5.1. Public health

Public health focuses on promoting health at the population level through investigating and intervening in the environmental, social and behavioural factors in health and disease (Jacobson & Parmet, 2019). It deals with prevention and health promotion rather than treatment of disease and recovery of health, which is the domain of medical care. It attempts to influence social, economic, political and medical factors that affect health and illness (Jacobson & Permet, 2019; Shi & Singh, 2019). The three core functions of public health defined by the IOM are assessment, policy development and assurance (Salinsky, 2010). The 10 essential services that correspond to these core functions are listed in Box5.3. (Salinsky, 2010).

Box5.3

5.1.1. Organization of public health services

Public health is promoted mostly through public agencies, primarily at the state level, but some private agencies also play a role. At the federal level, public health services are headed by the United States Public Health Service (USPHS), a division of the HHS. The USPHS is comprised of eight agencies listed in Box5.4 (US Department of Health and Human Services, nd).

Box5.4

The AHRQ, HRSA, NIH and Substance Abuse and Mental Health Services Administration (SAMHSA) are the chief federal agencies for funding health care programmes and research. The AHRQ funds research on quality, costs and administrative issues in health care, while the NIH funds biomedical and clinical research primarily. Although the AHRQ and NIH are considered to be part of the USPHS, in reality the bulk of their research is on medical, not public health, issues. The HRSA funds programmes and research on the indigent, uninsured, rural residents, other special need populations, and the health care workforce. Another major function of the HRSA is to collect data on the health care workforce. The HRSA’s functions have more of a public health purpose in that they help assure adequate health care resources, yet as with the AHRQ and NIH most of these resources go into providing medical care. The SAMHSA funds programmes and conducts its own studies into the prevention and treatment of alcoholism, substance abuse and mental illness. The SAMHSA’s funding is delivered mostly through block grants and contracts with state health agencies.

The Agency for Toxic Substances and Disease Registry (ATSDR) monitors and protects against exposure to hazardous wastes, and works to minimize ill-health effects of hazardous waste emergencies and pollution from hazardous wastes. The CDC is responsible for the surveillance, identification and prevention of disease and injury in the United States, and provides assistance to other countries and international health organizations regarding these health concerns. Major components of the CDC include identification and prevention of infectious and chronic diseases (including HIV/AIDS and sexually transmitted diseases (STDs)), injury prevention, immunization, health promotion, environmental health, occupational safety and health, emergency and terrorism preparedness, and cancer screening. The CDC also funds and collects data for public health research in these areas.

The FDA oversees the Federal Food, Drug, and Cosmetic Act, several related public health laws, and food safety (along with the US Department of Agriculture). Areas supervised include new medical devices, experimental drugs, biological products, tobacco products, cosmetics, food additives, food labels, domestic and imported foods (except for meat and poultry) and food given to livestock. The US Department of Agriculture is responsible for meat and poultry safety (more information on the FDA, CDC and other HHS agencies can be found in sections 2.2 and 2.7).

The Indian Health Service (IHS) provides public health services to American Indians and Native Alaskans, primarily on Indian reservations and in Eskimo villages. More than half of all American Indians, however, do not live on reservations and are not eligible for these services. When resources are available, services include preventive, ambulatory and hospital care, community health, alcohol programmes and rehabilitative services.

In addition to these agencies, the USPHS also has four offices that coordinate and serve USPHS agencies, programmes and clients (US Department of Health and Human Services, nd). These are the Office of the Assistant Secretary for Health (OASH); the Office of the Secretary; Program Support Center (PSC); and the Office of the Assistant Secretary for Preparedness and Response (ASPR). The OASH leads and coordinates public health and science across the HHS. The Office of the Secretary oversees programmes and one quarter of the HHS budget. The PSC provides products and services to HHS clients and other federal agencies. The ASPR provides advisory resources on bioterrorism and other public health emergencies.

At the state level, all 50 states have state health agencies that carry out public health efforts. States legally have the greatest authority for carrying out public health. While influencing state and local practices, federal laws tend to give states the leeway to determine the scope and amount of services and to establish the vehicles for providing those services.

As a result, the organizational structure of state public health agencies and the services provided by those agencies vary significantly across the states, making general descriptions difficult (ASTHO, 2012). Public health functions can be the sole domain of one state agency or part of the function of an agency that is also in charge of social services, licensing and regulation of acute and long-term care, the administration of Medicaid or insurance regulation (Salinsky, 2010). Public health functions, such as the regulation and inspection of health care facilities, the licensure of health professionals and the control of disease vectors such as mosquitoes, can also be spread over more than one state agency or can be performed in partnership with private organizations. States also differ with regard to whether the relationship between state and local public health agencies is decentralized, centralized or a hybrid of the two. In more decentralized models, local public health agencies have greater administrative control.

Many public health functions are delegated to local public health agencies (usually called “health departments”) within that jurisdiction. Jurisdictions can be at the county, city, town or township level (Salinsky, 2010). In 2008 most local health departments (60%) were at the county level, 18% covered a city, town or township, 11% were joint city–county jurisdictions and 9% were multicounty (Salinsky, 2010).

5.1.2. Public health services

Communicable disease control

Control of communicable diseases is carried out by local and state health agencies in collaboration with the CDC (Salinsky, 2010). Local and state agencies conduct surveillance of communicable diseases, and collect and analyse the data. Both private and state laboratories analyse specimens. Examples of communicable diseases of public health concern for becoming epidemics or pandemics are meningitis, West Nile virus, hantavirus, influenza strains such as H1N1, the plague and, most recently, the coronavirus. The CDC is notified of unusual or alarming outbreaks or trends. Outbreaks of communicable diseases, once reported to the CDC, are further investigated by this agency. Control and prevention measures are then implemented by the CDC in collaboration with the affected area(s). For communicable diseases that are endemic, such as STDs and tuberculosis, local public health departments offer both screening and treatment (see subsection Health promotion and disease prevention services below) (Salinsky, 2010).

Environmental hazards

Environmental (non-infectious, non-occupational) hazards are prevented, detected and corrected by federal, state and local public health agencies, or in some states by an environmental agency. At the federal level, the National Center for Environmental Health (NCEH) plans and directs an overall programme of environmental harm reduction (NCEH, 2019). Also, the ATSDR evaluates the risk of hazardous substances in the environment, identifies people at risk of exposure to hazardous substances, and prevents or minimizes the effects on health. The types of hazard typically controlled are air pollution, contaminated food and water, chemical spills, radon gas, mosquitoes and other disease vectors (Salinsky, 2010; NCEH, 2019).

Emergency, disaster and terrorism preparedness

Efforts to prepare for emergencies, disasters and terrorism are led by the CDC and the ASPR within the HHS, which publish protocols for action for state and local government agencies (Salinsky, 2010; CDC, 2019a). However, each local public health agency is responsible for developing a customized plan based on CDC protocols, and state governments play a key role by devoting resources to local preparedness planning (Salinsky, 2010). Preparedness and response efforts include surveillance, laboratory testing, outbreak investigation, and the treatment and quarantine of the population. Plans must have a coordinated emergency medical response. In the event of an incident, state and local agencies are responsible for implementing the plan in collaboration with the CDC.

Promotion of occupational health

Promoting of occupational health is carried out by the National Institute of Occupational Safety and Health (NIOSH), a part of the CDC, and the OSHA, a part of the US Department of Labor (NIOSH, 2018; OSHA, nd). The NIOSH funds research, investigates workplace safety and provides information, education and training in occupational safety and health, while the OSHA is responsible for developing and enforcing workplace safety and health regulations. State health agencies are also involved since they may be the first to be called regarding a safety issue. The NIOSH encourages employers and employees at all worksites to report possible safety violations. When a possible occupational hazard is reported, the NIOSH’s health hazard evaluation programme investigates the claim. The NIOSH employs a research-to-practice philosophy, in which it encourages the translation of research findings, technologies and information into prevention practices and products that can be adopted in the workplace. The NIOSH also engages in prevention through its total worker health programme, which combines occupational safety with health promotion to prevent illness and injury. This combination of research, regulations, prevention and surveillance comprises the core occupational health functions of the US public health system.

Surveillance of population health and well-being

Surveillance involves the collection, processing and maintenance of data on the following population measures: vital statistics (e.g. births and deaths); demographic characteristics (age, sex, race, ethnicity, education, employment, income and residence); childhood immunizations; behavioural risk factors; incidence of cancer, trauma and occupational injuries; communicable, acute and chronic diseases; insurance coverage; and health care utilization and expenditures (CDC, 2019a). State agencies collect much of this data through provider reports, hospital discharge databases, registries and population surveys (Salinky, 2010). Federal agencies contributing to this surveillance include AHRQ, BLS, CMS, National Cancer Institute, SAMSHA and the US Census Bureau (CDC, 2019a). Private agencies that contribute data include various medical associations and the Dartmouth Institute. The data from these agencies are shared with the CDC, which additionally sponsors several surveys that collect data on ambulatory care, hospital inpatient care, home and hospice care, nursing home care, vital statistics, immunizations, nutrition and population health (CDC, 2019a). For example, the CDC’s population health survey – the National Health Interview Survey (NHIS) – collects information on illnesses, injuries, activity limitation, chronic diseases, health insurance coverage and utilization of health care. US data are also compared internationally using OECD data. The CDC places much of this data, aggregated to the national level, into a publicly available (on the Internet) annual report entitled Health, United States (CDC, 2019a).

Health promotion and disease prevention services

These services are funded by federal and state governments while local health departments and CHCs provide the services. Most local public health departments provide screening and treatment for communicable diseases such as STDs and tuberculosis. Many also provide services to high-risk women and children (low income, special health care needs). Services may include perinatal home visits, well child clinics, developmental screening, and women, infants and children (WIC) nutrition counselling. Some other prevention services provided are: adult and childhood immunizations; screening for diabetes, cardiovascular and other chronic diseases; smoking prevention and cessation; and prevention of HIV/AIDs, unintended pregnancy, obesity, inactivity, substance abuse, injuries and violence. Supported educational activities include media campaigns, outreach to high-risk groups and general population education. Some activities are conducted in partnership with NGOs, non-health-care-related local government agencies or state health agencies. The amount of resources devoted to health promotion and disease prevention activities and the engagement of agencies vary by state and locality. Larger local health departments are more likely to provide a comprehensive set of services (Salinsky, 2010).

Public health screening programmes

There is no national public health screening programme in place in the United States, and screening programmes vary from state to state. State and local departments of health may screen for communicable diseases such as STDs and tuberculosis, newborn congenital diseases and chronic diseases such as diabetes and cardiovascular diseases. Screening programmes are also available in CHCs, doctors’ offices and retail health care settings (shopping malls, general stores, etc.). Outreach to the most vulnerable populations is always an issue, however. Many other diseases are screened in the United States (for example, breast and colon cancer) but whether these are offered to the individual patient is up to the discretion of the primary care provider and cannot be considered part of a public health effort except to the extent that there is public health education regarding the need to be screened.

Other services

Services funded or directly provided by state government include mental, correctional and child health services. Some state governments engage in the direct provision of mental and correctional health services, while most contract with private agencies to provide the services. Most states directly provide services for children with special health needs.

Licensing, regulation and planning of health care facilities and workforce

These functions are generally under the jurisdiction of state and local public health agencies. These agencies inspect and license health care facilities. State agencies license health care professionals and certify the non-professional health care workforce (see also section 4.2.7). State agencies may also measure the performance of health care providers and facilities, publish quality report cards based on those measures and engage in other activities to improve the quality of health care services. Other organizations that measure and publish quality data on providers are federal agencies such as the CMS (through its Hospital Compare and other reports) and the AHRQ (through its National Health Care Quality and Disparities Report), and numerous private agencies such as the NCQA. Some private agencies, such as the Joint Commission, monitor quality but do not publish results. Most state health departments also inspect and license food-processing facilities, solid waste removal services and other health-related facilities (see sections 2.5, 2.7 and 2.8 for more information).

5.1.3. Accessibility, adequacy and quality of public health services

For a number of years US public health services at the federal, state and local levels have been underfunded, resources at the local level are inadequate, the system is disorganized and services tend to be driven by immediate concerns and political expediency rather than a long-term vision (IOM, 2012; Jacobson & Parmet, 2018; Salinsky, 2010). The local public health workforce has declined over the last 30 years, and between just 2008 and 2010 it declined by approximately 19% (Jacobson & Parmet, 2018). Funding and resource availability have also been noted to vary substantially by locality, so that some agencies have sufficient resources while others, often the poorest communities, are significantly lacking (IOM, 2012).

Public health improvement initiatives began in the 1990s in response to the 1988 IOM recommendations and the Healthy People 2000 objective of having 90% of the population served by effective public health services by the year 2000 (Scutchfield, Mays & Lurie, 2009). In response to the Public Health Improvement Act enacted by Congress in 2000, overall funding increased for several years and the coordination, planning and delivery of services improved. These developments improved the access to and quality of public health services. But budget cuts in state funding, which began before the 2008 recession, and have deepened since, threaten the progress made to date (ASTHO, 2014; Krisberg, 2017). The ACA established a Prevention and Public Health Fund dedicated to public health and disease prevention, but it too is undergoing cuts (APHA, 2019; Jacobson & Parmet, 2018).