response capabilities, and communities without American Heart Association [AHA), American Lung Asso- to essential public health services. These problems leave ciation [ALA)), and others confront a related group of dis the nations health vulnerable--and not only to exotic germs ases(e.g, American Cancer Society [ACS]). Sometime nd bioterrorism ps join forces; cigarette smoking is a major risk factor for heart disease, lung disease, and cancer, so the AHA, Ala In response to this report and other voices, DHHS has nd aCs have worked together to curtail smoking. These grant programs to organizations raise money for research, public education, upgrade and integrate information systems, and developed patient care, such as Planned Parenthood, which strives for health departments. However, much remains to be done so agencies strive to fill the gaps left by the public health sysle a comprehensive approach to reproductive health. These that the public health system can maintain the gains made n the 20th century and prepare for the challenges of the 21st At the same time, these agencies form important stakehold entury ers that can substantially influence the success or failure of public health initiatives MMARY ⅣV. ORGANIZATIONS IN Public health services in the United States are provided by the federal, state, and local levels of government, although PREVENTIVE MEDICINE the primary authority for health lies with the states. The federal government becomes involved in health mostly by Many organizations in the United States emphasize public regulating international and interstate commerce and btt ealth and preventive medicine; the largest is the American power to tax for the general welfare. Local governmen Public Health Association(APHA), with annual meetings become involved in health as the states delegate authority for typically bringing together 12,000 to 15,000 people. APHa health to them. The fundamental health responsibilities have has gradually changed from an organization focusing or expanded greatly from the"basic six "minimum functions, science and the practice of public health to one emphasizing when infectious diseases were the greatest concern, to a large though and diverse set of functions that now include the control of some sections still emphasize science or practice. It publishes chronic diseases, injuries, and environmental toxins(preven the American Journal of Public Health and welcomes as tive medicine). In the intersectoral approach to public health, members anyone who is trained in, working in, or just inter all public policies are scrutinized for their impact on health estedinpublichealth(www.apha.or Other organizations that promote the health of commu- Ref nities include American College of Preventive Medicine erences (ACPM) and Association of Teachers of Preventive Medi- 1. Institute of Medicine(IOM): The future of the publics health cine(ATPM). With ATPM, ACPM copublishes the american in the 21st century, Washington, DC, 2002, National Journal of preventive Medicine and cosponsors a yearly con- AcademiesPress.http://books.napedu/catalog/10548.htmlon ference on prevention science and policy. ATPM members include university faculty, preventive medicine residency 2.USDepartmentofHealthandHumanServices:2012.http:// program directors and faculty, and others interested in 3. IOM: The future of public health, Washington, DC, 1988, ching health promotion and disease prevention in schools of medicine, public health, and other health professions. The 4. Centers for Disease Control and Prevention(CDC): Injury goal of ATPM is to improve e research, training, and practice bicycle helmets. MMWR 44: 1-17, in preventive medicine and to support the funding for 1995
CH ER 25 Public Health System: Structure and Function Jekel JF: Health departments in the U.S., 1920-1988: statements 16. Ashton ]: The new public health, Buckingham, UK, 1988, Open mission with special reference to the role of C -E A. winslow. University Press Yale Biol Med 64: 467-479, 1991 17. Duhl LJ, Lee PR, editors: Focus on healthy communities, Public 6. Hanlon J]: Is there a future for local health departments? Health Health rep1l5:114-289,2000. Serv rep88:898901,1973 Terris M: The epidemiologic revolution, national health insur nce,and the role of health departments. Am/ Public Health Select Readings 66:1155-1164,1976. 8.NationalPublicHealthStandards2012.http://www.cdc.gow/ ystem in the United States. In Wallace RB, editor: Maxcy 9. Jekel JF: Communicable disease control in the 1970s: hot war, Rosenau-Last: Public health and preventive medicine, ed 15, Ne d war, or peaceful coexistence? Am Public Health 62: 1578- York, 2008, McGraw-Hill Medical. Duhl LJ, Lee PR, editors: Focus on healthy communities, Pubi 10. Garrett L: Betrayal of trust: the collapse of global public health, Health Rep 115(2 and 3): 114-289, 2000 [special issues] New York, 2000, Hyperion Fallon FL, Zgodinski E: Essentials of public health management, 11.Cdc:Winnablebattleshttp://www.cdc.gov/ Boston, 2008, Jones Bartlett. Garrett L: Betrayal of trust: the collapse of global public health, New 12. Buttery CMG: The local health department. 2012. Chapter 1 York, 2000, Hyperion Accessedathttp://www.commed.vcuedu/local/2012/cHi local_health_director_12. pdf. 13.Whathealthinspectorslookforhttp://www.foodservice warehouse. com/education/health-safety/what-inspectors ovick LE, Mays GP: Public Health Administration, Gaithersburg, Md, 2001, Aspen 14. New York City Department of Health and Mental Hygie Letter grading Websites 15. Ottawa Charter for Health Promotion: Report of an Interna- tional Conference on Health Promotion, sponsored by the World Health Organization, Health and Welfare Canada, and the www.acpm.orgameRicanCollegeofPreventiveMedicinel www.atpm.org[associationofteAchersofpReventiveMedicine
