Amy Winterfeld 12/1/2013


There’s renewed effort to integrate the many public health programs into the overall health system.

By Amy Winterfeld

Some jobs, businesses and even entire government agencies go unnoticed until they’re not there—or until they’re shut down. Our nation’s massive public health system is a case in point.

Doctor with needle From the U.S. Centers for Disease Control and Prevention (CDC) to tiny county health departments, local, state and federal health agencies often are behind the scenes looking after the nation’s health and safety. By responding to disasters, vaccinating millions against diseases, and teaching the public how to avoid illness and injuries, public health agencies ensure the safety of everything from fresh produce to public places, and promote wellness from the workplace to the school yard.

Yet few Americans realize just how expansive their efforts are. But that changed a bit in October. When the federal government shut down, parts of the massive public health system did as well. And people noticed. Headlines reported an outbreak of salmonella in chicken that sickened more than 330 people, sending 40 percent of them to hospitals in 20 states and Puerto Rico. The CDC had to halt its influenza surveillance just as the flu season began. And 80 percent of public health staff at airport quarantine stations were furloughed at the same time Mexico reported a cholera outbreak and the World Health Organization reported an unusual measles outbreak in Turkey.

These examples serve as reminders of the many public health services, programs and policies that exist in our communities—what the CDC calls the “public health infrastructure”— and help to shine the light on current efforts to increase the efficiency of this massive infrastructure and to integrate more prevention efforts into the nation’s overall health system.

A State Role

State legislatures have been working to improve the health of their communities for years, supporting public health agencies by setting policies and providing funding in a variety of areas. In Utah, for example, legislators have taken several steps, big and small, to promote health and prevent disease. Before the federal health reform bill passed, the state had established its own health insurance marketplace to help consumers purchase affordable private coverage. And in other ways the state has sought to prevent illness by passing legislation like this year’s ban on smoking in cars when children are present, joining the five other states and Puerto Rico that have similar bans. The state’s health department is on board too, with its mission statement to “protect the public’s health by preventing avoidable illness, injury, disability and premature death; assuring access to affordable, quality health care; and promoting healthy lifestyles.”

“Any entity that helps improve preventive care is beneficial to health and society,” says Utah Representative Jim Dunnigan (R). “Prevention not only keeps people’s small health problems from becoming health catastrophes, it saves health costs.”

In Minnesota, lawmakers adopted a statewide health improvement plan in 2008 that awarded two-year grants to every county and tribal government for disease-prevention efforts. “This is aimed at keeping people from getting these chronic diseases,” says Representative Thomas Huntley (DFL), one of the law’s architects. “If they don’t smoke, and they watch what they eat and stay active, people are less likely to get heart disease or diabetes in the first place.”

Other examples of legislative efforts abound.

  • At least 26 states protect nonsmokers from secondhand smoke in indoor public places.
  •  Six states and one territory ban smoking in cars when children are present.
  •  All 50 states have laws that require specific vaccinations, such as whooping cough, measles, mumps and rubella for children entering public schools.
  •  Forty-five states and two territories protect women who breastfeed in public.
  • All states screen newborns for certain conditions.
  • Eighteen states and the District of Columbia have requirements on reporting foodborne illnesses.
  • Nineteen states inspect restaurants for food stafety.
  • At least 45 states prohibit minors from getting tattoos.
  • Thirty-eight states require parental permission for minors to get body piercings.
  • Seventeen states limit access to tanning salons by teenagers.

A Health Metamorphosis

Coordinating all the many public health services and integrating them into the entire health care system won’t be easy. It involves moving from a system that focuses primarily on treating the sick to one that encompasses a full spectrum of services to prevent illnesses and injuries, mitigate their severity, and even reverse the effects of diseases. For the states that have already made some progress at improving efficiency within public health programs, the shift will be easier, however.

For several years Kansas has promoted regional collaboration among certain public health facilities, such as laboratories that are expensive to fund locally, while retaining local delivery of services that consumers can more easily access near home, such as flu shots.

In 2008, Massachusetts lawmakers passed a bill requiring more efficient regional cooperation among local health departments. And this year, 14 states—with grants from the privately funded Center for Sharing Public Health Services—have been exploring ways to deliver public health services more efficiently across local health departments.

To improve efficiency, public health agencies are educating health care providers, hospitals and insurers in communities about the wealth of information they have to share on disease outbreaks and the prevalence of preventable chronic diseases such as heart disease and diabetes. While doctors, nurses and hospitals treat one patient at a time, public health workers promote good health for entire communities, states and the population as a whole. These different focuses complement each other.

Public health agencies are also making a stronger effort to share services they already perform—such as health laboratory facilities, immunizations, food safety inspections, and scientific expertise to prevent and fight health problems. Local health departments pool resources to pay for services such as public health laboratories for efficiency and cost savings, while retaining local control for services such as immunizations. 

The new, nonprofit Public Health Accreditation Board is also busy accrediting state public health agencies to ensure service quality, emergency readiness and public safety, just as hospitals are accredited by the Joint Commission for safety and quality, and doctors must be licensed to practice. As of August, the board had accredited 19 agencies in 11 states.

An Unhealthy Price to Pay

Despite long-term gains in public health, the challenges ahead are huge. Americans spend more per capita on health care than any other nation, yet remain less healthy than many. Americans, even those who are “highly advantaged,” according to a 2013 report from the National Academy of Sciences, “live shorter lives and experience more injuries and illnesses than people in other high-income countries.” In other words, there is a disconnect between money spent on health care and quality of health.

That’s where public health agencies come into play. Through their efforts to prevent illnesses and injuries, they hope to improve Americans’ health, all while lowering costs. It’s a big undertaking to say the least. But look how far they’ve come.

Top 5 Local Health Department Services

  • Adult immunizations
  • Surveillance of infectious diseases
  • Childhood immunizations
  • Tuberculosis screening and treatment

Restaurant inspections

Source: Centers for Disease Control and Prevention, 2013

Top 10 Public Health Achievements

  • Development of vaccinations
  • Safer workplaces
  • Safer food
  • Safer motor vehicles
  • Control of infectious diseases
  • Decline in deaths from coronary heart disease
  • Variety of family planning options
  • Recognition of tobacco as a health hazard
  • Healthier mothers and babies
  • Fluoridation of drinking water

Source: Centers for Disease Control and Prevention, 2013

Amy Winterfeld covers public health issues as a program director for NCSL

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