Answer Week One Discussion 2 (1-2 paragrahs)
Week One Discussion 2
(1-2 paragrahs)
Week One Discussion 2
Identify peer reviewed articles on public health within the last 2 years. Catalog the health problems (both conditions and risks) from that search and compare this with the listing of health problems and issues on Table 2-3 in Essentials of Public Health book page 31.
Are the types of conditions and risks you encountered in the print media similar? Were some conditions and risks either overrepresented or underrepresented in the media, in comparison with their relative importance as suggested by Table 2-3? What are the implications for the role of the media in informing and educating the public regarding public health issues?
Essentials of Public Health
THIRD EDITION
Bernard J. Turnock, MD, MPH
Clinical Professor
Division of Community Health Sciences
School of Public Health
University of Illinois at Chicago
Chicago, Illinois
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Library of Congress Cataloging-in-Publication Data
Turnock, Bernard J., author.
Essentials of public health / Bernard J. Turnock.—Third edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-284-06935-8 (pbk.)
I. Title.
[DNLM: 1. Public Health Administration—United States. 2. Public Health Practice—United States. WA 540 AA1]
RA445
362.1—dc23
2014036062
6048
Printed in the United States of America
18 17 16 15 14 10 9 8 7 6 5 4 3 2 1
Dedication
To Terry, Scott, and Linda—my dearly missed siblings.
Contents
New to This Edition
Prologue
Preface
Acknowledgments
About the Author
Chapter 1 What Is Public Health?
Learning Objectives
A Brief History of Public Health in the United States
Images and Definitions of Public Health
Public Health as a System
Unique Features of Public Health
Value of Public Health
Conclusion
References
Chapter 2 Measuring Population Health
Learning Objectives
Health in the United States
Health, Illness, and Disease
Measuring Health
Influences on Health
Analyzing Health Problems for Causative Factors
Economic Dimensions of Health Outcomes
Healthy People 2020
Conclusion
References
Chapter 3 Public Health and the Health System
Learning Objectives
Prevention and Health Services
The Health System in the United States
Changing Roles, Themes, and Paradigms in the Health System
Conclusion
References
Chapter 4 Law, Government, and Public Health
Learning Objectives
American Government and Public Health
Public Health Law
Governmental Public Health
Intergovernmental Relationships
Conclusion
References
Chapter 5 Twenty-First Century Community Public Health
Practice
Learning Objectives
Public Health Functions and Practice Before 1990
Public Health Functions and Practice After 1990
Community Health Assessment and Improvement Tools
Strategic Planning, Standards, and Accreditation
Conclusion
References
Chapter 6 Public Health Emergency Preparedness and
Response
Learning Objectives
Public Health Roles in Emergency Preparedness and Response
National Public Health Preparedness and Response Coordination
State and Local Public Health Preparedness and Response Coordination
Conclusion
References
Chapter 7 Public Health Workforce
Learning Objectives
Public Health Work and Public Health Workers
Size and Distribution of the Public Health Workforce
Composition of the Public Health Workforce
Public Health Worker Ethics and Education
Characteristics of Public Health
Occupations
Public Health Workforce Growth Prospects
Public Health Practitioner Competencies
Conclusion
References
Chapter 8 Public Health Administration
Learning Objectives
Occupational Classification
Public Health Practice Profile
Important and Essential Duties
Minimum Qualifications
Workplace Considerations
Positions, Salaries, and Career Prospects
Additional Information
Conclusion
References
Chapter 9 Environmental and Occupational Health
Learning Objectives
Occupational Classification
Public Health Practice Profile
Important and Essential Duties
Minimum Qualifications
Workplace Considerations
Positions, Salaries, and Career Prospects
Additional Information
Conclusion
References
Chapter 10 Public Health Nursing
Learning Objectives
Occupational Classification
Public Health Practice Profile
Important and Essential Duties
Minimum Qualifications
Workplace Considerations
Positions, Salaries, and Career Prospects
Additional Information
Conclusion
References
Chapter 11 Epidemiology and Disease Control
Learning Objectives
Occupational Classification
Public Health Practice Profile
Important and Essential Duties
Minimum Qualifications
Workplace Considerations
Positions, Salaries, and Career Prospects
Additional Information
Conclusion
References
Chapter 12 Public Health Education and Information
Learning Objectives
Occupational Classification
Public Health Practice Profile
Important and Essential Duties
Minimum Qualifications
Workplace Considerations
Positions, Salaries, and Career Prospects
Additional Information
Conclusion
References
Chapter 13 Additional Public Health Professional and Technical Occupations
Learning Objectives
Administrative Law Judges and Hearing Officers
Animal Control Workers
Audiologists
Behavioral, Social, Substance Abuse, and Mental Health Professionals
Dental/Oral Health Professionals
Dietitians and Nutritionists
Emergency Medical Technicians and Paramedics
Laboratory Workers
Optometrists
Pharmacists
Physician Assistants
Physicians
Veterinarians
Public Health Program Specialists
Policy Analysts
Public Health Information Specialists and Analysts
Additional Information
Conclusion
References
Chapter 14 Public Health Practice: Future Challenges
Learning Objectives
Lessons from a Century of Progress in Public Health
Limitations of 21st-Century Public Health
The Future of Public Health in 1988 and a Quarter Century Later
Conclusion: The Need for a More Effective Public Health System
References
Glossary
Index
New to This Edition
The Third Edition offers a number of new features and incorporates information on a variety of recent developments in
public health practice and the health sector. Implementation of the Affordable Care Act, strategic planning,
accreditation of public health organizations, and credentialing of public health workers are among the recent
developments covered in this revision. Extensive information on state and local public health practice derived from
national surveys conducted since 2012 is included throughout the book. Community public health practice and
emergency preparedness topics have been expanded into two separate chapters. New conceptual frameworks for the
public health system, overall health system, and public health workforce have been added. The number of
public
health occupations examined in this edition has been increased from 23 to 39. More than 60 new or revised charts and
tables are incorporated into the new edition, and a series of “outside-the-book thinking” exercises appears in each
chapter.
Prologue
Essentials of Public Health by Bernard Turnock has made important contributions to the Essential Public Health
series. It was an early text in the series and set the stage for the long list of books that followed. Professor Turnock’s
text, now in its third edition, continues to be an important part of the Essential Public Health series.
The Third Edition, like previous editions, takes advantage of Professor Turnock’s extensive experience working in
governmental public health. His in-depth knowledge of health departments and the changes that are occurring in
delivery of public health services is apparent throughout the book. He has a special interest and knowledge of careers
in public health, which is highlighted throughout the text.
The text follows the same framework and style used in the earlier editions including a large number of examples,
charts, graphs, and discussion questions. The Third Edition updates and expands on the second edition, providing a
state of the art approach to public health and public health careers.
For those who want an introduction to public health with a special focus on public health careers and the workings
of public health agencies, this is the perfect introductory text. Bernard Turnock writes with an approachable style and
a depth of knowledge. We are pleased to have the third edition of Essentials of Public Health as a continuing part of
the Essential Public Health series.
Richard Riegelman MD, MPH, PhD
Series Editor, Essential Public Health series
Preface
Blending basic public health practice concepts with the nuts and bolts of public health careers is both a unique
approach and a formidable challenge for a public health text. This book addresses that challenge by focusing on basic
concepts as well as career opportunities, topics that are often of interest for students seeking undergraduate or
graduate degrees. This approach is especially useful in courses that provide an introduction to public health, either as
a standalone survey course or as an introductory course for a concentration or major. Students are exposed to key
concepts underlying public health as a system and social enterprise, as well as to careers in the field. As a result,
students will take away an understanding of what public health is and how various occupations and professions
contribute to its mission and success.
The first six chapters cover important concepts and information on what public health is in 21st-century America.
Basic concepts underlying public health are presented in Chapter 1, including definitions, historical highlights, and
unique features of public health. This and subsequent chapters focus largely on public health in the United States,
although information on global public health and comparisons among nations appear in several chapters. Health and
illness and the various factors that influence health and quality of life are discussed in Chapter 2. This chapter also
presents data and information on health status and risk factors in the United States and introduces a method for
analyzing health problems to identify their precursors. Chapter 3 examines the overall health system and its various
intervention strategies, with special emphasis on trends and developments that are important to public health. It
highlights interfaces between public health and a rapidly changing health system and examines the implementation
status of key provisions of the Affordable Care Act. Chapter 4 examines the organization of public
health
responsibilities in the United States by reviewing their legal basis and the current structure of public health agencies
at the federal, state, and local levels. Chapters 5 and 6 focus on the community health improvement and emergency
preparedness and response roles of public health, including the opportunities afforded by increased public
expectations and a substantial influx of federal funding. Together, these six chapters serve as a primer on what public
health is and how it relates to health interests in modern America.
But public health is more than concepts and organizations. Its important work is carried out by a diverse and
committed workforce. Chapters 7 through 13 examine key aspects of the work of different public health occupations
and professionals in order to provide an understanding of the basic underpinnings of public health jobs and careers.
Despite an increasing recognition of its importance, there is little information available on the public health workforce
in terms of its size, distribution, composition, skills, and impact on health goals. Chapter 7 examines overall trends
affecting the public health workforce. Key characteristics for occupations and careers in public health practice are
defined and explained in this chapter. This framework of career characteristics becomes the lens through which the
major occupational categories and career pathways available to public health workers are examined. Chapters 8
through 13 provide basic information on 40 occupational categories and disciplines. The concluding chapter focuses
on future implications for public health workers and those considering a career in public health.
Each chapter includes a variety of figures and tables that illustrate key concepts and provide useful resources for
public health practitioners. New with this edition is a series of “outside-the-book” thinking exercises incorporated into
each chapter. These exercises allow the book to serve as a foundation for acquiring and integrating information from
other sources and personal experience into issues introduced in the book. An extensive glossary of public health
terminology is provided for the benefit of those unfamiliar with some of the commonly used terms, as well as to convey
the intended meaning for terms that may have several different connotations in practice.
The story of public health is not a simple one to tell, in part because public health is broadly involved with the
biologic, environmental, social, cultural, behavioral, and service utilization factors associated with health. Still, we all
share in the successes and failures of our collective decisions and actions, making us all accountable to each other for
the results of our efforts. My hope is that this book will present a broad view of the public health system and those
who work within it in order to deter current and future public health workers from narrowly defining public health in
terms of only what they do. At its core, the purpose of this book is to describe public health simply and clearly in terms
of what it is, what it does, and why this work is important to all of us and fulfilling to those who do it on a daily basis.
Acknowledgments
Whatever insights and wisdom might be found in this book have filtered through to me from my mentors, colleagues,
coworkers, and friends after more than three decades in the field. So many people have shaped the concepts and
insights provided in this book that it would be foolhardy for me to try to acknowledge them all here. This book blends
information and material from two other works published by Jones & Bartlett Learning—Public Health: What It Is and
How It Works, Sixth Edition (2015) and Public Health: Career Opportunities That Make a Difference (2006). Mike
Brown at Jones & Bartlett Learning was instrumental in providing guidance and suggestions for the development of
this book. Production Manager, Tracey McCrea, and Associate Editor, Lindsey Mawhiney, also at Jones & Bartlett
Learning, helped make it a reality. I am grateful for their many and varied contributions.
About the Author
Bernard J. (Barney) Turnock, MD, MPH, is currently Clinical Professor of Community Health Sciences at the
School of Public Health, University of Illinois at Chicago (UIC). Since he joined UIC School of Public Health in 1990, he
has also served as Acting Dean, Associate Dean for Public Health Practice, Director of the Division of Community
Health Sciences, as well as Director of the Center for Public Health Practice and Illinois Public Health Preparedness
Center. His major areas of interest involve performance measurement, capacity building, and workforce development
within the public health system. He is board certified in Preventive Medicine and Public Health, and he has extensive
practice experience, having served as Director of the Illinois Department of Public Health from 1985 through 1990,
Deputy Commissioner and Acting Commissioner of the Chicago Department of Health, and State Program Director for
Maternal and Child Health
and Emergency Medical Services during his distinguished career. He has played major
roles in a wide variety of public policy and public health issues in Illinois since 1978. He frequently consults on a
variety of public health and healthcare issues and has served as a member of the Illinois State Board of Health and as
President of the Illinois Public Health Association. He is also the author of two other recently published works: Public
Health: Career Choices That Make a Difference and Public Health: What It Is and How It Works. He has received two
prestigious awards from the American Public Health Association—one for Excellence in Health Planning and Practice
and another for Excellence in Health Administration. He is also a recipient of the UIC School of Public Health’s
“Golden Apple” award for excellence in teaching, and he was the developer and instructor for UIC’s first completely
online course.
CHAPTER 1
What Is Public Health?
LEARNING OBJECTIVES
Given the historical phenomena that have shaped the development of public health, formulate a working
definition and logic model for public health in the 21st century. Key aspects of this competency expectation
include being able to
• Articulate several different definitions of public health
• Describe the origins and content of public health responses over history
• Trace the development of the public health system in the United States
• Broadly characterize the contributions and value of public health
• Identify three or more distinguishing features of public health
• Describe public health as a system using a logic model with inputs, processes, outputs, and results, emphasizing the
role of core functions and essential public health services
• Identify five or more Internet web sites that provide useful information on the public health system in the United
States
The passing of one century and the early decades of the next afford a rare opportunity to look back at where public
health has been and forward to the challenges that lie ahead. Imagine a world 100 years from now where life
expectancy is 30 years more and infant mortality rates are 95% lower than they are today. The average human life
span would be more than 107 years, and less than one of every 2,000 infants would die before their first birthday.
These seem like unrealistic expectations and unlikely achievements; yet, they are no greater than the gains realized
during the 20th century in the United States. In 1900, few envisioned the century of progress in public health that lay
ahead. Yet by 1925 public health leaders such as C.E.A. Winslow were noting a nearly 50% increase in life expectancy
(from 36 years to 53 years) for residents of New York City between the years 1880 and 1920.1 Accomplishments such
as these caused Winslow to speculate what might be possible through widespread application of scientific knowledge.
With the even more spectacular achievements over the rest of the 20th century, we all should wonder what is possible
in the century that has just begun.
This year may be remembered for many things, but it is unlikely that many people will remember it as a spectacular
year for public health in the United States. No major discoveries, innovations, or triumphs set this year apart from
other years in recent memory. Yet, on closer examination, maybe there were! Like the story of the wise man who
invented the game of chess for his king and asked for payment by having the king place one grain of wheat on the first
square of the chessboard, two on the second, four on the third, eight on the fourth, and so on, the small victories of
public health over the past century have resulted in cumulative gains so vast in scope that they are difficult to
comprehend.
This year, there will be nearly 900,000 fewer cases of measles reported than in 1941, 200,000 fewer cases of
diphtheria than in 1921, more than 250,000 fewer cases of whooping cough than in 1934, and 21,000 fewer cases of
polio than in 1951.2 The early decades of the new century witnessed 50 million fewer smokers than would have been
expected, given trends in tobacco use through 1965. More than 2 million Americans were alive who otherwise would
have died from heart disease and stroke, and nearly 100,000 Americans were alive as a result of automobile seat belt
use. Protection of the U.S. blood supply had prevented more than 1.5 million hepatitis B and hepatitis C infections and
more than 50,000 human immunodeficiency virus (HIV) infections, as well as more than $5 billion in medical costs
associated with these three diseases.3 Today, average blood lead levels in children are less than one-third of what they
were a quarter century ago. This catalog of accomplishments could be expanded many times over. Figure 1-1
summarizes this progress, including two of the most widely followed measures of a population’s health status—life
expectancy and infant mortality.
These results did not occur by themselves. They came about through decisions and actions that represent the
essence of what is public health. It is the story of public health and its immense value and importance in our lives that
is the focus of this text. With this impressive litany of accomplishments, it would seem that public health’s story would
be easily told. For many reasons, however, it is not. As a result, public health remains poorly understood by its prime
beneficiary—the public—as well as many of its dedicated practitioners. Although public health’s results, as measured
in terms of improved health status, diseases prevented, scarce resources saved, and improved quality of life, are more
apparent today than ever before, society seldom links the activities of public health with its results. This suggests that
the public health community must more effectively communicate what public health is and what it does, so that its
results can be readily traced to their source.
This chapter is an introduction to public health that links basic concepts to practice. It considers three questions:
• What is public health?
• Where did it come from?
• Why is it important in the United States today?
To address these questions, this chapter begins with a sketch of the historical development of public health
activities in the United States. It then examines several definitions and characterizations of what public health is and
explores some of its unique features. Finally, it offers insight into the value of public health in biologic, economic, and
human terms.
Taken together, these topics provide a foundation for understanding what public health is and why it is important. A
conceptual framework that approaches public health from a systems perspective is introduced to identify the
dimensions of the public health system and facilitate an understanding of the various images of public health that
coexist in the United States today. We will see that, as in the story of the blind men examining the elephant, various
sectors of our society have mistaken separate components of public health for the entire system.
FIGURE 1-1 Percentage Improvement in Selected Measures of Life Expectancy and Age-Adjusted, Cause-
Specific Mortality for the Time Periods 1900–2000 and 1950–2000, United States
Data from Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States 2009. Hyattsville, MD: NCHS;
2009 and Rust G, Satcher D, Fryer GE, Levine RS, Blumenthal DS. Triangulating on success: innovation, public health, medical care, and cause-
specific US mortality over a half century (1950–2000). Am J Public Health. 2010; 100: S95–S104.
A BRIEF HISTORY OF PUBLIC HEALTH IN THE UNITED STATES
Early Influences on American Public Health
Although the complete history of public health is a fascinating saga in its own right, this section presents only selected
highlights. When ancient cultures perceived illness as the manifestation of supernatural forces, they felt that little in
the way of either personal or collective action was possible. For many centuries, disease was synonymous with
epidemic. Diseases, including horrific epidemics of infectious diseases such as the Black Death (plague), leprosy, and
cholera, were phenomena to be accepted. It was not until the so-called Age of Reason and the Enlightenment that
scholarly inquiry began to challenge the “givens” or accepted realities of the time. Eventually expansion of the science
and knowledge base would reap substantial rewards.
With the advent of industrialism and
imperialism
, the stage was set for epidemic diseases to increase their terrible
toll. As populations shifted to urban centers for the purpose of commerce and industry, public health conditions
worsened. The mixing of dense populations living in unsanitary conditions and working long hours in unsafe and
exploitative industries with wave after wave of cholera, smallpox, typhoid, tuberculosis, yellow fever, and other
diseases was a formula for disaster. Such disaster struck again and again across the globe, but most seriously and
most often at the industrialized seaport cities that provided the portal of entry for diseases transported as stowaways
alongside commercial cargo. The experience, and subsequent susceptibility, of different cultures to these diseases
partly explains how relatively small bands of Europeans were able to overcome and subjugate vast Native American
cultures. Seeing the Europeans unaffected by scourges such as smallpox served to reinforce beliefs that these light-
skinned visitors were supernatural figures, unaffected by natural forces.4
The British colonies in North America and the new American republic certainly bore their share of the burden.
American diaries of the 17th and 18th centuries chronicle one infectious disease onslaught after another. These
epidemics left their mark on families, communities, and even history. For example, the national capital had to be
moved out of Philadelphia because of a devastating yellow fever epidemic in 1793. This epidemic also prompted the
city to develop its first board of health in that same year.
The formation of local boards of distinguished citizens, the first boards of health, was one of the earliest organized
responses to epidemics. This response was revealing in that it represented an attempt to confront disease collectively.
Because science had not yet determined that specific microorganisms were the causes of epidemics, avoidance had
long been the primary tactic used. Avoidance meant evacuating the general location of the epidemic until it subsided
or isolating diseased individuals or those recently exposed to diseases on the basis of a mix of fear, tradition, and
scientific speculation. Several developments, however, were swinging the pendulum ever closer to more effective
counteractions.
The work of public health pioneers such as Edward Jenner, John Snow, and Edwin Chadwick illustrates the value of
public health, even when its methods are applied amidst scientific uncertainty. Well before Koch’s postulates
established scientific methods for linking bacteria with specific diseases and before Pasteur’s experiments helped to
establish the germ theory, both Jenner and Snow used deductive logic and common sense to do battle with smallpox
and cholera, respectively. In 1796, Jenner successfully used vaccination for a disease that ran rampant through
communities across the globe. This was the initial shot in a long and arduous campaign that, by the year 1977, had
totally eradicated smallpox from all of its human hiding places in every country in the world. The potential for its
reemergence through the actions of terrorists is a topic left to a fuller discussion of public health emergency
preparedness and response.
Snow’s accomplishments even further advanced the art and science of public health. In 1854, Snow traced an
outbreak of cholera to the well water drawn from the pump at Broad Street and helped to prevent hundreds, perhaps
thousands, of cholera cases. In that same year, he demonstrated that another large outbreak could be traced to one
particular water company that drew its water from the Thames River, downstream from London, and that another
company that drew its water upstream from London was not linked with cholera cases. In both efforts, Snow’s ability
to collect and analyze data allowed him to determine causation, which, in turn, allowed him to implement corrective
actions that prevented additional cases. All of this occurred without benefit of the knowledge that there was an odd-
shaped little bacterium that was carried in water and spread from person to person by hand-to-mouth contact!
England’s General Board of Health conducted its own investigations of these outbreaks and concluded that air,
rather than contaminated water, was the cause.5 Its approach, however, was one of collecting a vast amount of
information and accepting only that which supported its view of disease causation. Snow, on the other hand,
systematically tested his hypothesis by exploring evidence that ran contrary to his initial expectations.
Chadwick was a more official leader of what has become known as the sanitary movement of the latter half of the
19th century. In a variety of official capacities, he played a major part in structuring government’s role and
responsibilities for protecting the public’s health. Because of the growing concern over the social and sanitary
conditions in England, a National Vaccination Board was established in 1837. Shortly thereafter, Chadwick’s Report on
an Inquiry into the Sanitary Conditions of the Laboring Population of Great Britain articulated a framework for broad
public actions that served as a blueprint for the growing sanitary movement. One result was the establishment in 1848
of a General Board of Health. Interestingly, Chadwick’s interest in public health had its roots in Jeremy Bentham’s
utilitarian movement. For Chadwick, disease was viewed as causing poverty, and poverty was responsible for the great
social ills of the time, including societal disorder and high taxation to provide for the general welfare.6 Public health
efforts were necessary to reduce poverty and its wider social effects. This view recognizes a link between poverty and
health, although in an opposite direction to current thinking as to the social determinants of health and role of
fundamental causes of societal ills. Today, it is more common to consider poor health as a result of poverty, rather than
as its cause.
Chadwick was also a key participant in the partly scientific, partly political debate that took place in British
government as to whether deaths should be attributed to pathological conditions or to their underlying factors, such as
hunger and poverty. It was Chadwick’s view that pathologic, as opposed to less proximal social and behavioral, factors
should be the basis for classifying deaths.6 Chadwick’s arguments prevailed, although aspects of this debate continue
to the present day. William Farr, sometimes called the father of modern vital statistics, championed the opposing view.
OUTSIDE-THE-BOOK THINKING 1-1
Access the website of the national honorary society for public health (www.deltaomega.org) and select one of the classic
documents available there. Then describe the significance of this classic in the history of public health and its relevance
for public health practitioners today.
In the latter half of the 19th century, as sanitation and environmental engineering methods evolved, more effective
interventions became available against epidemic diseases. Further, the scientific advances of this period paved the way
for modern disease control efforts targeting specific microorganisms.
Growth of Local and State Public Health Activities in the United States
Lemuel Shattuck’s Report of the Sanitary Commission of Massachusetts in 1850 outlined existing and future public
health needs for that state and became America’s roadmap 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. Although
Shattuck’s report closely paralleled Chadwick’s efforts in Great Britain, acceptance of his recommendations did not
occur for several decades. In the latter part of the century, his farsighted and far-reaching recommendations came to
be widely implemented. With greater understanding of the value of environmental controls for water and sewage and
of the role of specific control measures for specific diseases (including quarantine, isolation, and vaccination), the
creation of local health agencies to carry out these activities supplemented—and, in some cases, supplanted—local
boards of health. These local health departments developed rapidly in the seaports and other industrial urban centers,
beginning with a health department in Baltimore in 1798, because these were the settings where the problems were
reaching unacceptable levels.
Because infectious and environmental hazards are no respecters of local jurisdictional boundaries, states began to
develop their own boards and agencies after 1870. These agencies often had very 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. In examining how law impacts governmental public health roles, we will revisit these powers and
duties because they serve as both a stimulus and a limitation for what can be done to address many contemporary
public health issues and problems.
Federal Public Health Activities in the United States
This sketch of the development of public health in the United States would be incomplete without a brief introduction
to the roles and powers of the federal government. Federal health powers, at least as enumerated in the U.S.
Constitution, are minimal. It is surprising to some to learn that the word “health” does not even appear in the
Constitution. As a result of not being a power explicitly granted to the federal government (such as defense, foreign
diplomacy, international and interstate commerce, or printing money), health was a power to be exercised by states or
reserved to the people themselves.
Two sections of the Constitution have been interpreted over time to allow for federal roles in health, in concert with
the concept of the so-called implied powers necessary to carry out explicit powers. These are the ability to tax in order
to provide for the “general welfare” (a phrase appearing in both the preamble and body of the Constitution) and the
specific power to regulate commerce, both international and interstate. These provisions allowed the federal
government to establish a beachhead in health, initially through the Marine Hospital Service (eventually to become the
Public Health Service). After the ratification of the 16th Amendment in 1916, authorizing a national income tax, the
federal government acquired the ability to raise substantial sums of money, which could then be directed toward
promoting the general welfare. The specific means to this end were a variety of grants-in-aid to state and local
governments. Beginning in the 1960s, federal grant-in-aid programs designed to fill gaps in the medical care system
nudged state and local governments further and further into the business of medical service provision. Federal grant
programs for other social, substance abuse, mental health, and community prevention services soon followed. The
expansion of federal involvement into these areas, however, was not accomplished by these means alone.
Prior to 1900, and perhaps not until the Great Depression, Americans did not believe that the federal government
should intervene in their social circumstances. Social values shifted dramatically during the Depression, a period of
such great social insecurity and need that the federal government was now permitted—indeed, expected—to intercede.
Other chapters will expand on the growth of the federal government’s influence on public health activities and its
impact on the activities of state and local governments.
OUTSIDE-THE-BOOK THINKING 1-2
Research the history of public health in your state or locality and then describe how public health strategies and
responses have changed over time. What influences were most responsible for these changes? Does this suggest that
public health roles and functions have changed over time, as well?
TABLE 1-1 Major Eras in Public Health History in the United States
Prior to 1850 Battling epidemics
1850–1949 Building state and local infrastructure
1950–1999 Filling gaps in medical care delivery
After 1999 Preparing for and responding to community health threats
To explain more easily the broad trends of public health in the United States, it is useful to delineate distinct eras in
its history. One simple scheme, outlined in Table 1-1, uses the years 1850, 1950, and 2000 as approximate dividers.
Prior to 1850, the system was characterized by recurrent epidemics of infectious diseases, with little in the way of
collective response possible. During the sanitary movement in the second half of the 19th and first half of the 20th
century, science-based control measures were organized and deployed through a public health infrastructure that was
developing in the form of local and state health departments. After 1950, gaps in the medical care system and federal
grant dollars acted together to increase public provision of a wide range of medical services. That increase set the
stage for the current reexamination of the links between medical and public health practice. Some retrenchment from
the direct service provision role has occurred since about 1990. As chronicled throughout this text, a new era for
public health that seeks to balance community-driven public health practice with preparedness and response for public
health emergencies is underway.
IMAGES AND DEFINITIONS OF PUBLIC HEALTH
The historical development of public health activities in the United States provides a case study for understanding
what public health is today. Nonetheless, the term public health evokes several different images among the general
public and those dedicated to its improvement. To only a relatively small number, the term describes a broad social
enterprise or system.
To others, the term describes the professionals and workforce whose job it is to solve certain important health
problems. At a meeting in the early 1980s to plan a community-wide education and outreach campaign in order to
reduce infant mortality, a community relations director of a large television station made some comments that
reflected this view. When asked whether his station had been involved in infant mortality reduction efforts in the past,
he responded, “Yes, but that’s not our job. If you people in public health had been doing your job properly, we wouldn’t
be called on to bail you out!” Obviously, this man viewed public health as an effort of which he was not a part.
Still another image of public health is that of a body of knowledge and techniques that can be applied to health-
related problems. Here, public health is seen as what public health does. Snow’s investigations exemplify this
perspective.
Similarly, many people perceive public health primarily as the activities ascribed to governmental public health
agencies. For the majority of the public, this latter image represents public health in the United States, resulting in the
common view that public health primarily involves the provision of medical care to indigent populations. Since 2001,
however, public health has also emerged as a front line defense against bioterrorism and other threats to personal
security and safety.
A final image of public health is that of the intended results of these endeavors. In this image, public health is
literally the health of the public, as measured in terms of health and illness in a population. The term population
health, often defined as health outcomes and their distribution in a population, is increasingly used for this image of
public health.7
This chapter will focus primarily on the first of these images, public health as a social enterprise or system. It is
important to understand what people mean when they speak of public health. As summarized in Table 1-2, the
profession, the methods, the governmental services, the ultimate outcomes, and even the broad social enterprise itself
are all commonly encountered images of what public health is today.
With varying images of what public health is, we would expect no shortage of definitions. There have been many,
but three definitions, each separated by a generation, provide especially important insights into what public health is.
These are highlighted in Table 1-3.
TABLE 1-2 Images of Public Health
• Public health: the system and social enterprise
• Public health: the profession
• Public health: the methods (knowledge and techniques)
• Public health: governmental services (especially medical care for the poor)
• Public health: the health of the public
TABLE 1-3 Selected Definitions of Public Health
• “the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized
community effort”9
• “Successive re-definings of the unacceptable”10
• “fulfilling society’s interest in assuring conditions in which people can be healthy”8
Data from Institute of Medicine, National Academy of Sciences. The Future of Public Health. Washington, DC: National Academy Press: 1988;
Winslow CEA. The untilled field of public health. Mod Med. 1920; 2:183–191, and Vickers G., What sets the goals of public health? Lancet.
1958;1:599–604.
In 1988 the prestigious Institute of Medicine (IOM) provided a useful definition in its landmark study of public
health in the United States, The Future of Public Health. The IOM report characterized public health’s mission as
“fulfilling society’s interest in assuring conditions in which people can be healthy.”8 This definition directs attention to
the many conditions that influence health and wellness, underscoring the broad scope of public health and legitimizing
its interest in social, environmental, economic, political, and medical care factors that affect health and illness. The
definition’s premise that society has an interest in the health of its members implies that improving conditions and
health status for others is acting in our own self-interest. The assertion that improving the health status of others
provides benefits to all is a core value of public health.
Another core value of public health is reflected in the IOM definition’s use of the term assuring. Assuring conditions
in which people can be healthy means vigilantly promoting and protecting everyone’s interests in health and well-
being. This value echoes the wisdom in the often-quoted African aphorism that “it takes a village to raise a child.”
Former Surgeon General David Satcher, the first African American to head this country’s most respected federal public
health agency, the Centers for Disease Control and Prevention (CDC), once described a visit to Africa in which he met
with African teenagers to learn firsthand of their personal health attitudes and behaviors. Satcher was struck by their
concerns over the rapid urbanization of the various African nations and the changes that were threatening their
culture and sense of community. These young people felt lost and abandoned; they questioned Satcher as to what
America and the world community were willing to do to help them survive these changes. As one young man put it,
“Where will we find our village?” In many respects, public health serves as everyone’s village, whether we are teens in
Africa or adults in the United States. The IOM report’s characterization of public health advocated for just such a
social enterprise and stands as a bold philosophical statement of mission and purpose.
The IOM report also sought to define the boundaries of public health by identifying three core functions of public
health: assessment, policy development, and assurance. In one sense, these functions are comparable to those
generally ascribed to the medical care system involving diagnosis and treatment. Assessment is the analogue of
diagnosis, except that the diagnosis, or problem identification, is made for a group or population of individuals.
Similarly, assurance is analogous to treatment and implies that the necessary remedies or interventions are put into
place. Finally, policy development is an intermediate role of collectively deciding which remedies or interventions are
most appropriate for the problems identified (the formulation of a treatment plan is the medical system’s analogue).
These core functions broadly describe what public health does—as opposed to what it is.
The concepts embedded in the IOM definition are also reflected in Winslow’s definition, developed nearly a century
ago. His definition describes both what public health does and how this gets done. It is a comprehensive definition that
has stood the test of time in characterizing public health as
… the science and art of preventing disease, prolonging life, and promoting health and efficiency through
organized community effort for the sanitation of the environment, the control of communicable infections,
the education of the individual in personal hygiene, the organization of medical and nursing services for the
early diagnosis and preventive treatment of disease, and for the development of the social machinery to
insure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as
to enable every citizen to realize his birthright of health and longevity.9
There is much to consider in Winslow’s definition. The phrases, “science and art,” “organized community effort,”
and “birthright of health and longevity” capture the substance and aims of public health. Winslow’s catalog of methods
illuminates the scope of the endeavor, embracing public health’s initial targeting of infectious and environmental risks,
as well as current activities related to the organization, financing, and accountability of medical care services. His
allusion to the “social machinery to insure everyone a standard of living adequate for the maintenance of health”
speaks to the relationship between social conditions and health in all societies.
There have been many other attempts to define public health, although these have received less attention than
either the Winslow or IOM definitions. Several build on the observation that, over time, public health activities reflect
the interaction of disease with two other phenomena that can be roughly characterized as science and social values:
(1) what do we know, and (2) what do we choose to do with that knowledge?
A prominent British industrialist, Geoffrey Vickers, provided an interesting addition to this mix more than a half
century ago while serving as Secretary of the Medical Research Council. In identifying the forces that set the agenda
for public health, Vickers noted, “The landmarks of political, economic, and social history are the moments when some
condition passed from the category of the given into the category of the intolerable. I believe that the history of public
health might well be written as a record of successive re-definings of the unacceptable.”10
The essence of Vickers’ formulation lies in its focus on social justice and the delicate and shifting interface between
science and social values. Through this lens, we can view a tracing of public health over history, facilitating an
understanding of why and how different societies have reacted to health risks differently at various points in time and
space. In this light, the history of public health is one of harnessing scientific knowledge to shape responses to
problems that have crossed the boundary into social unacceptability.
OUTSIDE-THE-BOOK THINKING 1-3
Which of the definitions of public health presented in this chapter best describes public health in the 21st century? Why?
Each of these definitions offers important insights into what public health is and what it does. Individually and
collectively, they describe a social enterprise and system that is both important and unique, as we will see in the
sections that follow.
FIGURE 1-2 Population Health System
Reproduced from Institute of Medicine, Committee on Public Health Strategies to Improve Health, Board on Population Health and Public Health
Practice. (June 2011). For the public’s health: Revitalizing law and policy to meet new challenges, Figure 1-1, page 17. Washington, DC: The
National Academies Press.
PUBLIC HEALTH AS A SYSTEM
So what is public health? Maybe no single answer will satisfy everyone. There are, in fact, several dimensions of public
health that must be considered. Viewing public health as a system of interconnected components, such as the
population health system illustrated in Figure 1-2, is one approach. Yet, the public health system described in this
chapter is more complex than the simple network of participants presented in this figure. The public health described
in this chapter is a broad social enterprise, more akin to a movement, that seeks to extend the benefits of current
knowledge in ways that will have the maximum impact on the health status of a population. It does so by identifying
problems that call for collective action to protect, promote, and improve health, primarily through preventive
strategies. This public health is unique in its interdisciplinary approach and methods, its emphasis on preventive
strategies, its linkage with government and political decision making, and its dynamic adaptation to new problems
placed on its agenda. Above all else, it is a collective effort to identify and address the unacceptable realities that
result in preventable and avoidable health and quality of life outcomes, and it is the composite of efforts and activities
that are carried out by people and organizations committed to these ends.
With this broad view of public health as a social enterprise, the question shifts from what public health is to what
these other images of public health represent and how they relate to each other. Logic models are widely used in
modern public health practice to illustrate how the various dimensions of a program relate to each other and achieve
their intended results. Basically, logic models indicate what occurs as a result of the preceding step using a basic “if…
then” rationale. Programs have structural elements, sometimes referred to as input or capacity, (e.g., workers,
information, relationships, facilities, funding, etc.) that are blended to carry out specific activities or processes which
then produce certain outputs that lead in turn to various effects or outcomes. The underlying logic for programs is that
inputs → processes → outputs → outcomes. Logic models are also useful in characterizing and analyzing more complex
entities, including organizations and systems.
Figure 1-3 characterizes the public health system in the form of such a logic model, demonstrating the utility of
this approach. For example, it is useful to consider inputs as resource investments. The efficiency of a program or
system reflects the ratio of outputs to inputs. The effectiveness of a program or system reflects the degree to which
intended outcomes are achieved. Equity reflects the degree to which outcomes are distributed fairly or proportionally.
Overall satisfaction with results in terms of effectiveness, efficiency and equity) contributes to whether a program or
system is valued by its stakeholders which in turn contributes to the level of resources made available. This important
feedback loop is apparent in the lower part of this logic model.
OUTSIDE-THE-BOOK THINKING 1-4
Develop a map or some other graphic representation of the national public health system. Your map can take any form
you choose. Which components or dimensions of the public health system are most important to capture in such a map?
This logic model framework integrates the mission and functions of public health in relation to the inputs,
processes, outputs, and outcomes of the system. Although descriptions for these system components are offered in
Table 1-4, it is sometimes easier to appreciate this model when a more familiar industry, such as the automobile
industry, is used as an example. The mission or purpose might be expressed as meeting the personal transportation
needs of the population. This industry carries out its mission by providing appropriate vehicles to its customers; this
characterizes its function. In this light, we can now examine the inputs, processes, outputs, and outcomes of the
system set up to carry out this function. Inputs would include steel, rubber, plastic, and so forth, as well as the
workers, know-how, technology, facilities, machinery, and support services necessary to allow the raw materials to
become cars and trucks. The key processes necessary to carry out the primary function might be characterized as
designing vehicles, making or acquiring parts, assembling parts into vehicles, moving vehicles to dealers, and selling
and servicing vehicles after purchase. No doubt this is an incomplete listing of this industry’s processes; it is
oversimplified here to make the point. In any event, these processes translate the abstract concept of getting vehicles
to people into the operational steps necessary to carry out this basic function. The outputs of these processes are
vehicles located where people can purchase them. The outcomes include satisfied customers and company profits.
FIGURE 1-3 Logic Model Representation of the Public Health System
TABLE 1-4 Dimensions of the Public Health System
Capacity (Inputs):
• The resources and relationships necessary to carry out the core functions and essential services of public health (e.g.,
human resources, information resources, fiscal and physical resources, appropriate relationships among the system
components)
Process (Practices and Outputs):
• Those collective practices or processes that are necessary and sufficient to ensure that the core functions and essential
services of public health are being carried out effectively, including the key processes that identify and address health
problems and their causative factors and the interventions intended to prevent death, disease, and disability, and to
promote quality of life
Outcomes (Results):
• Indicators of health status, risk reduction, and quality-of-life enhancement outcomes are long-term objectives that
define optimal, measurable future levels of health status; maximum acceptable levels of disease, injury, or dysfunction;
or prevalence of risk factors
Data from Centers for Disease Control and Prevention, Public Health Program Office, 1990.
Applying this same general framework to the public health system is also possible but may not be so obvious. The
mission and functions of public health are well described in the IOM report’s framework. The core functions of
assessment, policy development, and assurance are somewhat more abstract functions than making vehicles but still
can be made operational through descriptions of their key steps or processes.11,12 The inputs of the public health
system include its human, organizational, informational, fiscal, and other resources. These resources and relationships
are structured to carry out public health’s core functions through a variety of processes that are termed essential
public health practices or services. These processes produce outputs in the form of interventions (policies, programs
and services) that derive from assessing health and planning effective strategies.13 These outputs or interventions are
designed to produce the desired results, which, with public health, might well be characterized as health or quality-of-
life outcomes. The logic model representation of the public health system illustrates these relationships.
In this model, not all components are as readily understandable and measurable as others. Several of the inputs are
easily counted or measured, including human, fiscal, and organizational resources. Outputs are also generally easy to
recognize and count (e.g., prenatal care programs, number of immunizations provided, health messages on the
dangers of tobacco, laws and regulations). Health outcomes are also readily understood in terms of mortality,
morbidity, functional disability, time lost from work or school, and even more sophisticated measures, such as years of
potential life lost and quality-of-life years lost. The elements that are most difficult to understand and visualize are the
processes or essential services of the public health system. Identifying these operational aspects of the public health
system allow us to better understand public health practice, measure it, and relate it to its outputs and outcomes. A
national work group assembled by the U.S. Public Health Service in 1994 developed a consensus statement of what
public health is and does in language understandable to those both inside and outside the field of public health. Table
1-5 presents the result of that effort, a statement entitled “Public Health in America.”14 The conceptual framework
identified in the logic model representation of the public health system and the narrative representation in the “Public
Health in America” statement are useful models for understanding the public health system and how it works. Figure
1-4 demonstrates how the 10 essential public health services operationalize the three core public health functions
identified in the 1988 IOM report.
This framework attempts to bridge the gap between what public health is, what it does, and how it does what it
does (through its capacity, processes, and outcomes). It also allows us to examine the various components of the
system so that we can better appreciate how the pieces fit together.
UNIQUE FEATURES OF PUBLIC HEALTH
Several unique features are apparent in the public health system. These are spotlighted in Table 1-6 and include the
underlying social justice philosophy of public health; its inherently political nature; its ever-expanding agenda, with
new problems and issues being assigned over time; its link with government; its grounding in a broad base of
evidence-based biologic, physical, quantitative, social, and behavioral sciences; its focus on prevention as a prime
intervention strategy; and the unique bond and sense of mission that links its key stakeholders.
TABLE 1-5 Public Health in America
Vision:
Healthy People in Healthy Communities
Mission:
Promote Physical and Mental Health and Prevent Disease, Injury, and Disability
Public Health
• Prevents epidemics and the spread of disease
• Protects against environmental hazards
• Prevents injuries
• Promotes and encourages healthy behaviors
• Responds to disasters and assists communities in recovery
• Assures the quality and accessibility of health services
Essential Public Health Services
• Monitor health status to identify community health problems
• Diagnose and investigate health problems and health hazards in the community
• Inform, educate, and empower people about health issues
• Mobilize community partnerships to identify and solve health problems
• Develop policies and plans that support individual and community health efforts
• Enforce laws and regulations that protect health and ensure safety
• Link people with needed personal health services and assure the provision of health care when otherwise unavailable
• Assure a competent public health and personal health care workforce
• Evaluate effectiveness, accessibility, and quality of personal and population-based health services
• Research for new insights and innovative solutions to health problems
Reproduced from Essential Public Health Services Working Group of the Core Public Health Functions Steering Committee, U.S. Public Health
Service, 1994.
FIGURE 1-4 Public Health Core Functions and Essential Services
Reproduced from Centers for Disease Control and Prevention, National Public Health Performance Standards. Available at
http://www.health.gov/phfunctions/public.htm. Accessed June 17, 2014.
Social Justice Philosophy
It is vital to recognize the social justice orientation of public health and even more critical to understand the potential
for conflict and confrontation that it generates. Social justice is the foundation of public health. The concept first
emerged around 1848, a time that might be considered the birth of modern public health. Social justice argues that
public health is properly a public matter and that its results in terms of death, disease, health, and well-being reflect
the decisions and actions that a society makes, for good or for ill.15 Justice is an abstract concept that determines how
each member of a society is allocated his or her fair share of collective burdens and benefits. Societal benefits to be
distributed may include happiness, income, or social status. Burdens include restrictions of individual action and
taxation. Justice dictates that there is fairness in the distribution of benefits and burdens; injustices occur when
persons are denied some benefit to which they are entitled or when some burden is imposed unduly. If access to health
services, or even health itself, is considered to be a societal benefit (or if poor health is considered to be a burden), the
links between the concepts of justice and public health become clear. Market justice and social justice represent two
forms of modern justice.
TABLE 1-6 Selected Unique Features of Public Health
• Basis in social justice philosophy
• Inherently political nature
• Dynamic, ever-expanding agenda
• Link with government
• Grounding in the sciences
• Use of prevention as a prime strategy
• Uncommon culture and bond
Market justice emphasizes personal responsibility as the basis for distributing burdens and benefits. Other than
respecting the basic rights of others, individuals are responsible primarily for their own actions and are free from
collective obligations. Individual rights are highly valued, whereas collective responsibilities are minimized. In terms of
health, individuals assume primary responsibility for their own health. There is little expectation that society should
act to protect or promote the health of its members beyond addressing risks that cannot be controlled through
individual action.
Social justice argues that significant factors within the society can impede the fair distribution of benefits and
burdens.16 Examples of such impediments include social class distinctions, heredity, and discrimination on the basis of
race, ethnicity, gender, or sexual preference. Collective action, often leading to the assumption of additional burdens,
is necessary to neutralize or overcome those impediments. In the case of public health, the goal of extending the
potential benefits of the physical and behavioral sciences to all groups in the society, especially when the burden of
disease and ill health within that society is unequally distributed, is largely based on principles of social justice. It is
clear that many modern public health (and other public policy) problems disproportionately affect some groups,
usually a minority of the population, more than others. As a result, their resolution requires collective actions in which
those less affected take on greater burdens, while not commensurately benefiting from those actions. When the
necessary collective actions are not taken, even the most important public policy problems remain unsolved, despite
periodically becoming highly visible.16 This scenario explains our inadequate responses to such intractable American
problems as inadequate housing, poor public education systems, unemployment, racial discrimination, and poverty.
However, it is also true for public health problems such as tobacco-related illnesses, infant mortality, substance abuse,
mental health services, long-term care, and environmental pollution. The failure to effect comprehensive national
health reform in 1994 is an example of this phenomenon. At that time, middle-class Americans deemed the modest
price tag of health reform to be excessive, refusing to pay more out of their own pockets when they perceived that
their own access and services were not likely to improve. The bitter political conflict accompanying the enactment of
national health reform legislation in the form of the Affordable Care Act of 2010 reflected these same themes.
These and similar examples suggest that a critical challenge for public health as a social enterprise lies in
overcoming the social and ethical barriers that prevent us from doing more with the knowledge and tools already
available to us.16 Extending the frontiers of science and knowledge may not be as effective for improving public health
as shifting the collective values of our society to act on what we already know. Recent public health successes, such as
public attitudes toward smoking in both public and private locations and operating motor vehicles after alcohol
consumption, provide evidence in support of this assertion. These advances came through changes in social norms,
rather than through bigger and better science.
Inherently Political Nature
The social justice underpinnings of public health serve to stimulate political conflict. Public health is both public and
political in nature. It serves populations, which are composites of many different communities, cultures, and values.
Politics allows for issues to be considered, negotiated, and finally determined within societies. At the core of political
processes are differing values and perspectives as to both the ends to be achieved and the means for achieving those
ends. Advocating causes and agitating various segments of society to identify and address unacceptable conditions
that adversely affect health status often lead to increased expectations and demands on society, generally through
government. As a result, public health advocates appear at times as antigovernment and anti-institutional.
Governmental public health agencies seeking to serve the interests of both government and public health are
frequently caught in the middle. This creates tensions and conflict that can put these public health professionals at
odds with governmental leaders on the one hand and external public health advocates on the other.
Expanding Agenda
A third unique feature of public health is its broad and ever-increasing scope. Traditional domains of public health
interest include biology, environment, lifestyle, and health service organization. Within each of these domains are
many factors that affect health status; in recent decades, many new public policy problems have been moved onto the
public health agenda as their predisposing factors have been identified and found to fall into one or more of these
domains. A multilevel, multidimensional view of the determinants of population health, often termed a social-ecological
model of health, represented in Figure 1-5, has emerged to guide public health practice.
The assignment of new problems to the public health agenda is an ever-evolving phenomenon. For example, prior to
1900, the primary problems addressed by public health were infectious diseases and related environmental risks. After
1900, the focus expanded to include problems and needs of children and mothers to be addressed through health
education and maternal and child health services as public sentiment over the health and safety of children increased.
In the middle of the century, chronic disease prevention and medical care fell into public health’s realm as an
epidemiologic revolution began to identify causative agents for chronic diseases and links between use of health
services and health outcomes. Later, substance abuse, mental illness, teen pregnancy, long-term care, and other issues
fell to public health, as did several emerging problems, most notably the epidemics of violence and HIV infections. The
public health agenda expanded even further as a result of the recent national dialogue over health reform and how
health services will be organized and managed. Bioterrorism preparedness is an even more recent addition to this
agenda amidst heightened concerns and expectations after the events of September 11, 2001, and the anthrax attacks
the following month.
Link with Government
A fourth unique facet of public health is its link with government. Although public health is far more than the
aggregate activities of federal, state, and local health agencies, many people think only of governmental public health
agencies when they think of public health. Government does play a unique role in seeing that the key elements are in
place and that public health’s mission gets addressed. Only government can exercise the enforcement provisions of
our public policies that limit the personal and property rights of individuals and corporations in areas such as retail
food establishments, sewage and water systems, occupational health and safety, consumer product safety, infectious
disease control, and drug efficacy and safety. Government also can play the convener and facilitator role for identifying
and prioritizing health problems that might be addressed through public resources and actions. These roles derive
from the underlying principle of beneficence, in that government exists to improve the well-being of its members.
Beneficence often involves a balance between maximizing benefits and minimizing harms on the one hand and doing
no harm on the other.
FIGURE 1-5 A Social-Ecological Framework for Thinking about the Determinants of Population Health
Notes:
Adapted from Whitehead M and Dahlgren G. What can be done about inequalities in health? Lancet. 1991;338(8774):1059–63. The dashed lines
between levels of the model denote interaction effects between and among the various levels of health determinants (Worthman, CM. Epidemiology
of human development. In Hormones, Health and Behavior: A Socio-Ecological and Lifespan Perspective. Panter-Brink C and Worthman CM (eds),
47–104. Cambridge: Cambridge University Press.).
*Social conditions include, but are not limited to, economic inequality, urbanization, mobility, cultural values, attitudes, and policies related to
discrimination and intolerance on the basis of race, gender, and other differences.
†Other conditions at the national level might include major sociopolitical shifts, such as recession, war, and governmental collapse.
‡The built environment includes transportation, water and sanitation, housing, and other dimensions of urban planning.
Reproduced from The Committee on Assuring the Health of the Public in the 21st Century, Institute of Medicine. The Future of the Public’s Health
in the 21st Century. Washington, DC: National Academy Press; 2003. Reprinted with permission, copyright 2003, National Academy of Sciences.
Two general strategies are available for governmental efforts to influence public health. At the broadest level,
governments can modify public policies that influence health through social and environmental conditions, such as
policies for education, employment, housing, public safety, child welfare, pollution control, workplace safety, and
family support. In line with the IOM report’s definition of public health, these actions seek to ensure conditions in
which people can be healthy. Another strategy of government is to directly provide programs and services that are
designed to meet the health needs of the population. It is often easier to garner support for relatively small-scale
programs directed toward a specific problem (such as tuberculosis or HIV infections) than to achieve consensus
around broader health and social issues. This strategy is basically a “command-and-control” approach, in which
government attempts to increase access to and utilization of services largely through deployment of its own resources
rather than through working with others. A variation of this strategy for government is to ensure access to healthcare
services through public financing approaches (Medicare and Medicaid are prime examples) or through specialized
delivery systems (such as the Veterans Administration facilities, the Indian Health Service, and federally funded
community health centers).
Whereas the United States has largely opted for the latter of these strategies, other countries have acted to place
greater emphasis on broader social policies. Both the overall level of investment for and relative emphasis between
these strategies contribute to the widely varying results achieved in terms of health status indicators among different
nations.
Many factors dictate the approaches used by a specific government at any point in time. These factors include
history, culture, the structure of the government in question, and current social circumstances. There are also several
underlying motivations that support government intervention. For paternalistic reasons, governments may act to
control or restrict the liberties of individuals to benefit a group, whether or not that group seeks these benefits. For
utilitarian reasons, governments intervene because of the perception that the state as a whole will benefit in some
important way. For equality considerations, governments act to ensure that benefits and burdens are equally
distributed among individuals. For equity considerations, governments justify interventions in order to distribute the
benefits of society in proportion to need. These motivations reflect the views of each society as to whether health itself
or merely access to health services is to be considered a right of individuals and populations within that society. Many
societies, including the United States, act through government to ensure equal access to a broad array of preventive
and treatment services. Equity in health status for all groups within the society may not be an explicit aspiration
however, even where efforts are in place to ensure equality in access. Even more important for achieving equity in
health status are concerted efforts to improve health status in population groups with the greatest disadvantage,
mechanisms to monitor health status and contributing factors across all population groups, and participation of
disadvantaged population groups in the key political decision-making processes within the society.17 To the extent that
equity in health status among all population groups does not guide actions of a society’s government, these other
elements will be only marginally effective.
As noted previously, the link between government and public health makes for a particularly precarious situation
for governmental public health agencies. The conflicting value systems of public health and the wider community
generally translate into public health agencies having to document their failure in order to make progress. It is said
that only the squeaky wheel gets the grease; in public health, it often takes an outbreak, disaster, or other tragedy to
demonstrate public health’s value. Since 1985, increased funding for basic public health protection programs quickly
followed outbreaks related to bacteria-contaminated milk in Illinois, tainted hamburgers in Washington State, and
contaminated public water supplies in Milwaukee. Following concerns over preparedness of public health agencies to
deal with bioterrorism and other public health threats, a massive infusion of federal funding occurred.
The assumption and delegation of public health responsibilities are quite complex in the United States, with
different patterns in each of the 50 states. Over recent decades, the concept of a governmental presence in health has
emerged and gained widespread acceptance within the public health community. This concept characterizes the role of
local government, often, but not necessarily always, operating through its official health agencies, which serve as the
residual guarantors that needed services will actually be there when needed. In practice it means that, no matter how
duties are assigned locally, there is a presence that ensures that health needs are identified and considered for
collective action. How this concept is operationalized will become apparent in chapters focusing on the role that
government plays in carrying out the core functions of public health.
Grounded in Science
One of the most unique aspects of public health—and one that continues to separate public health from many other
social movements—is its grounding in science. This relationship is clear for the medical and physical sciences that
govern our understanding of the biologic aspects of humans, microorganisms, and vectors, as well as the risks present
in our physical environments. However, it is also true for the social sciences of anthropology, sociology, psychology,
and economics that affect our understanding of human culture and behaviors influencing health and illness. The
quantitative sciences of epidemiology and biostatistics remain essential tools and methods of public health practice.
Often five basic sciences of public health are identified: epidemiology, biostatistics, environmental science,
management sciences, and behavioral sciences. These constitute the core education of public health professionals.
The importance of a solid and diverse scientific base is both a strength and weakness of public health. Surely there
is no substitute for evidence-based science in the modern world. The public remains curiously attracted to scientific
advances, at least in the physical and biologic sciences, and this base is important to market and promote public
health interventions. For many years, epidemiology has been touted as the basic science of public health practice,
suggesting that public health itself is applied epidemiology. Modern public health thinking views epidemiology less as
the basic science of public health than as one of many contributors to a complex undertaking. In recent decades,
knowledge from the social sciences has greatly enriched and supplemented the physical and biologic sciences. Yet
these are areas less familiar to and perhaps less well appreciated by the public, making it difficult to garner public
support for newer, more socially and behaviorally mediated public health interventions. The old image of public health
based on the hard sciences underlying environmental sanitation and communicable disease control is being
superseded by a new image of public health approaches more grounded in what the public perceives to be “softer”
science. This transition, at least temporarily, lessens public understanding and confidence in public health and its
methods.
Focus on Prevention
If public health professionals were pressed to provide a one-word synonym for public health, the most frequent
response would probably be prevention. In general, prevention characterizes actions that are taken to reduce the
possibility that something will happen or in hopes of minimizing the damage that may occur if it does happen.
Prevention is a widely appreciated and valued concept that is best understood when its object is identified. Although
prevention is considered by many to be the purpose of public health, the specific intentions of prevention can vary
greatly. Prevention can target deaths, hospital admissions, days lost from school, consumption of human and fiscal
resources, and many other ends. There are as many targets for prevention as there are various health outcomes and
effects to be avoided.
Prevention efforts often lack a clear constituency because success results in unseen consequences. Because these
consequences are unseen, people are less likely to develop an attachment for or support the efforts preventing them.
Advocates for such causes as mental health services, care for individuals with developmental disabilities, and organ
transplants often make their presence felt. However, few state capitols have seen candlelight demonstrations by
thousands of people who did not get diphtheria. This invisible constituency for prevention is partly a result of the
interdisciplinary nature of public health. With no predominant discipline, it is even more difficult for people to
understand and appreciate the work of public health. From one perspective, the undervaluation of public health is
understandable; the majority of the beneficiaries of recent and current public health prevention efforts have not yet
been born! Despite its lack of recognition, prevention as a strategy has been remarkably successful and appears to
offer great potential for future success, as well.
Uncommon Culture
The final unique feature of public health to be discussed here appears to be both a strength and weakness. The tie that
binds public health professionals is neither a common preparation through education and training nor a common set of
work experiences and work settings. Public health is unique in that the common link is a set of intended outcomes
toward which many different sciences, arts, and methods can contribute. As a result, public health professionals
include anthropologists, sociologists, psychologists, physicians, nurses, nutritionists, lawyers, economists, political
scientists, social workers, laboratory workers, managers, sanitarians, engineers, epidemiologists, biostatisticians,
gerontologists, disability specialists, and dozens of other professions and disciplines. All are bound to common ends,
and all employ somewhat different perspectives from their diverse education, training, and work experiences.
“Whatever it takes to get the job done” is the theme, suggesting that the basic task is one of problem solving around
health issues. This aspect of public health is the foundation for strategies and methods that rely heavily on
collaborations and partnerships.
This multidisciplinary and interdisciplinary approach is unique among professions, calling into question whether
public health is really a unified profession at all. An argument can be made that public health is not a profession.
There is no minimum credential or training that distinguishes public health professionals from either other
professionals or nonprofessionals. Only a tiny proportion of those who work in organizations dedicated to improving
the health of the public possess one of the academic public health degrees (the master’s of public health degree and
several other master’s and doctoral degrees granted by schools of public health and other institutions). With the vast
majority of public health workers not formally trained in public health, it is difficult to characterize its workforce as a
profession.
OUTSIDE-THE-BOOK THINKING 1-5
Which of its unique features distinguish public health from medicine as a profession? Which distinguish it from social
work? From law?
Until only recently, public health has lacked key characteristics that distinguish professions from occupations.
Significant progress has been made such that public health now meets several of these defining criteria, including: (1)
a distinct body of knowledge, (2) an educational credential offered by schools and programs accredited by a
specialized accrediting body, (3) career paths that include autonomous practice, and (4) a separate credential,
Certified in Public Health (CPH), indicative of self-regulation based on the newly launched examination of the National
Board of Public Health Examiners.18
Nonetheless, several obstacles will continue to challenge independent professional status, including the viability of
the new credential and variability in the content of graduate training programs. The impact of complete
professionalization could be considerable in terms of recruitment into the field, autonomy of practice, ultimate
strengthening of the public health infrastructure, and impact on public health policy and outcomes.
VALUE OF PUBLIC HEALTH
How can we measure the value of public health efforts? This question is addressed both directly and indirectly
throughout this text. Later chapters will examine the dimensions of public health’s value in terms of lives saved and
diseases prevented, as well as in dollars and cents. Nonetheless, some initial information will set the stage for greater
detail later.
Public opinion polls conducted in recent years suggest that public health is already highly valued in the United
States.19 The overwhelming majority of the public rate a variety of key public health services as “very important.”
Substantially more Americans believe that “public health/protecting populations from disease” is more important than
“medicine/treating people who are sick.” Public opinion surveys such as these suggest that public health’s
contributions to health and quality of life have not gone unnoticed. Other assessments of the value of public health
support this contention.
In 1965, McKeown concluded, “health has advanced significantly only since the late 18th century and until recently
owed little to medical advances.”20 This conclusion is bolstered by more recent studies concluding that public health’s
prevention efforts are responsible for 25 years of the nearly 30-year improvement in life expectancy at birth in the
United States since 1900. This bold claim is based on evidence that only 5 years of the 30-year improvement were the
result of medical care.21 Even for these 5 years, medical treatment accounted for 3.7 years, and clinical preventive
services (such as immunizations and screening tests) accounted for 1.5 years. The remaining 25 years have resulted
largely from prevention efforts in the form of social policies, community actions, and personal decisions. Many of these
decisions and actions targeted infectious diseases affecting infants and children early in the 20th century. The
dramatic reduction in deaths due to infectious diseases between 1900 and 1950 is evident in Figure 1-6. Later in that
century, gains in life expectancy were largely achieved through reductions in chronic diseases affecting adults,
including cardiovascular disease as demonstrated in Figure 1-1. A study of life years gained from modern health
disease treatments and changes in population risk factors in England and Wales from 1981 to 2000 concluded that
79% of the increase in life years gained was attributed to reductions in major risk factors. Only 21% of the life years
gained could be attributed to medical and surgical treatments of coronary heart disease.22
The value of public health is further reflected in Table 1-7, which identifies ten great public health achievements
that occurred during the 20th century. These may appear to be distant and sterile accomplishments, but they tell also
tell the story of public health in very human terms. A poignant example dates from the 1950s, when the United States
was in the midst of a terrorizing polio epidemic. Few communities were spared during the periodic onslaughts of this
serious disease during the first half of the 20th century in America. Public fear was so great that public libraries,
community swimming pools, and other group activities were closed during the summers when the disease was most
feared. Biomedical research had discovered a possible weapon against epidemic polio in the form of the Salk vaccine,
however, which was developed in 1954 and licensed for use one year later. A massive and unprecedented campaign to
immunize the public was quickly undertaken, setting the stage for a triumph of public health. The real triumph came in
a way that might not have been expected, however, because soon into the campaign, isolated reports of vaccine-
induced polio were identified in Chicago and California. Within two days of the initial case reports, action by
governmental public health organizations at all levels resulted in the determination that these cases could be traced to
one particular manufacturer. This conclusion was reached only a few hours before the same vaccine was to be
provided to hundreds of thousands of California children. The result was prevention of a disaster and rescue of the
credibility of an immunization campaign that has virtually cut this disease off at its knees. The campaign proceeded on
schedule and, five decades later, wild poliovirus has been eradicated from the western hemisphere.
FIGURE 1-6 Crude Death Rate (per 100,000) for Infectious Diseases United States, 1900–1996
Reproduced from Centers of Disease Control and Prevention. Public health achievments, United States, 1900-1999: control of infectious diseases.
MMWR. 1999; 48: 621-629.
TABLE 1-7 Ten Great Public Health Achievements—United States, 1900–1999
• Vaccination
• Motor-vehicle safety
• Safer workplaces
• Control of infectious diseases
• Decline in deaths from coronary heart disease and stroke
• Safer and healthier foods
• Healthier mothers and babies
• Family planning
• Fluoridation of drinking water
• Recognition of tobacco use as a health hazard
Data from Centers for Disease Control and Prevention. Ten great public health achievements—United States, 1900–1999. MMWR. 1999; 48(12):
241–243.
Similar examples have occurred throughout history. The battle against diphtheria is a case in point. A major cause
of death in 1900, diphtheria infections are virtually unheard of today. This achievement cannot be traced solely to
advances in bacteriology and the antitoxins and immunizations that were deployed against this disease. Neither was
this disease defeated by brilliant political and programmatic initiatives led by public health experts. It was the
confluence of scientific advances and public perception of the disease itself that resulted in diphtheria’s demise as a
threat to entire populations.23 These forces shaped public health policies and the effectiveness of intervention
strategies. This is a story of science and social values as the major forces shaping public health.
OUTSIDE-THE-BOOK THINKING 1-6
Search for and become familiar with the web sites of the American Public Health Association (APHA), Association of State
and Territorial Health Officials (ASTHO), National Association of County and City Health Officials (NACCHO, Public
Health Foundation (PHF), U.S. Environmental Protection Agency (EPA), U.S. Department of Homeland Security (DHS),
U.S. Department of Health and Human Services (DHHS) and its various Public Health Services Agencies, such as the
Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), Health Resources and Services
Administration (HRSA), National Institutes of Health (HIH), and Agency for Healthcare Research and Quality (AHRQ).
Each site offers useful insights into the central question for this chapter, “What Is Public Health?”
CONCLUSION
Public health evokes different images for different people, and, even to the same people, it can mean different things
in different contexts. The intent of this chapter has been to describe some of the common perceptions of public health
in the United States. Is it a complex, dynamic, social enterprise, akin to a movement? Or is it best characterized as a
goal of the improved health outcomes and health status that can be achieved by the work of all of us, individually and
collectively? Or is public health some collection of activities that move us ever closer toward our aspirations? Or is it
the profession that includes all of those dedicated to its cause? Or is public health merely what we see coming out of
our official governmental health agencies—a strange mix of safety-net medical services for the poor and a variety of
often-invisible community prevention services?
Although it is tempting to consider expunging the term public health from our vocabularies because of the baggage
associated with these various images, this would do little to address the obstacles to accomplishing our central task,
because public health encompasses all of these images and perhaps more!
Based on principles of social justice, inherently political in its processes, addressing a constantly expanding agenda
of problems, inextricably linked with government, grounded in science, emphasizing preventive strategies, and with a
workforce bound by common aspirations, public health is unique in many ways. Its value, however, transcends its
uniqueness. Public health efforts have been major contributors to recent improvements in health status and can
contribute even more in a new century with new challenges.
By carefully examining the various dimensions of the public health system in terms of its inputs, practices, outputs,
and outcomes, we can gain insight into what it does, how it works, and how it can be improved. Better results do not
come from setting new goals; they come from understanding and improving the processes that will then produce
better outputs, in turn leading to better outcomes. Understanding the public health system as a necessary step
towards its improvement is a theme that recurs throughout this text.
REFERENCES
1. Winslow CEA. Public health at the crossroads. Am J Public Health. 1926; 16: 1075–1085.
2. Hinman A. Eradication of vaccine-preventable diseases. Ann Rev Public Health. 1999; 20: 211–229.
3. U.S. Public Health Service. For a Healthy Nation: Returns on Investment in Public Health. Washington, DC: PHS; 1994.
4. McNeil WH. Plagues and Peoples. New York: Doubleday; 1977.
5. Paneth N, Vinten-Johansen P, Brody H. A rivalry of foulness: official and unofficial investigations of the London cholera epidemic of 1854. Am J
Public Health. 1998; 88: 1545–1553.
6. Hamlin C. Could you starve to death in England in 1839? The Chadwick-Farr controversy and the loss of the “social” in public health. Am J
Public Health. 1995; 85: 856–866.
7. Kindig DA. Understanding population health terminology. Milbank Q. 2007; 85: 139–161.
8. Institute of Medicine, National Academy of Sciences. The Future of Public Health. Washington, DC: National Academy Press; 1988.
9. Winslow CEA. The untilled field of public health. Mod Med. 1920; 2: 183–191.
10. Vickers G. What sets the goals of public health? Lancet. 1958; 1: 599–604.
11. Baker EL, Melton RJ, Stange PV, et al. Health reform and the health of the public. JAMA. 1994; 272: 1276–1282.
12. Harrell JA, Baker EL. The essential services of public health. Leadership Public Health. 1994; 3: 27–30.
13. Handler A, Issel LM, Turnock BJ. A conceptual framework to measure performance of the public health system. Am J Public Health. 2001; 91:
1235–1239.
14. Public Health Functions Steering Committee. Public Health in America. Washington, DC: U.S. Public Health Service; 1995.
15. Krieger N, Brin AE. A vision of social justice as the foundation of public health: commemorating 150 years of the spirit of 1848. Am J Public
Health. 1998; 88: 1603–1606.
16. Beauchamp DE. Public health as social justice. Inquiry. 1976; 13: 3–14.
17. Susser M. Health as a human right: an epidemiologist’s perspective on public health. Am J Public Health. 1993; 83: 418–426.
18. Evashwick CJ, Begun JW, Finnegan JR. Public health as a distinct profession: has it arrived? J Public Health Management Practice. 2013; 19(5):
412–419.
19. Harris Polls. Public Opinion about Public Health, United States. 1999.
20. McKeown T. Medicine in Modern Society. London, England: Allen & Unwin; 1965.
21. Bunker JP, Frazier HS, Mosteller F. Improving health: measuring effects of medical care. Milbank Q. 1994; 72: 225–258.
22. Unal B, Critchley JA, Fidan D, Capewell S. Life-years gained from modern cardiological treatments and population risk factor changes in
England and Wales, 1981–2000. Am J Public Health. 2005; 95: 103–108.
23. Hammonds EM. Childhood’s Deadly Scourge: The Campaign to Control Diphtheria in New York City, 1880–1930. Baltimore, MD: Johns Hopkins
University Press; 1999.
CHAPTER 2
Measuring Population Health
LEARNING OBJECTIVES
Given an ecological perspective of the varied influences on the health status of populations, incorporate
appropriate measures of health and illness (including risk factors) into a population or community health
needs assessment activity. Key aspects of this competency expectation include being able to
• Articulate a definition of health consistent with that of the World Health Organization
• Identify four or more categories of factors that influence health
• For each of these categories, specify three or more specific factors that influence health
• Identify several categories of commonly used measures of health status
• For each of these categories, identify three or more commonly used measures
• Describe major trends in health status for the United States over the past 100 years
• Access and utilize comprehensive and current national data on health status and factors influencing health in the
United States
• Utilize information on factors that influence health and measures of health to develop community health priorities and
effective interventions for improving community health status
The 21st century began much as its predecessor did, with immense opportunities to advance the health of the public
through actions that ensure conditions favorable for health and quality of life. All systems direct their efforts toward
certain outcomes; they track progress by ensuring that these outcomes are clearly defined and measurable. In public
health, this calls for clear definitions and measures of health and quality of life in populations. That task is the focus of
this chapter. Key questions to be addressed are:
• What is health?
• What factors influence health and illness?
• How can health status and quality of life be measured?
• What do current measures tell us about the health status and quality of life of Americans in the early decades of
the 21st century?
• How can this information be used to assess population and community health status and develop effective public
health interventions and public policy?
The relevance of these questions resides in their focus on factors that cause or influence particular health
outcomes. Efforts to identify and measure key aspects of health and factors influencing health have relied largely on
traditional approaches over the past century, although there are signs that this pattern may be changing. The key
questions identified above will be addressed slightly out of order, for reasons that should become apparent as this
chapter unfolds.
HEALTH IN THE UNITED STATES
Many important indicators of health status in the United States have improved considerably over the past century,
although there is evidence that health status could be even better than it is. At the turn of the 20th century, nearly 2%
of the U.S. population died each year. The crude mortality rate in 1900 was about 1,700 deaths per 100,000
population. Life expectancy at birth was 47 years. Additional life expectancy at age 65 was another 12 years. Medicine
and health care were largely proprietary in 1900 and of questionable benefit to health. More extensive information on
the health status of the population at that time would be useful, but very little exists.
Indicators of health status improved in the United States throughout the 20th century.1 Between the years 1900 and
2000, the crude mortality rate was cut in half to 872 per 100,000. By the year 2000, life expectancy at birth was nearly
77 years and life expectancy at age 65 was another 18 years.
The leading causes of death also changed dramatically over the 20th century, as demonstrated in Figure 2-1
depicting causes of death in 1900 and 2000. In 1900, the 10 leading causes of death were influenza and pneumonia,
tuberculosis, diarrhea and related diseases, heart disease, stroke, chronic nephritis, accidents, cancer, perinatal
conditions, and diphtheria. By the year 2000, tuberculosis, gastroenteritis, and diphtheria dropped off the list of the
top 10 killers, and deaths from influenza and pneumonia fell from first to seventh position on the list. Diseases of aging
and other chronic conditions superseded these infectious disease processes as changes in the age structure of the
population, especially the increase in persons over age 65, resulted in higher overall crude rates for heart disease and
cancer and the appearance of diabetes, Alzheimer’s disease, chronic kidney conditions, and septicemia on the modern
list of the top 10 killers.
Changes in crude death rates substantially understate the gains in life expectancy realized for all age groups over
the 20th century. On an age-adjusted basis, improvements were even more impressive. Age-adjusted mortality rates
fell about 75% between 1900 and 2000, with infant and child mortality rates 95% lower, adolescent and young adult
mortality rates 80% lower, rates for 25–64 year-old adults lower by 60%, and rates for adults older than age 65 falling
35%.
These gains were not solely the result of better prevention and control of infectious diseases and advances in
antibiotics and vaccinations in the first half of the century. During the second half of the 20th century, overall age-
adjusted mortality rates fell about 50%, while infant mortality rates declined more than 75%. During that period,
mortality rates among children and young adults (ages 1–24 years) and adults 45–64 years were reduced by more than
one-half. Mortality rates among adults 25–44 years fell more than 40%, and rates for elderly persons (age 65 and
older) fell about one-third. Figure 2-2 demonstrates that age-adjusted mortality rates continued to fall faster than
overall crude mortality rates through the first decade of the 21st century.
Gains for adult age groups in recent decades have outstripped those for younger age groups, a trend that began
about 1960 as progress accelerated toward reduction of mortality from injuries and certain major chronic diseases
that largely affected adults. Over the second half of the 20th century, dramatic reductions in the death rates for heart
disease, stroke, unintentional injuries, influenza and pneumonia, and infant mortality have been joined by more recent
reductions in rates for human immunodeficiency virus (HIV) infections, liver diseases, and suicide. On the other hand,
death rates have increased for diabetes, Alzheimer’s disease, and chronic lung and kidney conditions, signaling the
new morbidities associated with longer life spans. Homicide rates have improved somewhat over the past decade but
still reflect a substantial increase since 1950.1
Despite this progress, considerable disparities persist for many of the major causes of death. Differences among
races are notable, but there are also significant differences by gender for the various causes of death. These
differences are often dramatic and run from top to bottom through the chain of causation. Disparities are found not
only in indicators of poor health outcomes, such as mortality, but also in the levels of risk factors in the population
groups most severely affected. A sobering example of these disparities is reflected in the 12-year difference in life
expectancy between white females and black males.
OUTSIDE-THE-BOOK THINKING 2-1
Examine each of these Web sites. Which ones are most useful for the major topics examined in this chapter? Why?
• Healthfinder (www.healthfinder.gov), a Department of Health and Human Services (DHHS)-sponsored gateway site
that provides links to more than 550 Web sites (including more than 200 federal sites and 350 state, local, not-for-
profit, university, and other consumer health sources), nearly 500 selected online documents, frequently asked
questions on health issues, and databases and Web search engines by topic and agency
• Fedstats (fedstats.sites.usa.gov/), a gateway to a variety of federal agency data and information, including health
statistics
• National Center for Health Statistics (NCHS) (www.cdc.gov/nchs/index.htm), an invaluable resource for data and
information, especially “Health, United States,” which can be downloaded from this site
• Centers for Disease Control and Prevention (CDC) Mortality and Morbidity Weekly Report (www.cdc.gov/mmwr/)
and MMWR morbidity and mortality data by time and place (www.cdc.gov/mmwr/distrnds.html)
• U.S. Census data (www.census.gov), the best general denominator data anywhere
FIGURE 2-1 The 10 Leading Causes of Death as a Percentage of All Deaths in the United States, 1990 and 2000
Reproduced from the Office of Disease Prevention and Health Promotion. Healthy People 2010: Understanding and Improving Health. Rockville,
MD:ODPHP; 2000 and National Center for Health Statistics. Health, United States, 2002. Hyattsville, MD: NCHS; 2002.
FIGURE 2-2 Crude and Age-Adjusted Mortality Rates, United States, 1980–2011
Reproduced from Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System.
There is also evidence that disability levels are declining in the general population over time. Disability levels
among individuals aged 55–70 years who were offspring of the famous Framingham Heart Study cohort were
substantially lower, in comparison with their parents’ experience at the same age.2 In addition, fewer offspring had
chronic diseases or perceived their health as fair or poor. Self-reported health status and activity limitations because of
chronic conditions changed little during the 1990s, and injuries with lost workdays steadily declined during the 1990s.
In sum, U.S. health indicators tell two very different tales. By many measures, the American population has never
been healthier. By others, much more needs to be done for specific racial, ethnic, and gender groups. The gains in
health status over the past century have not been shared equally by all subgroups of the population. In fact, relative
differences have been increasing. This widening gap in health status creates both a challenge and a dilemma for future
health improvement efforts. The greatest gains can be made through closing these gaps and equalizing health status
within the population. Yet the burden of greater risk and poorer health status resides in a relatively small part of the
total population, calling for efforts that target those minorities with increased resources. An alternative approach is to
continue current strategies and resource deployment levels in order to sustain steady overall improvement among all
groups in the population. This strategy, however, is likely to continue or worsen existing gaps. In the early years of the
new century, the major health challenge facing the United States appears to be less related to the need to improve
population-wide health outcomes than the need to eliminate or reduce disparities. This challenges the nation’s
commitment to its principles of equality and social justice as addressing inequities in measures of health and quality of
life requires a greater understanding of health and the measures used to describe it than afforded by death rates and
life expectancies.
HEALTH, ILLNESS, AND DISEASE
Relationships among health outcomes and the factors that influence them are complex, often confounded by different
understandings of the concepts in question and how they are measured. Health is difficult to define and more difficult
yet to measure. For much of history, the notion of health has been negative. This was due in part to the continuous
onslaught of epidemic diseases. With disease a frequent visitor, health became the disease-free state. One was healthy
by exclusion.
As knowledge of disease increased and methods of prevention and control improved, health has come to be
considered from a more positive perspective. The World Health Organization (WHO) seized this opportunity in its 1946
constitution, defining health as not merely the absence of disease but a state of complete physical, mental, and social
well-being.3 This definition of health emphasizes that there are different, complexly related forms of wellness and
illness, and suggests that a wide range of factors can influence the health of individuals and groups. It also suggests
that health is not an absolute concept.
Although health and well-being may be synonyms, health and disease are not necessarily opposites. Most people
view health and illness as existing along a continuum and as opposite and mutually exclusive states. However, this
simplistic, one-dimensional model of health and illness does not comport very well with the real world. A person can
have a condition or injury and still be healthy and feel well. There are many examples, but certainly Olympic
wheelchair racers would fit into this category. It is also possible for someone without a specific disease or injury to feel
ill or not well. If health and illness are not mutually exclusive, then they exist in separate dimensions, with wellness
and illness in one dimension and the presence or absence of disease or injury in another.
These distinctions are important because disease is a relatively objective, pathologic phenomenon, whereas
wellness and illness represent subjective experiences. This allows for several different states to exist: wellness without
disease or injury, wellness with disease or injury, illness with disease or injury, and illness without physical disease or
injury. This multidimensional view of health states is consistent with the WHO delineation of physical, mental, and
social dimensions of health or well-being. Health or wellness is more than the absence of disease alone. Furthermore,
one can be physically but not mentally and socially well.
With health measurable in several different dimensions, the question arises as to whether there is some maximum
or optimal end point of health or well-being or whether health is something that can always be improved through
changes in its physical, mental, and social facets. This suggests that the goal should be a minimal acceptable level of
health, rather than a state of complete and absolute health. Due in part to these considerations, WHO revised its
definition in 1978, calling for a level of health that permits people to lead socially and economically productive lives.4
This shifts the focus of health from an end in itself to a resource for everyday life, linking physical to personal and
social capacities. It also suggests that it will be easier to identify measures of illness than of health.
Disease and injury are often viewed as phenomena that may lead to significant loss or disability in social
functioning, making one unable to carry out one’s main personal or social functions in life, such as parenting,
schooling, or employment. In this perspective, health is equivalent to the absence of disability; individuals able to carry
out their basic functions in life are healthy. This characterization of health as the absence of significant functional
disabilities is perhaps the most common one for this highly sought state. Still, this definition is a negative one in that it
defines health as the absence of disability.
The concept of well-being advanced in the WHO definition goes beyond the physical aspects of health that are the
usual focus of measurements and comparisons. Including the mental and social aspects of well-being or health
legitimizes the examination of factors that affect mental and social health. Together, these themes underscore the need
to consider carefully what is being measured in order to understand what these measures tell us about health, illness,
and disease states in a population and the factors that influence these outcomes.
MEASURING HEALTH
The plethora of information on health outcomes suggests that measuring the health status of populations is a simple
task. However, although often interesting and sometimes even dramatic, the commonly used measures of health status
fail to paint a complete picture of health. Many of the reasons are obvious. The commonly used measures actually
reflect disease and mortality, rather than health itself. The long-standing misperception that health is the absence of
disease is reinforced by the relative ease of measuring disease states, in comparison with states of health. Actually, the
most commonly used indicators focus on a state that is neither health nor disease—namely, death.
Despite the many problems with using mortality as a proxy for health, mortality data are generally available and
widely used to describe the health status of populations. This is ironic because such data only indirectly describe the
health status of living populations. Unfortunately, data on morbidity (illnesses, injuries, and functional limitations of
the population) are neither as available nor as readily understood as are mortality data. This situation is improving,
however, as new forms and sources of information on health conditions become more readily available. Sources for
information on morbidities and disabilities now include medical records from hospitals, managed care organizations,
and other providers, as well as information derived from surveys, businesses, schools, and other sources. Assessments
of the health status of populations are increasingly utilizing measures from these sources. An excellent compilation of
data and information on both health status and health services, Health United States, is published annually by the
National Center for Health Statistics.1 Much of the data used in this chapter is derived from this source.
Mortality-Based Measures
Although mortality-based indicators of health status are both widely used and useful, there are some important
differences in their use and interpretation. The most commonly used are crude mortality, age-specific and age-adjusted
mortality, life expectancy, and years of potential life lost (YPLL). Although all are based on the same events, each
provides somewhat different information as to the health status of a population.
Crude mortality rates count deaths within the entire population and are not sensitive to differences in the age
distribution of different populations. The mortality comparisons presented in Figure 2-2 comparing crude and age-
adjusted death rates illustrate the limitations of using crude death rates to assess the mortality experience of the U.S.
population. On the basis of these data, we might conclude that mortality rates in the United States had declined about
10% since 1980. However, because there has been an increasing proportion of population in the higher age categories
over recent decades, these are not truly comparable populations. The 10% reduction actually understates the
differences in mortality experience over this 30-year period after changes in the age structure of the population are
controlled. The 10% reduction then becomes a 30% reduction! Because differences in the age characteristics of the
two populations are a primary concern, we look for methods to correct or adjust for the age factor. Age-specific and
age-adjusted rates do just that. The second half of the 20th century witnessed decreases of 50% or more for age-
adjusted mortality rates for stroke, heart disease, infant deaths, tuberculosis, influenza and pneumonia, syphilis,
unintentional injuries, HIV infections, and gastric, uterine and cervical cancers.1 Improvements in age-adjusted
mortality rates for the leading causes of death are continuing in the early years of the new century.1
Age-specific mortality rates relate the number of deaths to the number of persons in a specific age group. The
infant mortality rate is probably the best-known example, describing the number of deaths of live-born infants
occurring in the first year of life per 1,000 live births. Public health studies often use age-adjusted mortality rates to
compensate for different mixes of age groups within a population (e.g., a high proportion of children or elderly). Age-
adjusted rates are calculated by applying age-specific rates to a standard population (we now use the 2000 U.S.
population). This adjustment permits more meaningful comparisons of mortality experience between populations with
different age distribution patterns. Differences between crude and age-adjusted mortality rates can be substantial.
Life expectancy, also based on the mortality experience of a population, is a computation of the number of years
between any given age (e.g., birth or age 65) and the average age of death for that population. Figure 2-3 presents
recent data and trends for life expectancy at birth in the United States; Figure 2-4 provides international comparisons
for life expectancy. Together with infant mortality rates, life expectancies are commonly used in comparisons of health
status among nations. These two mortality-based indicators are often considered to be general indicators of the overall
health status of a population. Infant mortality and life expectancy measures for the United States are lackluster in
comparison with those of other developed nations. The figure presenting international comparisons of life expectancy
at birth by gender suggests that the United States is far from being the healthiest nation in the world.
FIGURE 2-3 Life Expectancy at Birth by Race and Gender, United States, 1980–2010
Reproduced from CDC/NCHS, Health, United States, 2013, Figure 1. Data from the National Vital Statistics System.
FIGURE 2-4 Life Expectancy at Birth, by Sex, United States and Selected Countries and Territories, 2011 (or
Nearest Year)
Reproduced from OECD (2013), Health at a Glance 2013: OECD Indicators, OECD Publishing. Available at http://dx.doi.org/10.1787/health_glance-
2013-en. [OECD: International Organization for Economic Cooperation and Development].
YPLL is a mortality-based indicator that places greater weight on deaths that occur at younger ages. Years of life
lost before some arbitrary age (often age 65 or 75) are computed and used to measure the relative impact on society of
different causes of death. If age 65 is used as the threshold for calculating YPLL, an infant death would contribute 65
YPLL, and a homicide at age 25 would contribute 40 YPLL. A death due to stroke at age 70 would contribute no years
of life lost before age 65, and so on. Until relatively recently, age 65 was widely used as the threshold age. With life
expectancies now exceeding 75 years at birth, YPLL calculations using age 75 as the threshold have become more
common. Data on YPLL before age 75 is presented in Table 2-1, illustrating the usefulness of this approach in
providing a somewhat different perspective as to which problems are most important in terms of their magnitude and
impact. The use of YPLL ranks cancer, HIV infections, and various forms of injury-related deaths higher than does the
use of crude numbers or rates. Conversely, the use of crude rates ranks heart disease, stroke, pneumonia, diabetes,
and chronic lung and liver diseases higher than does the use of YPLL. Four of the top 10 causes of death, as
determined by the number of deaths, do not appear in the list of the top 10 causes of YPLL. Each of these various
mortality indicators can be examined for various racial and ethnic subpopulations to identify disparities among these
groups.
Morbidity, Disability, and Quality Measures
Mortality indicators can also be combined with other health indicators that describe quality considerations to provide
a measure of the span of healthy life. These indicators can be an especially meaningful measure of health status in a
population because they also consider morbidity and disability from conditions that impact on functioning but do not
cause death (e.g., cerebral palsy, schizophrenia, arthritis). A commonly used measure of aggregate disease burden is
the disability-adjusted life-year or DALY. Other variants on this theme are span-of-healthy-life indicators (called years
of healthy life) that combine mortality data with self-reported health status and activity limitation data acquired
through the National Health Interview Survey. Depending on the healthy life expectancy measure, Americans average
about 10 years of poor health, 15 years of activity limitation, and 30 years of living with a chronic disease. Women
have better health status than men, and whites do better than blacks on virtually all of these measures. For healthy life
expectancies at age 65, a similar picture appears. The implication is that extending healthy life expectancy can be
achieved through several pathways. One would be to extend life expectancy without increasing the measures of poor
health, activity limitation, and chronic disease burden. Another would be to reduce the measures of poor health,
activity limitation, and chronic disease burden within a constant life expectancy. The optimal approach would
accomplish both by extending life expectancy and reducing the burden of poor health, activity limitation, and chronic
disease.
TABLE 2-1 Age-Adjusted Years of Potential Life Lost (YPLL) before Age 75 by Cause of Death and Ranks for
YPLL and Number of Deaths, United States, 2000
Note: Years lost before age 75 per 100,000 population younger than 75 years of age.
Reproduced from National Center for Health Statistics. Health, United States, 2002. Hyattsville, MD: NCHS; 2002.
Although less frequently encountered, indicators of morbidity and disability are also quite useful in measuring
health status. Both prevalence (the number or rate of cases at a specific point or period in time) and incidence (the
number or rate of new cases occurring during a specific period) are widely used measures of morbidity.
Increasingly, information on self-reported health status and on days lost from work or school because of acute or
chronic conditions is collected through surveys of the general population. The National Center for Health Statistics
also conducts ongoing surveys of health providers on complaints and conditions requiring medical care in outpatient
settings. These surveys provide direct information on self-reported health status and illuminate some of the factors,
such as household income levels, that are associated with health status.
INFLUENCES ON HEALTH
In 1996, public health surveillance in the United States took a historic step. At that time, the Centers for Disease
Control and Prevention (CDC) added prevalence of cigarette smoking to the list of diseases and conditions to be
reported by states to CDC.5 This action marked the first time that a health behavior, rather than an illness or disease,
was considered nationally reportable—a groundbreaking step for surveillance efforts. How the focus of public health
efforts shifted from conventional disease outcomes to reporting on underlying causes amenable to public health
intervention is an important story.
Risk Factors
The recognition of tobacco use as a major health hazard was no simple achievement, partly because many factors
directly or indirectly influence the level of a health outcome in a given population. For example, greater per capita
tobacco use in a population is associated with higher rates of heart disease and lung cancer, and lower rates of early
prenatal care are associated with higher infant mortality rates. Because these factors are part of the chain of causation
for health outcomes, tracking their levels provides an early indication as to the direction in which the health outcome
is likely to change. These factors increase the likelihood or risk of particular health outcomes occurring and can be
characterized broadly as risk factors.
The types and number of risk factors are as varied as the influences themselves. Depending on how these factors
are lumped or split, traditional categories include biologic factors (from genetic endowment to aging), environmental
factors (from food, air, and water to communicable diseases), lifestyle factors (from diet to injury avoidance and sexual
behaviors), psychosocial factors (from poverty to stress, personality, and cultural factors), and use of and access to
health-related services. Refinements of this framework are reflected in Figure 2-5, which differentiates several
outcomes of interest, including disease, functional capacity, prosperity, and well-being that can be influenced by
various risk factors. These various components are often interrelated (e.g., stress, a social environmental factor, may
stimulate individual responses, such as tobacco or illicit drug use, which, in turn, influence the likelihood of disease,
functional capacity, and well-being). In addition, variations in one outcome, such as disease, may influence changes in
others, such as well-being, depending on the mix of other factors present. This complex set of interactions, consistent
with the social-ecological model, draws attention to fundamental factors or causes that can result in many diseases,
rather than focusing on specific factors that contribute little to population-wide health status.
Although many factors are causally related to health outcomes, some are more direct and proximal causes than
others. Specific risk factors have been clearly linked to specific adverse health states through epidemiologic studies.
For example, numerous studies have linked unintentional injuries with a variety of risk factors, including the
accessibility to firearms and the use of alcohol, tobacco, and seat belts. Tobacco, hypertension, over-nutrition, and
diabetes are well-known risk factors for heart disease. As documented in Table 2-2, epidemiologic research and
studies over the past 50 years have linked numerous behavioral risk factors to many common diseases and conditions.6
Ongoing behavioral risk factor surveys (often through telephone interviews) are conducted by governmental public
health agencies to track trends in the prevalence of many important risk behaviors within the population. These
surveys document that the health-related behaviors of tens of millions of Americans place them at risk for developing
chronic disease and injuries.
FIGURE 2-5 Determinants of Health
Reproduced from Evans RG, Stoddard GL. Producing health, consuming health. Soc Sci Med. 1990;31:1359, with permission from Elsevier.
TABLE 2-2 Selected Behavioral Risk Factors Related to Leading Causes of Deaths in the United States, 2000
Data for causes and percent deaths from National Center for Health Statistics. Health United States 2002. Hyattsville, MD: NCHS; 2002. Risk
factors related to causes from Brownson RC, Remington PL, Davis JR, et al. Chronic Disease Epidemiology and Control. 2nd ed. Washington, DC;
American Public Health Association; 1998 and U.S. Public Health Service. The Surgeon General’s Report on Nutrition and Health. Washington,
DC: PHS; 1988.
Despite the recent emphasis on behavioral factors, risk factors in the physical environment remain important
influences on health. Air pollution, for example, is directly related to a wide range of diseases, including lung cancer,
pulmonary emphysema, chronic bronchitis, and bronchial asthma. National standards exist for many of the most
important air pollutants and are tracked to determine the extent of these risks in the general population. The
proportion of the U.S. population residing in counties that have exceeded national standards for these pollutants
suggests that air pollution risks, like behavioral risks, affect tens of millions of Americans.7 The physical environment
influences health through several pathways, including facilitating risk-taking behaviors, influencing social
relationships, and even exposing residents to visual cues that can arouse fear, anxiety, and depression.
Behavioral and environmental risk factors are clearly germane to public health interest and efforts. Focusing on
these factors provides a different perspective of the enemies of personal and public health than that conveyed by
disease-specific incidence or mortality data. Such a focus also promotes more rational policy development and
interventions. Unfortunately, determining which underlying factors are most important is more difficult than it appears
because of differences in the outcomes under study and measures used. For example, a study using 1980 data found
tobacco, hypertension, and over-nutrition responsible for about three-fourths of deaths before age 65 and injury risks,
alcohol, tobacco, and gaps in primary prevention accounting for about three-fourths of all YPLL before age 65.8
Further complicating these analyses is the finding that individual risk factors may result in several different health
outcomes. For example, alcohol use is linked with motor vehicle injuries, other injuries, cancer, and cirrhosis; tobacco
use can result in heart disease, stroke, ulcers, fire and burn injuries, and low birth weight, as well as cancer.6,8
Despite problems with their measurement, the identification of antecedent causes is important for public health
policy and interventions. Table 2-3 compares deaths in the year 2000 by their listed causes of death and their actual
causes (major risk factors).9 The two lists provide contrasting views as to the major health problems and needs of the
U.S. population.
Coroners and medical examiners report immediate and underlying causes of death through death certificates which
have two parts, one for entering the immediate and underlying conditions that caused the death and a second for
identifying conditions or injuries that contributed to death but did not cause death. For example, a death attributed to
cardiovascular disease might list cardiac tamponade as the immediate cause, due to or as a consequence of a ruptured
myocardial infarction, which itself was due to or a consequence of coronary arteriosclerosis. For this death,
hypertensive cardiovascular disease might be listed as a significant condition contributing to, but not causing, the
immediate and underlying causes. So where do smoking, obesity, diet, and physical inactivity get identified as the real
causes of such deaths? Perhaps the Chadwick-Farr debate of the mid-19th century continues today in terms of whether
deaths in the year 2000 should be attributed to tobacco use, just as many of those in England in 1839 might have been
attributed to starvation.
TABLE 2-3 Listed and Actual Causes of Death, United States, 2000
Data from Mokdad AM, Marks JS, Stoup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004; 291: 1238–1245.
OUTSIDE-THE-BOOK THINKING 2-2
Visit the Internet web site of several national print media and use the search features to identify articles on public health
for a recent month. Catalog the health problems (both conditions and risks) from that search and compare this with the
listing of health problems and issues on Table 2-3. Are the types of conditions and risks you encountered in the print
media similar? Were some conditions and risks either overrepresented or underrepresented in the media, in comparison
with their relative importance as suggested by Table 2-3? What are the implications for the role of the media in informing
and educating the public regarding public health issues?
Social and Cultural Influences
Understanding the health effects of biologic, behavioral, and environmental risk factors is straightforward in
comparison with understanding the effects of social, economic, and cultural factors on the health of populations. This
is due in part to a lack of agreement as to what is being measured. Socioeconomic status and poverty are two factors
that generally reflect position in society. There is considerable evidence that social position is an overarching
fundamental determinant of health status, even though the indicators used to measure social standing are imprecise,
at best.
Social standing affects lifestyle, environment, and the utilization of services; it remains an important predictor of
good and poor health in our society. Social class differences in mortality have long been recognized around the world.
In 1842, Chadwick reported that the average ages at death for occupationally stratified groups in England were as
follows: “gentlemen and persons engaged in the professions, 45 years; tradesmen and their families, 26 years;
mechanics, servants and laborers, and their families, 16 years.”10 Life expectancies and other health indicators have
improved considerably in England and elsewhere since 1842, but differences in mortality rates among the various
social classes persist to the present day.
OUTSIDE-THE-BOOK THINKING 2-3
Great Debate: There are three propositions to be considered. Proposition A: Disease entities should be listed as official
causes of death. Proposition B: Underlying factors that result in these diseases should be listed as official causes of death.
Proposition C: No causes of death should be listed on death certificates. Select one of these positions and develop a
position statement with your rationale.
Several countries, including Great Britain and the United States, have identifiable social strata that permit
comparisons of health status by social class. Britain conducts ongoing analyses of socioeconomic differences according
to official categorizations based on general social standing within the community. For the United States, educational
status, race, and family income are often used as indirect or proxy measures of social class. Despite the differences in
approaches and indicators, there is little evidence of any real difference between Britain and the United States in
terms of what is being measured. In both countries, explanations for the differences in mortality appear to relate
primarily to inequalities in social position and material resources.11,12 This effect operates all up and down the
hierarchy of social standing; at each step improvements in social status are linked with improvements in measures of
health status. For example, a study based on 1971 British census follow-up data found that a relatively affluent, home-
owning group with two cars had a lower mortality risk than did a similar relatively privileged group with only one car.11
In the United States, epidemiologists have studied socioeconomic differences in mortality risk since the early 1900s.
Infant mortality has been the subject of many studies that have consistently documented the effects of poverty.
Findings from the National Maternal and Infant Health Survey, for example, demonstrated that the effects of poverty
were greater for infants born to mothers with no other risk factors than for infants born to high-risk mothers.13 Poverty
status was associated with a 60% higher rate of neonatal mortality and a 200% higher rate for postneonatal mortality
than for those infants of higher-income mothers.
Poverty affects many health outcomes. Low-income families in the United States have an increased likelihood (or
relative risk) of a variety of adverse health outcomes, often two to five times greater than that of higher-income
families. The percentage of persons reporting fair or poor health is about four times as high for persons living below
the poverty level as for those with family income at least twice the poverty level.1
The implications of the consistent relationship between measures of social standing and health outcomes suggest
that studies need to consider how and how well social class is categorized and measured. Imprecise measures may
understate the actual differences that are the result of socioeconomic position in society. Importantly, if racial or ethnic
differences are simply attributed to social class differences, factors that operate through race and ethnicity, such as
racism or ethnic discrimination, will be overlooked. These additional factors also affect the difference between the
social position one has and the position one would have attained, were it not for one’s race or ethnicity. Race in the
United States, independent of socioeconomic status, is linked to mortality, although these effects vary across age and
disease categories.14 Nevertheless, anthropologists concluded long ago that race is not an appropriate generic
category for comparing health outcomes. Its usefulness does not derive from any biologic or genetic differences, but
rather, it derives from its social, cultural, political, and historical meanings.
Studies of the effect of social factors on health status across nations add some interesting insights. In general,
health appears to be closely associated with income differentials within countries, but there is only a weak link
between national mortality rates and average income among the developed countries.15 This pattern suggests that
health is affected less by changes in absolute material standards across affluent populations than by relative income
differences and the resulting disadvantage in each country. It is not the richest countries that have the greatest life
expectancy. Rather, it is those developed nations with the narrowest income differentials between rich and poor. This
finding argues that health in the developed world is less a matter of a population’s absolute material wealth than of
how the population’s circumstances compare with those of other members of their society. A similar perspective views
income to be related to health through two pathways: a direct effect on the material conditions necessary for survival,
and an effect on social participation and the opportunity to control one’s own life circumstances.16 In settings or
societies that provide little in the way of material conditions (e.g., clean water, sanitation services, ample food,
adequate housing), income is more important for health. Where material conditions are conducive to good health,
income acts through social participation.
The effects of culture on health and illness are also becoming better understood. To medical anthropologists,
diseases are not purely independent phenomena. Rather, they are to be viewed and understood in relation to ecology
and culture. Certainly, the type and severity of disease varies by age, sex, social class, and ethnic group. For example,
Puerto Rican children overall have a higher prevalence of asthma than Mexican American, non-Hispanic white, and
African American children.17 Differences in poverty status do not explain the disparities for Puerto Rican and African
American children, two populations that have higher asthma rates than non-Hispanic white and Mexican American
children regardless of poverty status. The reason for the higher rate among Puerto Rican children overall is unknown,
but the different distributions and social patterns suggest differences in culture-mediated behaviors. Such insights are
essential to developing successful prevention and control programs. Culture serves to shape health-related behaviors,
as well as human responses to diseases including changes in the environment, which, in turn, affect health. As a
mechanism of adapting to the environment, culture has great potential for both positively and negatively affecting
health.
There is evidence that different societies shape the ways in which diseases are experienced and that social patterns
of disease persist, even after risk factors are identified and effective interventions become available.18,19 For example,
the link between poverty and various outcomes has been well established; yet even after advances in medicine and
public health and significant improvement in general living and working conditions, the association persists. One
explanation is that as some risks were addressed, others developed, such as health-related behaviors, including violent
behavior and alcohol, tobacco, and drug use. In this way, societies create and shape the diseases that they experience.
This makes sense, especially if we view the social context in which health and disease reside—the setting and social
networks. For problems such as HIV infections, sexually transmitted diseases, and illicit drug use, spread is heavily
influenced by the links between those at risk.20 This also helps to explain why people in disorganized social structures
are more likely to report their own health as poor than are similar persons with more social capital.21,22
Societal responses to diseases are also socially constructed. Efforts to prevent the spread of typhoid fever by
limiting the rights of carriers (such as Typhoid Mary) differed greatly from those to reduce transmission risks from
diphtheria carriers. Because many otherwise normal citizens would have been subjected to extreme measures in order
to avoid the risk of transmission, it was not socially acceptable to invoke similar measures for these similar risks.
If these themes of social and cultural influences are on target, they place the study of health disparities and
inequities at the top of the public health agenda. They also argue that health should be viewed as a social
phenomenon. Rather than attempting to identify each and every risk factor that contributes only marginally to
disparate health outcomes of the lower social classes, a more effective approach would be to directly address the
broader social policies (distribution of wealth, education, employment, discrimination, and the like) that foster the
social disparities that cause the observed differences in health outcomes.19 This social-ecological view of health and its
determinants is critical to understanding and improving health status in the United States and other nations.
Global Health Influences
Considerable variation exists among the world’s nations on virtually every measure of health and illness currently in
use. The principal factors responsible for observed trends and obvious inequities across the globe fall into the general
categories of the social and physical environment, personal behavior, and health services. Given the considerable
variation in social, economic, and health status among the developed, developing, and underdeveloped nations, it is
naive to make broad generalizations. Countries with favorable health status indicators, however, generally have a well-
developed health infrastructure, ample opportunities for education and training, relatively high status for women, and
economic development that counterbalances population growth. Nonetheless, countries at all levels of development
share some problems, including the escalating costs involved in providing a broad range of health, social, and
economic development services to disadvantaged subgroups within the population. Social and cultural upheaval
associated with urbanization is another problem common to countries at all levels of development. Over the course of
the 20th century, the proportion of the world’s population living in urban areas tripled—to about 40%; this trend is
expected to continue throughout the new century.
The principal environmental hazards in the world today appear to be those associated with poverty. This is true for
developed as well as developing and underdeveloped countries. Some international epidemiologists predict that, in the
21st century, the effects of overpopulation and production of greenhouse gases will join poverty as major threats to
global health. These factors represent human effects on the world’s climate and resources and are easily remembered
as the “3 Ps” of global health (pollution, population, and poverty):
• Pollution of the atmosphere by greenhouse gases, which will result in significant global warming, affecting both
climate and the occurrence of disease
• Worldwide population growth, which will result in a population of 10–12 billion people within the next century
• Poverty, which is always associated with ill health and disease23,24
It surprises many Americans that population is a major global health concern. Birth rates vary inversely with the
level of economic development and the status of women among the nations of the world. Continuing high birth rates
and declining death rates will mean even more rapid growth in population in developing countries. It has taken all of
history to reach the world’s current population level, but it will take less than half a century to double that. Many
factors have influenced this growth, including public health, which has increased the chances of conception by
improving the health status of adults, increasing infant and child survival, preventing premature deaths of adults in
the most fertile age groups, and reducing the number of marriages dissolved by one partner’s premature death.
Global warming represents yet another phenomenon with considerable potential for health effects. Climate change
has direct temperature effects on humans and increases the likelihood of extreme weather events. A number of
infectious diseases are also climate sensitive, some because of effects on mosquitoes, ticks, and other vectors in terms
of their population size and density and changes in population movement, forest clearance and land use practices,
surface water configurations, and human population density.25 Global warming will also contribute to air quality-
related health conditions and concerns.
In general, public health approaches to dealing with world health problems must overcome formidable obstacles,
including the unequal and inefficient distribution of health services, lack of appropriate technology, poor management,
poverty, and inadequate or inappropriate government programs to finance needed services. Much of the preventable
disease in the world is concentrated in the developing and underdeveloped countries, where the most profound
differences exist in terms of social and economic influences.
Although many of these factors appear to stem from low levels of national wealth, the link between national health
status and national wealth is not firm, and comparisons across nations are seldom straightforward. Improved health
status correlates more closely with changes in standards of living, advances in the politics of human relations, and a
nation’s literacy, education, and welfare policies than with specific preventive interventions. The complexities involved
in identifying and understanding these forces and their interrelationships often confound comparisons of health status
between the United States and other nations.
ANALYZING HEALTH PROBLEMS FOR CAUSATIVE FACTORS
The ability to identify risk factors and pathways for causation is essential for rational public health decisions and
actions to address important health problems in a population. First, however, it is necessary to define what is meant by
health problem. Here, health problem means a condition of humans that can be represented in terms of measurable
health status or quality-of-life indicators. It is important to note that this basic definition must be modified for the
purposes of community problem solving and the development of interventions. This characterization of a health
problem as something measured only in terms of outcomes is difficult for some to accept. They point to important
factors, such as access to care or poverty itself, and feel that these should rightfully be considered as health problems.
Important problems they may be, but if they are truly important in the causation of some unacceptable health
outcome, they can be dealt with as related factors rather than health problems.
The factors linked with specific health problems are often generically termed risk factors and can exist at one of
three levels. Those risk factors most closely associated with the health outcome in question are often termed
determinants. Risk factors that play a role further back in the chain of causation are called direct and indirect
contributing factors. Risk factors can be described at either an individual or a population level. For example, tobacco
use for an individual increases the chances of developing heart disease or lung cancer, and an increased prevalence of
tobacco use in a population increases that population’s incidence of (and mortality rates from) these conditions.
Determinants are scientifically established factors that relate directly to the level of a health problem. As the level
of the determinant changes, the level of the health outcome changes. Determinants are the most proximal risk factors
through which other levels of risk factors act. The link between the determinant and the health outcome should be
well established through scientific or epidemiologic studies. For example, for neonatal mortality rates, two well-
established determinants are the low birth weight rate (the number of infants born weighing less than 2,500 g, or
about 5.5 pounds, per 100 live births) and weight-specific mortality rates. Improvement in the neonatal mortality rate
cannot occur unless one of these determinants improves. Health outcomes can have one or many determinants.
Direct contributing factors are scientifically established factors that directly affect the level of a determinant.
Again, there should be solid evidence that the level of the direct contributing factor affects the level of the
determinant. For the neonatal mortality rate example, the prevalence of tobacco use among pregnant women has been
associated with the risk of low birth weight. A determinant can have many direct contributing factors. For low birth
weight, other direct contributing factors include low maternal weight gain and inadequate prenatal care.
Indirect contributing factors affect the level of the direct contributing factors. Although several steps distant from
the health outcome in question, these factors are often proximal enough to be modified. The indirect contributing
factor affects the level of the direct contributing factor, which, in turn, affects the level of the determinant. The level of
the determinant then affects the level of the health outcome. Many indirect contributing factors can exist for each
direct contributing factor. For prevalence of tobacco use among pregnant women, indirect contributing factors might
include easy access to tobacco products for young women, lack of health education, and lack of smoking cessation
programs.
OUTSIDE-THE-BOOK THINKING 2-4
Select a health outcome and analyze that outcome for its determinants and contributing factors, using the method
described in the text. Identify at least two major determinants for the problem that you select. For each determinant,
identify at least two direct contributing factors, and for each direct contributing factor, identify at least two indirect
contributing factors.
The health problem analysis framework begins with the identification of a health problem (defined in terms of
health status indicators) and proceeds to establish one or more determinants; for each determinant, one or more
direct contributing factors; and for each direct contributing factor, one or more indirect contributing factors.
Intervention strategies at the community level generally involve addressing these indirect contributing factors. When
completed, an analysis identifies as many of the causal pathways as possible to determine which contributing factors
exist in the setting in which an intervention strategy is planned. The framework for this approach is presented in
Table 2-4 and Figure 2-6. This framework forms the basis for developing meaningful interventions; it is used in
several of the processes and instruments to assess community health needs that are currently in wide use at the local
level. Community health improvement processes and tools are topics for another chapter.
TABLE 2-4 Risk Factors
Determinant Scientifically established factor that
relates directly to the level of the health
problem. A health problem may have any
number of determinants identified for it.
Example: Low birth weight is a
prime determinant for the health
problem of neonatal mortality.
Direct contributing factor Scientifically established factor that
directly affects the level of the
determinant.
Example: Use of prenatal care is
one factor that affects the low-
birth-weight rate.
Indirect contributing factor Community-specific factor that affects the
level of a direct contributing factor. Such
factors can vary considerably from one
community to another.
Example: Availability of day care or
transportation services within the
community may affect the use of
prenatal care services.
Data from Centers for Disease Control and Prevention, Public Health Practice Program Office, 1991.
FIGURE 2-6 Health Problem Analysis Worksheet
Reproduced from Centers for Disease Control and Prevention. Public Health Practice Program Office, 1991.
Although this framework is useful, it does not fully account for the relationships among the various levels of risk
factors. Some direct contributing factors may affect more than one determinant, and some indirect contributing
factors may influence more than one direct contributing factor. For example, illicit drug use during pregnancy
influences both the likelihood of low birth weight and birth weight-specific survival rates. To account fully for these
interactions, some direct and indirect contributing factors may need to be included in several different locations on the
worksheet. Despite the advancement of epidemiologic methods, many studies ignore the contributing factors that
affect the level of these major risk factors, leading to simplistic formulations of multiple risk factors for health
problems that exist at the community level.26
ECONOMIC DIMENSIONS OF HEALTH OUTCOMES
The ability to measure and quantify outcomes and risks is essential for rational decisions and actions. Specific
indicators, as well as methods of economic analysis, are available to provide both objective and subjective valuations.
Several health indicators attempt to value differentially health status; outcomes, including age-adjusted rates; span of
healthy life; and YPLL. For example, YPLL represents a method of weighting or valuing health outcomes by placing a
higher value on deaths that occur at earlier ages. Years of life lost thus become a common denominator or, in one
sense, a common currency. Health outcomes can be translated into this currency or into an actual currency, such as
dollars. This translation allows for comparisons to be made among outcomes in terms of which costs more per person,
per episode, or per another reference point. Cost comparisons of health outcomes and health events have become
common in public health. Approaches include cost-benefit, cost-effectiveness, and cost-utility studies.
Cost-benefit analyses provide comprehensive information on both the costs and the benefits of an intervention. All
health outcomes and other relevant impacts are included in the determination of benefits. The results are expressed in
terms of net costs, net benefits, and time required to recoup an initial investment. If the benefits are expressed in
health outcome terms, years of life gained or quality-adjusted life-years (QALYs) may be calculated. This provides a
framework for comparing disparate interventions. QALYs are calculated from a particular perspective that determines
which costs and consequences are included in the analysis. For public health analyses, societal perspectives are
necessary. When comprehensively performed, cost-benefit analyses are considered the gold standard of economic
evaluations.
Cost-effectiveness analyses focus on one outcome to determine the most cost-effective intervention when several
options are possible. Cost-effectiveness examines a specific option’s costs to achieve a particular outcome. Results are
often specified as the cost per case prevented or cost per life saved. For example, screening an entire town for a
specific disease might identify cases at a cost of $150 per new case, whereas a screening program directed only at
high-risk groups within that town might identify cases at a cost of $50 per new case. Although useful for evaluating
different strategies for achieving the same result, cost-effectiveness approaches are not very helpful in evaluating
interventions intended for different health conditions.
Cost-utility analyses are similar to cost-effectiveness studies, except that the results are characterized as cost per
QALY. These are most useful when the intervention affects both morbidity and mortality, and there are a variety of
possible outcomes that include quality of life.
These approaches are especially important for interventions based on preventive strategies. The argument is
frequently made that “an ounce of prevention is worth a pound of cure.” If this wisdom is true, preventive
interventions should result in savings equal to 16 times their actual cost. Not many preventive interventions measure
up to this standard, but even crude information on the costs of many health outcomes suggests that prevention has
economic as well as human savings. The U.S. Public Health Service has estimated that as much as 11% of health
expenditures for the year 2000 could have been averted through investments in public health for six conditions: motor
vehicle injuries, occupationally related injuries, stroke, coronary heart disease, firearms-related injuries, and low-birth-
weight infants.27 Beyond the direct medical effects, there are often nonmedical costs related to lost wages, taxes, and
productivity.
Economists assert that the future costs for care and services that result from prevention of mortality must be
considered a negative benefit of prevention. For example, the costs of preventing a death from motor vehicle injuries
should include all subsequent medical care costs for that individual over his or her lifetime, because these costs would
not have occurred otherwise. They also argue that it is unfair to compare future savings to the costs of current
prevention programs and that those savings must be discounted to their current value. If a preventive program will
save $10 million 20 years from now, that $10 million must be translated into its current value in computing cost
benefits, cost-effectiveness, or cost utility. It may be that the value of $10 million 20 years from now is only $4 million
now. If the program costs $1 million, its benefit/cost ratio would be 4:1 instead of 10:1 before we even added any
additional costs associated with medical care for the lives that were saved. These economic considerations contribute
to the difficulty of marketing preventive interventions.
Two additional economic considerations are important for public health policy and practice. The first of these is
what is known as opportunity costs, which represents the costs involved in choosing one course of action over another.
Resources spent for one purpose are not available to be spent for another. As a result, there is a need to consider the
costs of not realizing the benefits or gains from paths not chosen. A second economic consideration important for
public health is related to the heavy emphasis of public health on preventive strategies. The savings or gains from
successful prevention efforts are generally not reinvested in public health or even other health purposes. These
savings or gains from investments in prevention are lost. Maybe this is proper, because the overall benefits accrue
more broadly to society, and public health remains, above all else, a social enterprise. However, imagine the situation
for American industry and businesses if they could not reinvest their gains to grow their businesses. This is often the
situation faced by public health, further exacerbating the difficulty of arguing for and securing needed resources.
HEALTHY PEOPLE 2020
The data and discussion in this chapter only broadly describe health status measures in the United States in the early
decades of the new century. Several common themes emerge, however, that form the basis for national health
objectives focusing on the year 2020.28 Figure 2-7 (consistent with the social-ecological model described earlier)
presents a Healthy People process grounded in a broad view of the many factors influencing health. The year 2020
objectives build on the nation’s experience with three previous panels of health objectives established for the years
1990, 2000, and 2010.
Assessments of the Healthy People 2000 and Healthy People 2010 efforts yielded similar findings. In general,
progress was apparent for many of the broader goals, especially the age-adjusted mortality targets for age groups
under age 70. Nonetheless, a substantial proportion of the objectives targeting special populations, especially African
Americans and Native Americans, were found to be moving in the wrong direction. These findings fueled concerns that
health inequities and disparities were persisting, if not increasing, in the United States. In addition, with nearly 500
objectives established in both the 2000 and 2010 efforts, tracking became a complex undertaking. Many objectives
could not be tracked because of the unavailability of or lack of consensus for the tracking measures.
FIGURE 2-7 The Healthy People 2020 Model
Reproduced from U.S. Department of Health and Human Services, Healthy People 2020 Framework, available at www.healthypeople.gov website.
Accessed March 15, 2014.
Healthy People 2020 (HP2020), summarized in Table 2-5, provides a comprehensive set of 10-year, national goals
and objectives for improving the health of all Americans. HP2020 contains 42 topic areas with over 1,200 objectives. A
smaller set of objectives, called Leading Health Indicators, is identified in Table 2-6; these were selected to
communicate high-priority health issues and actions that can be taken to address them.
The graphic framework for HP2020 offered in Figure 2-5 illustrates the fundamental interrelationships among the
social determinants of health and emphasizes their collective impact and influence on health outcomes and conditions.
The HP2020 framework also underscores a continued focus on population disparities, including those categorized by
race/ethnicity, socioeconomic status, gender, age, disability status, sexual orientation, and geographic location. Four
foundational health measures serve as indicators of progress towards achieving these goals: general health status,
health-related quality of life, determinants of health, and disparities. Table 2-7 provides additional details on these
measures.
Central to the Healthy People 2020 effort are four overarching goals, two of which focus on:
1. Attaining high-quality, longer lives free of preventable disease, disability, injury, and premature death; and
2. Achieving health equity, eliminating disparities, and improving the health of all groups.
Although these two overarching goals appear appropriate, they are only arguably linked. From one perspective,
they represent two very different approaches to improving outcomes for the population as a whole. If we view the
health status of the entire population as a Gaussian curve, one approach would be to shift the entire curve further
toward better outcomes, and a second approach would be to change the shape of the curve, reducing the difference
between the extremes. These represent quite different strategies that would be associated with quite different policies
and interventions. Focusing on the tail end of the distribution of health requires investment in questionably effective
attempts that benefit relatively few and fail to promote the health of the majority. On the other hand, even small
improvements in overall society-wide health measures have provided greater gains for society than very perceptible
improvements in the health of a few.29 The choice is one that can be viewed as focusing on “epiphenomena,” such as
risk factors or on the larger context and social environment. Healthy People 2020 ambitiously seeks to do both.
TABLE 2-5 Healthy People 2020 Vision, Mission, Goals, and Focus Areas
Vision
A society in which all people live long, healthy lives.
Mission
Healthy People 2020 strives to:
• Identify nationwide health improvement priorities.
• Increase public awareness and understanding of the determinants of health, disease, and disability and the
opportunities for progress.
• Provide measurable objectives and goals that are applicable at the national, state, and local levels.
• Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best
available evidence and knowledge.
• Identify critical research, evaluation, and data collection needs.
Overarching Goals
• Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
• Achieve health equity, eliminate disparities, and improve the health of all groups.
• Create social and physical environments that promote good health for all.
• Promote quality of life, healthy development, and healthy behaviors across all life stages.
Focus Areas
1. Access to health services
2. Adolescent health
3. Arthritis, osteoporosis, and chronic back conditions
4. Blood disorders and blood safety
5. Cancer
6. Chronic kidney diseases
7. Dementia, including Alzheimer’s disease
8. Diabetes
9. Disability and secondary conditions
10. Early and middle childhood
11. Educational and community-based programs
12. Environmental health
13. Family planning
14. Food safety
15. Genomics
16. Global health
17. Health communication and health information technology
18. Healthcare-associated infections
19. Hearing and other sensory or communication disorders (ear, nose, throat—voice, speech, and language)
20. Heart disease and stroke
21. HIV
22. Immunization and infectious diseases
23. Injury and violence prevention
24. Lesbian, gay, bisexual, and transgender health
25. Maternal, infant, and child health
26. Medical product safety
27. Mental health and mental disorders
28. Nutrition and weight status
29. Occupational safety and health
30. Older adults
31. Oral health
32. Physical activity
33. Preparedness
34. Public health infrastructure
35. Quality of life and well-being
36. Respiratory diseases
37. Sexually transmitted diseases
38. Sleep health
39. Social determinants of health
40. Substance abuse
41. Tobacco use
42. Vision
Reproduced from U.S. Department of Health and Human Services. Healthy People 2020 Web site. www.healthypeople.gov. Accessed June 3,
2014.
OUTSIDE-THE-BOOK THINKING 2-5
Projections call for a continuing increase in life expectancy through the first half of the 21st century. What effect will
increased life expectancy have on the major goals of Healthy People 2020—increasing the quality and years of healthy life
and eliminating health disparities?
Monitoring all national health objectives is not considered feasible at the state and local level. Instead, only
priorities linked to the national health objectives will likely be tracked. An Institute of Medicine committee in 1997
identified a basic set of indicators for use in community health improvement processes (Table 2-8). Together with the
catalog of leading health indicators from the current Healthy People process, these measures provide a useful starting
point for population-based community health assessment and improvement initiatives.
OUTSIDE-THE-BOOK THINKING 2-6
Your community is about to undertake a community health assessment and you have been tasked to review and improve
the list of community health profile indicators proposed for this process. These include the Healthy People 2020 Leading
Health Indicators (Table 2-6) and the basic community health indictors proposed by the IOM (Table 2-8). Identify and
justify three indicators you would add to this list, based on what you know about the health status and needs of your
community.
TABLE 2-6 Healthy People 2020 Leading Health Indicators
Access to Health Services
• Persons with medical insurance
• Persons with a usual primary care provider
Clinical Preventive Services
• Adults who receive a colorectal cancer screening based on the most recent guidelines
• Adults with hypertension whose blood pressure is under control
• Adult diabetic population with an A1c value greater than 9 percent
• Children aged 19 to 35 months who receive the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella,
and PCV vaccines
Environmental Quality
• Air Quality Index (AQI) exceeding 100
• Children aged 3 to 11 years exposed to secondhand smoke
Injury and Violence
• Fatal injuries
• Homicides
Maternal, Infant, and Child Health
• Infant deaths
• Preterm births
Mental Health
• Suicides
• Adolescents who experience major depressive episodes
Nutrition, Physical Activity, and Obesity
• Adults who meet current Federal physical activity guidelines for aerobic physical activity and muscle-strengthening
activity
• Adults who are obese
• Children and adolescents who are considered obese
• Total vegetable intake for persons aged 2 years and older
Oral Health
• Persons aged 2 years and older who used the oral health care system in past 12 months
Reproductive and Sexual Health
• Sexually active females aged 15 to 44 years who received reproductive health services in the past 12 months
• Persons living with HIV who know their serostatus
Social Determinants
• Students who graduate with a regular diploma 4 years after starting 9th grade
Substance Abuse
• Adolescents using alcohol or any illicit drugs during the past 30 days
• Adults engaging in binge drinking during the past 30 days
Tobacco
• Adults who are current cigarette smokers
• Adolescents who smoked cigarettes in the past 30 days
Reproduced from U.S. Department of Health and Human Services. Healthy People 2020 Web site. www.healthypeople.gov. Accessed June 3,
2014.
TABLE 2-7 Measures of Progress toward Healthy People 2020 Goals
General Health Status
• Life expectancy (with international comparison)
• Healthy life expectancy
• Years of potential life lost (YPLL) (with international comparison)
• Physically and mentally unhealthy days
• Self-assessed health status
• Limitation of activity
• Chronic disease prevalence
Health-Related Quality of Life (HRQoL) and Well-Being
• Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Measure – assesses global
physical, mental and social HRQoL through questions on self-rated health, physical HRQoL, mental HRQoL, fatigue,
pain, emotional distress, social activities, and roles.
• Well-Being Measures – assess the positive evaluations of people’s daily lives – when they feel very healthy and satisfied
or content with life, the quality of their relationships, their positive emotions, resilience, and realization of their
potential.
• Participation Measures – reflect individuals’ assessments of the impact of their health on their social participation
within their current environment. Participation includes education, employment, civic, social and leisure activities. The
principle behind participation measures is that a person with a functional limitation – for example, vision loss, mobility
difficulty, or intellectual disability – can live a long and productive life and enjoy a good quality of life.
Determinants of Health
• Policymaking
• Social factors
• Health services
• Individual behavior
• Biology and genetics
Disparities
• Race and ethnicity
• Gender
• Sexual identity and orientation
• Disability status or special health care needs
• Geographic location (rural and urban)
Reproduced from U.S. Department of Health and Human Services. Healthy People 2020 Web site. www.healthypeople.gov. Accessed June 3,
2014.
TABLE 2-8 Proposed Indicators for a Community Health Profile
Sociodemographic Characteristics
1. Distribution of the population by age and race/ethnicity
2. Number and proportion of persons in groups such as migrants, homeless, or the non-English speaking for whom
access to community services and resources may be a concern
3. Number and proportion of persons aged 25 and older with less than a high school education
4. Ratio of the number of students graduating from high school to the number of students who entered ninth grade 3
years previously
5. Median household income
6. Proportion of children less than 15 years of age living in families at or below the poverty level
7. Unemployment rate
8. Number and proportion of single-parent families
9. Number and proportion of persons without health insurance
Health Status
10. Infant mortality rate by race/ethnicity
11. Numbers of deaths or age-adjusted death rates for motor vehicle crashes, work-related injuries, suicide, homicide,
lung cancer, breast cancer, cardiovascular diseases, and all causes, by age, race, and gender, as appropriate
12. Reported incidence of AIDS, measles, tuberculosis, and primary and secondary syphilis, by age, race, and gender, as
appropriate
13. Births to adolescents (ages 10–17) as proportion of total live births
14. Number and rate of confirmed abuse and neglect cases among children
Health Risk Factors
15. Proportion of 2-year-old children who have received all age-appropriate vaccines, as recommended by the Advisory
Committee on Immunization Practices
16. Proportion of adults aged 65 and older who have ever been immunized for pneumococcal pneumonia; proportion who
have been immunized in the past 12 months for influenza
17. Proportion of the population who smoke, by age, race, and gender, as appropriate
18. Proportion of the population aged 18 or older who are obese
19. Number and type of U.S. Environmental Protection Agency air quality standards not met
20. Proportion of assessed rivers, lakes, and estuaries that support beneficial uses (e.g., fishing- and swimming-approved)
Health Care Resource Consumption
21. Per-capita health care spending for Medicare beneficiaries (the Medicaid adjusted average per-capita cost)
Functional Status
22. Proportion of adults reporting that their general health is good to excellent
23. During the past 30 days, average number of days for which adults report that their physical or mental health was not
good
Quality of Life
24. Proportion of adults satisfied with the healthcare system in the community
25. Proportion of persons satisfied with the quality of life in the community
Data from the Institute of Medicine. Using Performance Monitoring to Improve Community Health: A Role for Performance Monitoring.
Washington, DC: National Academy Press; 1997.
CONCLUSION
From a social-ecological perspective, the health status of a population is influenced by many factors drawn from
biology, behavior, the physical and social environment, and the use of health services. Social and cultural factors also
play an important role in the disease patterns experienced by different populations, as well as in the responses of
these populations to disease and illness. Globally, risks associated with population growth, pollution, and poverty
result in mortality and morbidity that are still associated with infectious disease processes. In the United States,
behaviorally mediated risks, including tobacco, diet, alcohol, and injury risks, rather than infectious disease processes,
are the major contributors to health status, and the considerable gap between low-income minority populations and
other Americans continues to widen. Public health activities strive to improve population health status (effectiveness)
through cost-beneficial strategies and interventions (efficacy) and with equal benefits for all segments of the
population (equity). Elimination and reduction of the disparities in health status among population groups have
emerged as the most critical national health goal for the year 2020. With the increasing availability of data on health
status, as well as on determinants and contributing factors, the potential for more rational policies and interventions
has increased. Over the long term, public policies that narrow income disparities and increase access to education,
jobs, and housing do far more to improve the health status of populations than do efforts to provide more healthcare
services. Health improvement efforts require more than data on health problems and contributing factors, which view
health from a negative perspective. Also needed is information from a positive perspective, in terms of community
capacities, assets, and willingness. More important still, there must be recognition and acceptance that the right to
health is a basic human right and one inextricably linked to all other human rights, lest quality of life be seriously
compromised.30 It is this right to health that energizes and challenges public health workers to measure health and
quality of life in ways that promote its improvement.
REFERENCES
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GA: Carter Center; 1985: 181–187.
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J Public Health. 1999; 89: 1748–1751.
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16. Marmot M. The influence of income on health: views of an epidemiologist. Health Affairs. 2002; 21: 31–46.
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United States, 2003–2005. MMWR. 2007; 56(5): 99.
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471–473.
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1999; 89: 1181–1186.
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30. Universal Declaration of Human Rights. GA res 217 A(iii), UN Doc A/810, art 25(1);1948.
CHAPTER 3
Public Health and the Health System
LEARNING OBJECTIVES
Given a prevalent health problem (disease or condition), incorporate strategies of health-related and illness-
related interventions impacting through each of the three levels of prevention in a plan to prevent further
spread of the disease/condition and minimize its effects to the greatest extent possible. Key aspects of this
competency expectation include being able to
• Describe three or more major issues that make the health system a public health concern
• Identify five intervention strategies directed toward health and illness
• Identify and describe three levels of preventive interventions
• Describe the approximate level of national expenditures for all health and medical services and for the population-
based and public health activity components of this total
• Cite important economic, demographic, and utilization dimensions of the health sector
• Access and utilize current data and information resources available through the Internet’s World Wide Web
characterizing the roles and interests of key stakeholders in the health sector
More than five decades of discussion, debate, and inaction later, significant health reform finally came to the health
system in the United States in the second decade of the 21st century. Some believe it was too much, too quickly.
Others found it too little and too late. The Patient Protection and Affordable Care Act (P.L. 111-148, more commonly
known as the Affordable Care Act or “Obamacare”) was enacted in 2010 with its major provisions to be implemented
piecemeal over the ensuing decade. The extent to which the Affordable Care Act addresses the major problems and
issues facing the health system in the United States rests in large part on what those problems and issues were, are,
and will be. This chapter picks up where the previous chapter left off—with influences on health. The influences to be
examined in this chapter, however, are the interventions and services available through the health system.
The relationship between public health and other health-related activities has never been clear. Some of the lack of
clarity may be the result of the several different images of public health described previously, but certainly not all. In
addition to the health system remaining poorly understood by the American public, there are different views among
health professionals and policymakers as to whether public health is part of the health system or whether it is a
separate, parallel enterprise. Most agree that these entities serve the same ends but disagree as to the balance
between the two and the locus for strategic decisions and actions. The issue of ownership—which entity’s leadership
and strategies will predominate—underlies these different perspectives. In this text, the term health system will refer
to all aspects of the organization, financing, and provision of programs and services for the prevention and treatment
of illness and injury. Public health activities are an important component of this larger health system and, indeed, the
entire health system serves the health of the public. This view differs from the image that most people have of our
health system; the public commonly perceives the health system to include only the medical care and treatment
aspects of the overall system.
Although their relationship may not be clear, there is ample cause for public health interest in the health system.
Perhaps most compelling is the sheer size and scope of the U.S. health system, characteristics that have made the
health system as much an ethical as an economic issue. More than 15 million workers and $3.0 trillion in resources are
devoted to health-related purposes.1 However, this huge investment in fiscal and human resources may not be
accomplishing what it can and should in terms of health outcomes. Lack of access to needed health services for an
alarming number of Americans and inconsistent quality have been contributing to less than optimal health outcomes.
Although access and quality have long been public health concerns, costs associated with excess capacity within the
health system has emerged as another important issue for public health.
This chapter examines the U.S. health system from several perspectives that consider the public health implications
of costs and affordability, as well as several other important public policy and public health questions:
• Does the United States have a rational strategy for investing its resources to maintain and improve people’s
health?
• Does the current strategy inequitably limit access to and benefit from needed services?
• Is the health system accountable to its end-users and ultimate payers for the quality and results of its services?
• Are the changes occurring from recent health reform legislation (Affordable Care Act) bringing meaningful
reform to the U.S. health system?
It is these issues of health, excess, access, accountability, and quality that make the health system a public health
concern.
Complementary, even synergistic, efforts involving medicine and public health are apparent in many of the
important gains in health outcomes achieved during the 20th century. Underlying these synergies is an appreciation
that a successful health system deploys and integrates a variety of strategies and activities that differ in terms of their
strategic intent, level of prevention, relationship to medical and public health practice, and community or individual
focus. Key economic, demographic, and resource trends will then be briefly presented as a prelude to understanding
important themes and emerging paradigm shifts. New opportunities afforded by sweeping changes in the health
system will be apparent in the review of these issues.
OUTSIDE-THE-BOOK THINKING 3-1
Great debate: This debate examines contributors to improvement in health status in the United States since 1900. There
are two propositions to be considered. Proposition A: Public health interventions are responsible for these improvements.
Proposition B: Medical care interventions are responsible for these improvements. Select one—and only one—of these
positions and present a compelling argument.
PREVENTION AND HEALTH SERVICES
Improved health status in the United States over the past 100+ years is due to a variety of intervention strategies and
services.2 Key relationships among health, illness, and various interventions intended to maintain or restore health are
illustrated in Figure 3-1. Wellness and illness are dynamic states that are influenced by a wide variety of biologic,
environmental, behavioral, social, cultural, and health service factors that interact within a social-ecological
framework. The complex interaction of these factors contributes to the occurrence or absence of disease or injury,
which, in turn, contributes to the health status and well-being of individuals and populations.
Several different intervention points are possible, including two general strategies—health promotion and specific
protection—that seek to maintain health by intervening prior to the development of disease or injury.3 Each involves
activities that alter the interaction of the various health-influencing factors in ways that either avert or alter the
occurrence of disease or injury.
Health Promotion and Specific Protection
Health promotion activities attempt to modify human behaviors to reduce those known to affect adversely the ability to
resist disease or injury-inducing factors, thereby eliminating exposures to harmful factors. Examples of health
promotion activities include interventions such as nutrition counseling, genetic counseling, family counseling, and the
myriad activities that constitute health education. However, health promotion also properly includes the provision of
adequate housing, employment, and recreational conditions, as well as other forms of community development
activities. What is clear from these examples is that many fall outside the common understanding of what constitutes
health care. Several of these are viewed as the duty or responsibility of other societal institutions, including public
safety, housing, education, and even business. It is somewhat ironic that activities that focus on the state of health and
that seek to maintain and promote health are not commonly perceived to be “health services.” To some extent, this is
also true for the other category of health-maintaining strategies—specific protection activities.
FIGURE 3-1 Public Health Intervention Strategies and Effects
Modified from U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Syndemics Prevention Network, 2008.
Specific protection activities provide individuals with resistance to factors (such as microorganisms like viruses and
bacteria) or modify environments to decrease potentially harmful interactions of health-influencing factors (such as
toxic exposures in the workplace). Examples of specific protection include activities directed toward specific risks
(e.g., the use of protective equipment for asbestos removal), immunizations, occupational and environmental
engineering, and regulatory controls and activities to protect individuals from environmental carcinogens (such as
exposure to secondhand or side-stream smoke) and toxins. Several of these are often identified with settings other
than traditional healthcare settings. Many are implemented and enforced through governmental agencies.
Early Case Finding and Prompt Treatment, Disability Limitation, and Rehabilitation
Although health promotion and specific protection focus on the healthy state and seek to prevent disease, a different
set of strategies and activities is necessary after disease or injury occurs. In such circumstances, the appropriate
strategies are those facilitating early detection, prompt treatment, or rehabilitation, depending on the stage of
development of the disease.
In general, early detection and prompt treatment reduce individual pain and suffering and are less costly to both
the individual and society than treatment initiated after a condition has reached a more advanced state. Interventions
to achieve early detection and prompt treatment include screening tests, case-finding efforts, and periodic physical
exams. Screening tests are increasingly available to detect illnesses before they become symptomatic. Case-finding
efforts for both infectious and noninfectious conditions are directed at populations at greater risk for the condition on
the basis of criteria appropriate for that condition. Periodic physical exams and other screenings, such as those
consistent with the age-specific recommendations of the U.S. Preventive Health Services Task Force, incorporate these
practices and are best provided through an effective primary medical care system.4 Primary care providers who are
sensitive to disease patterns and predisposing factors can play substantial roles in the early identification and
management of most medical conditions.
Another strategy targeting disease is disease management through effective and complete treatment. It is these
activities that most Americans equate with the term health care, largely because this strategy constitutes the lion’s
share of the U.S. health system in terms of resource deployment. Quite appropriately, these efforts largely aim to
arrest or eradicate disease and to limit disability and prevent death. The final intervention strategy focusing on disease
—rehabilitation—is designed to return individuals who have experienced a condition to the maximum level of function
consistent with their capacities.
Links with Prevention
An important aspect of this view of the health system is that it emphasizes the potential for prevention inherent in
each of the five health intervention strategies. Prevention can be categorized in several ways. The best-known
approach classifies prevention in relation to the stage of the disease or condition.
Preventive intervention strategies are considered primary, secondary, or tertiary. Primary prevention involves
prevention of the disease or injury itself, generally through reducing exposure or risk factor levels. Secondary
prevention attempts to identify and control disease processes in their early stages, often before signs and symptoms
become apparent. In this case, prevention is akin to preemptive treatment. Tertiary prevention seeks to prevent
disability through restoring individuals to their optimal level of functioning after damage is done.
The relationship of the five health intervention strategies to the three levels of prevention is also illustrated in
Figure 3-1. Health promotion and specific protection are primary prevention strategies seeking to prevent the
development of disease. Early case finding and prompt treatment represent secondary prevention, because they seek
to interrupt the disease process before complications occur. Disease management and rehabilitation are considered
tertiary-level prevention in that they seek to prevent or reduce disability associated with disease or injury. Although
these are considered tertiary prevention, they receive primary attention under current policy and resource
deployment.
Figure 3-2 further illustrates each of the three levels of prevention strategies in relation to population disease
status and effect on disease incidence and prevalence. The various potential benefits from the three prevention levels
derive from the basic epidemiologic concepts of incidence and prevalence. Prevalence (the rate of existing cases of
illness, injury, or a health event) is a function of both incidence (the rate of new cases) and duration. Reducing either
incidence or duration can lower prevalence. Primary prevention aims to reduce the incidence of conditions, whereas
secondary and tertiary prevention seek to reduce prevalence by shortening duration and minimizing the effects of
disease or injury. It should be apparent that there is a finite limit to how much a condition’s duration can be reduced.
As a result, approaches emphasizing primary prevention have greater potential benefit than do approaches
emphasizing other levels of prevention. The importance of the differential impact of prevention and treatment
approaches to a particular health problem or condition cannot be overstated.
These same considerations are pertinent to the concept of postponement of morbidity as a prevention strategy.
Increased life expectancy without postponement of morbidity may actually increase the burden of illness within a
population, as measured by prevalence. However, postponement may result in the development of a condition so late
in life that it results in either no or less disability in functioning.
Within this framework for considering intervention strategies aimed at health or illness, the potential for prevention
as an element of all strategies is clear. There are substantial opportunities to use primary and secondary prevention
strategies to improve health in general and reduce the burden of illness for individuals and for society. As noted in the
discussion of measuring population health, reducing the burden of illness carries the potential for substantial cost
savings. These concepts serve to promote a more rational intervention and investment strategy for the U.S. health
system.
OUTSIDE-THE-BOOK THINKING 3-2
Select an important health problem (disease or condition) and describe interventions for this problem across the five
strategies of health-related and illness-related interventions (health promotion, specific protection, early detection,
disability limitation, and rehabilitation) discussed in this chapter.
FIGURE 3-2 Comprehensive Model of Chronic Disease Prevention and Control
Modified from National Public Health Partnership. Preventing Chronic Disease: A Strategic Framework [Background paper]; 2001.
Links with Public Health and Medical Practice
Another useful aspect of this view of the health system is in its allocation of responsibilities for carrying out the
various interventions. Three practice domains can be roughly delineated: public health practice, medical practice, and
long-term care practice.3 This framework assigns public health practice primary responsibility for health promotion,
specific protection, and a good share of early case finding. It is important to note that the concept of public health
practice here is a broad one that accommodates the activities carried out by many different types of health
professionals and workers, not only those working in public health agencies. Although many of these activities are
carried out in public health agencies of the federal, state, or local government, many are not. Public health practice
occurs in voluntary health agencies, as well as in settings such as schools, social service agencies, industry, and even
traditional medical care settings. In terms of prevention, public health practice embraces all of the primary prevention
activities in the model, as well as some of the activities for early diagnosis and prompt treatment.
The demarcations between public health and medical practice are neither clear nor absolute. In recent decades,
public health practice has been extensively involved in screening and has become an important source of primary
medical care for populations with diminished access to care.
The mix of population-based and personal health services considered to represent public health practice varies over
time and by location and history. The essential public health services framework largely focuses on population-based
activities, including monitoring health status, investigating health problems and hazards, informing and educating
people about health issues, mobilizing community partnerships, developing policies and plans, enforcing laws and
regulations, ensuring a competent workforce, evaluating effectiveness and quality of services, and researching for new
insights and solutions. One of these essential public health services, however, focuses on personal health services by
linking people with needed health services and ensuring the provision of health care when it is otherwise unavailable.
TABLE 3-1 Healthcare Pyramid Levels
• Tertiary Medical Care
• Subspecialty referral care requiring highly specialized personnel and facilities
• Secondary Medical Care
• Specialized attention and ongoing management for common and less frequently encountered medical conditions,
including support services for people with special challenges due to chronic or long-term conditions
• Primary Medical Care
• Clinical preventive services, first-contact treatment services, and ongoing care for commonly encountered medical
conditions
• Population-Based Public Health Services
• Interventions aimed at disease prevention and health promotion that shape a community’s overall health profile
Reproduced from U.S. Public Health Service. For a Healthy Nation: Return on Investments in Public Health. Hyattsville, MD: PHS; 1994.
Even as public health practice has branched into personal health services, medical practice continues to provide the
major share of primary care services to most segments of the population. Medical practice—those services usually
provided by or under the supervision of a physician or other traditional healthcare provider—have long been viewed as
including three levels as depicted in Table 3-1. Primary medical care has been variously defined but generally focuses
on the basic health needs of individuals and families. It is first-contact health care in the view of the patient; provides
at least 80% of necessary care; includes a comprehensive array of services, on site or through referral, including
health promotion and disease prevention, as well as curative services; and is accessible and acceptable to the patient
population. This comprehensive characterization of primary care differs substantially from what is commonly
encountered as primary care in the U.S. health system. Often lacking from current so-called primary care services are
those relating to health promotion and disease prevention.
Modern concepts of disease management have evolved from efforts to provide a more integrated approach to health
care delivery in order to improve health outcomes and reduce costs, often for defined populations such as Medicaid
enrollees. Disease management focuses on identifying and proactively monitoring high risk populations, assisting
patients and providers to adhere to treatment plans that are based on proven interventions, promoting provider
coordination, increasing patient education, and preventing avoidable medical complications.
Beyond primary medical care are two more specialized categories of care that are often termed secondary and
tertiary care. Secondary care is specialized care serving the major share of the remaining 20% of the need that lies
beyond the scope of primary care. Physicians or hospitals generally provide secondary care, ideally upon referral from
a primary care source. Tertiary medical care is even more highly specialized and technologically sophisticated medical
and surgical care for those with unusual or complex conditions (generally no more than a few percent of the need in
any service category). Tertiary care is characteristically provided in large medical centers or academic health centers.
Long-term care is appropriately classified separately because of the special needs of the population requiring such
services and the specialized settings where many of these services are offered. This, too, is changing as specialized
long-term care services increasingly move out of long-term care facilities and into home and community settings.
These three levels of healthcare services are often portrayed as the upper tiers of a pyramid with population-based
public health services included as a fourth tier, as illustrated in Figure 3-3. In this pyramid, primary prevention is
largely represented by the bottom tier and secondary prevention activities are largely included in primary medical
care. Tertiary prevention activities fall largely in the secondary and tertiary medical care components of the pyramid.
The use of a pyramid to represent health services implies that each level serves a different proportion of the total
population. Everyone should be served by population-wide public health services, and nearly everyone should be
served by primary medical care. However, increasingly smaller proportions of the total population require secondary-
and tertiary-level medical care services. This formulation suggests that the medical services should be built on a
foundation of population-based services and that the system of services, like a pyramid, should be constructed from
the bottom up. It would not be rational to build a pyramid or a health system from the top down; there might not be
enough resources to address the lower levels that served the vast majority of the population. Nonetheless, there is
ample evidence in later sections of this chapter that this is exactly what has occurred with the U.S. health system. An
alternative perspective to the health services pyramid, the health impact pyramid presented in Figure 3-4, suggests a
more rational design for a health system.
FIGURE 3-3 Health Services Pyramid
Reproduced from U.S. Public Health Service. For a Healthy Nation: Return on Investments in Public Health. Washington, DC: PHS; 1994.
Targets of Health Service Strategies
A final facet of this health system framework characterizes the targets for the various strategies and activities.
Generally, primary preventive services are community-based and targeted toward populations or groups rather than
individuals. Early case-finding activities can be directed toward groups or toward individuals. For example, many
screening activities target groups at higher risk when these are provided through public health agencies. The same
screening activities can also be provided for individuals through physicians’ offices and hospital outpatient
departments. Much of primary and virtually all of secondary and tertiary medical care is appropriately individually
oriented. It should be noted that there is a concept, termed community-oriented primary care, in which primary care
providers assume responsibility for all of the individuals in a community, rather than only those who seek out care
from the provider. Even in this model, however, care is provided on an individual basis. Long-term care involves
elements of both community-based service and individually oriented service. These services are tailored for individuals
but often in a group setting or as part of a package of services for a defined number of recipients, as in a long-term
care facility.
Public Health and Medical Practice Interfaces
This framework also sheds light on the potential conflicts between public health and medical practice. Although the
two are described as separate domains of practice, there are many interfaces that provide a template for either
collaboration or conflict. Both paths have been taken over the past century. Public health practitioners have
traditionally deferred to medical practitioners for providing the broad spectrum of services for disease and injuries in
individuals. Medical practitioners have generally acknowledged the need for public health practice for health
promotion and specific protection strategies. The interfaces raise difficult issues. For example, for one specific
protection activity—childhood immunizations—the extensive role of public health practice may actually have served to
fragment health services for children. It would be logical to provide these services within a well-functioning primary
care system, where they could be better integrated with other services for this population. Despite occasional
differences as to roles, in most circumstances, medical practice has supported the role of public health to serve as the
provider of last resort in ensuring medical care for persons who lack financial access to private health care. This, too,
has varied over time and from place to place.
FIGURE 3-4 Health Impact Pyramid
Reproduced from A framework for public health action: the health impact pyramid. Fieden TR. Am J Public Health. 2010 April; 100(4): 590–595.
doi: 10.2105/AJPH.2009.185652
OUTSIDE-THE-BOOK THINKING 3-3
What are the most critical issues facing the healthcare system in the United States today? Before answering this question,
see what insights you can find at the web sites of these major health organizations: American Medical Association
(www.ama-assn.org), American Hospital Association (www.aha.org), American Nurses Association (www.ana.org), and the
Association of American Medical Colleges (www.aamc.org).
Advances in bacteriologic diagnoses in public health laboratories, for example, fostered friction between medical
practitioners and public health professionals for diseases such as tuberculosis and diphtheria that were often difficult
for clinicians to identify from other common but less serious maladies. Clinicians feared that laboratory diagnoses
would replace clinical diagnoses and that, in highly competitive medical markets, paying patients would abandon
private physicians for public health agencies.
Some of the most serious conflicts have come in the area of primary care services, including early case-finding
activities. Because of the increased yield of screening tests when these are applied to groups at higher risk, public
health practice has sought to deploy more widely risk group or community case-finding methods (including outreach
and linkage activities). This has, at times, been perceived by medical practitioners as encroachment on their practice
domain for certain primary care services, such as prenatal care. Although there has been no rule that public health
practice could not be provided within the medical practice domain and vice versa, the perception that these are
separate, but perhaps unequal, territories has been widely held by both groups.
It is important to note that this territoriality is not based only on turf issues. There are significant differences in the
world views and approaches of these two domains. Medical practice quite properly seeks to produce the best possible
outcome through the development and execution of individualized treatment plans. Seeking the best possible outcome
for an individual suggests that decisions are made primarily for the benefit of that individual. Costs and resource
availability are secondary considerations. Public health practice, on the other hand, seeks to deploy its limited
resources to avoid the worst outcomes at the group or population level. Some level of risk is tolerated at the collective
level to prevent an unacceptable level of adverse outcomes from occurring. These are quite different approaches to
practice: maximizing individual positive outcomes, as opposed to minimizing adverse collective outcomes. As a result,
differences in perspective and philosophy often underlie differences in approaches that initially appear to be concerns
over territoriality.
An example that illustrates these differences is apparent in approaches to widespread use of human
immunodeficiency virus (HIV) antibody testing in the mid- and late 1980s. Medical practitioners perceived that HIV
antibody testing would be very useful in clinical practice and that its widespread use would enhance case finding. As a
result, medical practitioners generally opposed restrictions on use of these tests, such as specific written informed
consent and additional confidentiality provisions. Public health practitioners perceived that widespread use of the test
without safeguards and protections would actually result in fewer persons at risk being tested and decreased case
finding in the community. With both groups focusing on the same science in terms of the accuracy of the specific
testing regimen, these differences in practice approaches may be difficult to understand. However, in view of their
ultimate aims and concerns as to individual versus collective outcomes, the conflict is more understandable.
Perspectives and roles may differ for public health and medical practice, but both are important and necessary. The
real question is how best to blend these approaches for purposes of improving health status throughout the
population. There is sufficient cause to question current policy and investment strategies. Table 3-2 examines the
potential contributions of various strategies (personal responsibility, healthcare services, community action, and social
policies) toward reducing the impact of the actual causes of death discussed previously. This table suggests that more
medical care services are not as likely to reduce the toll from these causes as are public health approaches
(community action and social policies). Yet, there are opportunities available through the current system and perhaps
even greater opportunities in the near term as the system seeks to address the serious problems that have brought it
to the brink of major reform.
Medicine and Public Health Collaborations
The need for a renewed partnership between medicine and public health generated several promising initiatives in the
final years of the 20th century. Just as bacteriology brought together public health professionals and practicing
physicians at the turn of the 20th century to battle diphtheria and other infectious diseases, technology and economics
may become the driving forces for a renewed partnership at the dawn of the 21st century. In pursuit of this vision, the
American Medical Association and the American Public Health Association established the Medicine/Public Health
Initiative to provide an ongoing forum to define mutual interests and promote models for successful collaborations. As
a result of this initiative, a variety of collaborations developed, foreshadowing several important components of the
Affordable Care Act.5
Collaborations between public health and hospitals have also gained momentum. Even prior to the enactment of the
Affordable Care Act in 2010, hospitals and managed care organizations had begun to pursue community health goals,
at times in concert with public health organizations and at other times filling voids that exist at the community level. In
many parts of the United States, hospitals play a leading role in organizing community health planning activities. More
frequently, however, they participate as major community stakeholders in health planning efforts organized through
the local public health agency. A variety of positive interfaces with managed care organizations have been
documented. Hospital boards and executives now commonly include community benefit objectives in their annual
performance evaluations. Examples of community health strategies include:
TABLE 3-2 Actual Causes of Death in the United States and Potential Contribution to Reduction
*Plus sign indicates relative magnitude (4+ scale).
Data from Fielding J, Halfon L. Where is the health in health system reform? JAMA. 1994;272:1292–1296 and Mokdad AH, Marks JS, Stroup DF,
Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004:291:1238–1245.
• Establishing “boundary spanner” positions that report to the chief executive officer but focus on community-
wide, rather than institutional, interests
• Changing reward systems in terms of salaries and bonuses that executives and board members linked to the
achievement of community health goals
• Educating staff on the mission, vision, and values of the institution, and linking these with community health
outcomes
• Exposing board to the work of community partners
• Engaging board members with the staff and community
• Reporting on community health performance (report cards)6
THE HEALTH SYSTEM IN THE UNITED STATES
This section does not attempt to provide a comprehensive view of the health system in the United States. The intent
here is to examine those aspects of the health industry and health system that interface with public health or raise
issues of public health significance, with a special focus on the problems of the system that are fueling reform and
change. Data from the Health United States series, published annually by the National Center for Health Statistics,
will be used throughout these sections to describe the economic, demographic, and resource aspects of the American
health system.
Economic Dimensions
The health system in the United States is immense and growing steadily, as illustrated in Figure 3-5. Total national
health expenditures in the United States doubled in the first dozen years of the 21st century to over $2.8 trillion, four
times the sum expended in 1990 and 10 times more than in 1980. Health expenditures are on a pace to reach $4.5
trillion by the year 2020. In order to understand how public health interfaces with other components of the health
system in the United States, it is important to consider the context in which these interactions take place—the health
sector of modern America. The first decade of the new century witnessed weak economic growth and employment in
the United States until the economy deteriorated even further into the recession of 2008–2009. Nonetheless, through
periods of both economic prosperity and retrenchment, the health sector has remained a powerful component of the
overall U.S. economy accounting for more than one-sixth of the total national gross domestic product (GDP) in 2012.
Figure 3-6 traces the growth in health expenditures as a proportion of GDP.
FIGURE 3-5 National Health Expenditures, United States, Selected Years, 1980–2012
Data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group.
The United States spends a greater share of its GDP on health care than any other industrialized nation. Health
expenditures in the United Kingdom and Japan are about one-half and in Germany and Canada about two-thirds the
United States figure. Per capita expenditures on health show the same pattern, with United States per capita spending
on health more than twice that of Germany, Canada, Japan, and the United Kingdom. Several factors, illustrated in
Figure 3-7, suggest that this is too much; such as (1) the current system is reaching the point of no longer being
affordable; (2) the U.S. population is no healthier than other nations that spend far less; and (3) the opportunity costs
are considerable.
Figures 3-8 and 3-9 trace where the money comes from and what it purchases in the U.S. health system.
Expenditures for personal healthcare services comprise 85% of all health expenditures. A little more than one-half of
the nation’s health expenditures (52%) pay for hospital, physician, and other clinical services; 5% goes for nursing
home care, 9% purchases prescription drugs, and 7% supports program administration. Another 24% covers a wide
array of other services, including oral health, home health care, durable medical products, over-the-counter medicines,
other personal care, research, and facilities, with only 3% devoted to government public health activities (about $75
billion in 2012).
FIGURE 3-6 Percentage of National Gross Domestic Product (GDP) Expenditures Spent for Health-Related
Purposes, United States, Selected Years, 1980–2012
Data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group; U.S. Department of Commerce,
Bureau of Economic Analysis.
FIGURE 3-7 Life Expectancy at Birth and Health Spending per Capita, United States and Other OECD
Countries, 2011 (or Nearest Year)
Reproduced from OECD (2013), Health at a Glance 2013: OECD Indicators, OECD Publishing. http://dx.doi.org/10.1787/health_glance-2013-en.
[OECD: International Organization for Economic Cooperation and Development].
There are three main sources for overall national health expenditures, which include government at all levels,
private health insurance, and individuals paying out of pocket. Steadily increasing costs for health services have hit all
three sources in their pocketbooks, and each is reaching the point at which further increases may not be affordable.
The largest single purchaser of health care in the United States is the federal government, but for all three sources,
the ultimate payers are individuals as taxpayers, employees, and consumers. Individuals and families covered by
health insurance plans have been experiencing a steady increase in the triple burden of higher premiums, increased
cost sharing, and reduced benefits. Health reform provisions of the Affordable Care Act seek to address some of these
concerns as we will encounter in later sections of this chapter.
FIGURE 3-8 Health Services Purchased by National Health Expenditures, United States, 2012
Data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group.
Only limited historical information is available on expenditures for prevention and population-based public health
services. A study using 1988 data estimated that total national expenditures for all forms of health-related prevention
(including clinical preventive services provided to individuals and population-based public health programs, such as
communicable disease control and environmental protection) amounted to $33 billion.7 The analysis sought to include
all activities directed toward health promotion, health protection, disease screening, and counseling. Included in this
total, however, was $14 billion for activities not included in the calculation of national health expenditures (such as
sewage systems, water purification, and air traffic safety). The remaining $18 billion in prevention-related health
expenditures that was included in the calculation of total national health expenditures represented only 3.4% of all
national health expenditures for that year. The share of these expenditures that represents population-based public
health services cannot be determined precisely from this study but appears to be in the $6 billion to $7 billion range
for 1988.
As part of the development of a national health reform proposal in 1994, federal officials developed an estimate of
national health expenditures for population-based services.8 On the basis of expenditures in 1993, this analysis
concluded that about 1% of all national health expenditures ($8.4 billion) supported population-based programs and
services. U.S. Public Health Service (PHS) agencies spent $4.3 billion for population-based services in 1993, and state
and local health agencies expended another $4.1 billion. PHS officials estimated that achieving an “essential” level of
population-based services nationwide would require doubling 1993 expenditure levels to $17 billion and that achieving
a “fully effective” level would require tripling the 1993 levels to 25 billion.
FIGURE 3-9 Sources of Funding for National Health Expenditures, United States, 2012
Reproduced from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group.
The 1994 national health reform effort likely undercounted population-based public health activity expenditures by
state and local governments. The results from a comprehensive examination of public health-related expenditures in
nine states for 1994 and 1995, together with federal public health activity spending for 1995, suggest that national
population-based public health spending totaled $13.8 billion in that year.
Data from the National Health Accounts identify government public health activity as a distinct category within
total national health expenditures. The public health activity category captures the bulk of public health spending
funded by government agencies, although it excludes spending for several personal services programs widely
considered to be important public health services, such as maternal and child health, public hospitals, substance abuse
prevention, and mental health services. Environmental health activities provided through environmental protection
agencies are also excluded. Nonetheless, the government public health activity category within the annual national
health expenditures total provides useful insights into general public health funding trends over time. Government
public health activity spending was $75 billion in 2012, $11 billion from the federal level, and $64 billion from state
and local governments. Figure 3-10 documents the tenfold increase in federal, state and local, and total government
public health activity expenditures from 1980 through 2012.
Adjustments to public health activity expenditures are necessary in order to more accurately reflect the full array of
activities included in the essential public health services framework, which includes the provision of personal health
services when otherwise unavailable in addition to a battery of population-based activities. Figure 3-10 includes an
estimate of total essential public health services expenditures developed by adding spending for mental health and
substance abuse prevention, maternal and child health services, school health, and public hospitals to the public
health activity category in the national health expenditures. For 2012, estimated essential public health services
expenditures were $120 billion, about two times greater than in 2000 and three times more than in 1990.
FIGURE 3-10 Public Health Activity (PHA) and Essential Public Health Services (EPHS) Expenditures by
Government Level, United States, Selected Years 1980–2012
Data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group.
A subset of overall public health activity expenditures supports population-based public health activities. Methods
for estimating population-based public health expenditures, derived from studies completed in the mid-1990s, suggest
that national population-based public health expenditures represent only about 1% of total national health
expenditures.9
On a per capita basis, expenditures for essential public health services and overall governmental public health
activities increased by 5–8 times between 1980 and 2012 (Figure 3-11). Nonetheless, per capita public health
expenditures represented only a tiny fraction of total per capita health spending ($9,500 per person) in the United
States in 2012. That share was only 4.3% ($380 per capita) for total essential public health services spending and 2.6%
($240 per capita) for governmental public health activity spending in that year (Figure 3-12).
OUTSIDE-THE-BOOK THINKING 3-4
Is an ounce of prevention still worth a pound of cure in the United States? If not, what is the relative value of prevention
in comparison with treatment?
Macroeconomic trends, however, tell only part of the story. The disparities between rich and poor have also been
growing, leaving an increasing number of Americans without financial access to many healthcare services. These and
other important aspects will be examined as we review the demands on and resources of the U.S. health system.
FIGURE 3-11 Per Capita Governmental Public Health Activity and Essential Public Health Services
Expenditures, United States, Selected Years 1980–2012
Data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group.
FIGURE 3-12 Expenditures for Essential Public Health Services and Government Public Health Activity as a
Percentage of Total Health Spending, United States, Selected Years 1980–2012
Data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group.
FIGURE 3-13 Population Age 65 and Over and Age 85 and Over, Selected Years 1900–2010 and Projected 2020–
2050
Reproduced from Federal Interagency Forum on Aging-Related Statistics. Available at www.agingstats.gov. Accessed June 28, 2014. Date from U.S.
Census Bureau, 1900 to 1940, 1970, and 1980, U.S. Census Bureau, 1983, Table 42; 1950, U.S. Census Bureau, 1953, Table 38; 1960, U.S. Census
Bureau, 1964, Table 155; 1990, U.S. Census Bureau, 1991, 1990 Summary Table File; 2000, U.S. Census Bureau, 2001, Census 2000 Summary File
1; U.S. Census Bureau, Table 1: Intercensal Estimates of the Resident Population by Sex and Age for the U.S.: April 1, 2000 to July 1, 2010 (US-
EST00INT-01); U.S. Census Bureau, 2011. 2010 Census Summary File 1; U.S. Census Bureau, Table 2: Projections of the population by selected age
groups and sex for the United States: 2010–2050 (NP2008-t2).
Demographic and Utilization Trends
Several important demographic trends affect the U.S. healthcare system. These include the slowing population growth
rate, the shift toward an older population, the increasing diversity of the population, changes in family structure, and
persistent lack of access to needed health services for too many Americans. The relative prevalence of particular
diseases is another demographic phenomenon but will not be addressed here, although recent history with diseases
such as HIV infections and H1N1 influenza illustrates how specific conditions can place increasing demands on fragile
healthcare systems.
Census studies document that the growth of the U.S. population has been slowing, a trend that would be expected
to restrain future growth in demand for healthcare services. However, this must be viewed in light of the projected
changes in the age distribution of the U.S. population that are illustrated in Figure 3-13. Between 2000 and 2030, the
population older than age 65 and older than 85 will double, whereas the younger age groups will grow little, if at all.
There is no evidence that excessive utilization or overuse of services contributes significantly to the high cost of
health care in the United States. Underuse of care is actually a greater problem than overuse. Quality reviews
consistently document that patients fail to receive recommended care almost half the time and that only about 10% of
the time do they receive additional care that is not recommended for their specific health problem or condition.10 Use
of healthcare services, in general, is closely correlated with the age distribution of the population. For example, adults
age 75 years and older visit physicians three to four times as frequently as do children younger than age 17. Because
older persons utilize more healthcare services than do younger people, their expenditures are higher. Obvious reasons
for the higher utilization of healthcare resources by the elderly include the high prevalence of chronic conditions, such
as arteriosclerosis, cerebrovascular disease, diabetes, senility, arthritis, and mental disorders. As the population ages,
it is expected that the prevalence of chronic disorders and the treatment costs associated with them will also increase.
This could be minimized through prevention efforts that either avert or postpone the onset of these chronic diseases.
Nonetheless, these important demographic shifts portend greater demand for healthcare services in the future.
FIGURE 3-14 Current and Projected Racial and Ethnic Composition of U.S. Population, 2000, 2025, 2050
Reproduced from U.S. Census Bureau, 2001.
Another important demographic trend is the increasing diversity of the population. The nonwhite population is
growing three times faster than the white population, and the Hispanic population is increasing at five times the rate
for the entire U.S. population. Between 1980 and 2000, Hispanics increased from 6.4% to 12.5% of the U.S. population.
African Americans increased from 11.5% to 14.5% of the total population, while the number of Asian/Pacific Islanders
more than doubled from 1.6% to 3.7%. The white population declined from 79.7% to 69.1% of the total population over
these two decades. Figure 3-14 projects these trends forward through mid-century. Notably, these trends reflect
differences in fertility and immigration patterns and disproportionately affect the younger age groups, suggesting that
services for mothers and children will face considerable challenges in their ability to provide culturally sensitive and
acceptable services. This scenario also underscores the importance of cultural competence skills for health
professionals. Cultural competence is a set of behaviors and attitudes, as well as a culture within an institution or
system that respects and takes into account the cultural background, cultural beliefs, and values of those served and
incorporates this into the way services are delivered. At the same time, the considerably less diverse baby boom
generation will be increasing its ability to affect public policy decisions and resource allocations in the early decades
of the 21st century.
Changes in family structure also represent a significant demographic trend in the United States. There is only a
50% chance that married partners will reach their 25th anniversary. One in three children live part of their lives in a
one-parent household; for black children, the chances are two in three. Labor force participation for women has more
than doubled over the past 50 years. Even more indicative of gender changes in the labor market, the proportion of
married women in the workforce with children under age five has been increasing in recent decades. Many American
households have maintained their economic status over the recent decades with the second paycheck from women in
the workforce. As the structure of families diversifies, so do their needs for access, availability, and even types of
services (such as substance abuse, family violence, and child welfare services).
Intermingled with many of these trends are the persistent inequalities in access to services for low-income
populations, including blacks and Hispanics. For example, despite higher rates of self-reported fair or poor health and
greater utilization of hospital inpatient services, low-income persons are substantially less likely to report physician
contacts within the past 2 years than are persons in high-income households. Utilization rates for prenatal care and
childhood immunizations are also lower for low-income populations.
Healthcare Resources
The supply of healthcare resources is another key dimension of the healthcare system. During the past quarter-
century, the number of active U.S. physicians increased by more than two-thirds, with even greater increases among
women physicians and international medical graduates. The specialty composition of the physician population also
changed during this period, as a result of many factors, including changing employment opportunities, advances in
medical technology, and the availability of residency positions. Suffice it to say that medical and surgical subspecialties
grew more rapidly than did the primary care specialties. Projections suggest that the 21st century will see a
substantial shortage of primary care physicians even while there will be a surplus of physicians trained in the surgical
and medical specialties. A continuing shortage of registered nurses has reached crisis proportions in many regions of
the United States.
Healthcare delivery models have also experienced major changes in recent years. For example, hospital-based
resources have changed dramatically. Since the mid-1970s, the number of community hospitals has decreased, and the
numbers of admissions, days of care, average occupancy rates, and average length of stay have all declined, as well.
On the other hand, the number of hospital employees per 100 average daily patients has continued to increase.
Hospital outpatient visits have also been increasing since the mid-1970s.
The growth in the number and types of healthcare delivery systems in recent years is another reflection of a rapidly
changing healthcare environment. Increasing competition, combined with cost containment initiatives, has led to the
proliferation of group medical practices, health maintenance organizations, preferred provider organizations,
ambulatory surgery centers, and emergency centers. Common to many of these delivery systems since the early 1990s
have been managed care strategies designed to control the utilization of services. Elements of managed care
strategies generally include some combination of the following:
• Risk sharing with providers to discourage the provision of unnecessary diagnostic and treatment services and, to
some degree, to encourage preventive measures
• To attract specific groups, designing of tailored benefit packages that include the most important (but not
necessarily all) services for that group; cost sharing for some services through deductibles and copayments can
be built into these packages
• Case management, especially for high-cost conditions, to encourage seeking out of less expensive treatments or
settings
• Primary care gatekeepers, generally the enrollee’s primary care physician, who control referrals to specialists
• Second opinions as to the need for expensive diagnostic or elective invasive procedures
• Review and certification for hospitalizations, in general, and hospital admissions through the emergency
department, in particular
• Continued-stay review for hospitalized patients as they reach the expected number of days for their illness (as
determined by diagnosis-related groupings)
• Discharge planning to move patients out of hospitals to less expensive care settings as quickly as possible11
The growth and expansion of these delivery systems has significant implications for the cost of, access to, and
quality of health services. These, in turn, have substantial impact on public health organizations and their programs
and services. The majority of the U.S. population is now served through a managed care organization, and that share
continues to increase.
CHANGING ROLES, THEMES, AND PARADIGMS IN THE HEALTH SYSTEM
Even a cursory review of the health sector requires an examination of the key participants or key players in the health
industry. The list of major stakeholders has been expanding as the system has grown and now includes government,
business, third-party payers, healthcare providers, drug companies, and labor, as well as consumers. The federal
government has become the largest purchaser of health care and, along with business, has attempted to become a
more prudent buyer by exerting more control over payments for services. Government seeks to reduce rising costs by
altering the economic performance of the health sector through stimulation of a more competitive healthcare market.
At the same time, efforts to expand access through Medicaid and state child health insurance programs and isolated
state initiatives toward universal coverage require more, not less, governmental spending. Still, budget problems at all
levels make it increasingly difficult for government to fulfill commitments to provide healthcare services to the poor,
the disadvantaged, and the elderly. Over recent years, new and expensive medical technology, inflation, and
unexpected increases in utilization forced third parties to pay out more for health care than they anticipated when
premiums were determined. As a result, insurers have joined government in becoming more aggressive in efforts to
contain healthcare costs. Many commercial carriers deploy methods to anticipate utilization more accurately and to
control outlays through managed care strategies. Business, labor, patients, hospitals, and professional organizations
are all trying to restrain costs while maintaining access to health services.
Reducing the national deficit and balancing the federal budget rely in part on controlling costs within Medicare and
Medicaid, as well as in discretionary federal health programs. Except for Medicare, such efforts are likely to be
politically popular, even though the public has little understanding of the federal budget. For example, a 1994 poll
found that Americans believe healthcare costs comprise 5% of the federal budget, although these costs actually
constituted 16% at the time.12 At the same time, Americans believed that foreign aid and welfare comprise 27% and
19%, respectively, of the federal budget when, in fact, they constituted only 2% and 3%, respectively. When the time
comes to balance the federal budget and reduce the national deficit, the American public faces difficult choices as to
which programs can be reduced. Public health programs, largely discretionary spending, may not fare well in this
scenario.
As these stakeholders search for methods to reduce costs and as competition intensifies, efforts to preserve the
quality of health care have become increasingly important. An Institute of Medicine study concluded that medical
errors account for as many deaths each year as motor vehicle crashes and breast cancer.13 Despite the difficulty in
measuring quality of medical care, it is likely that quality measurement systems will increase substantially.
Almost certainly, health policy issues will become increasingly politicized. The debate on healthcare issues will
continue to expand beyond the healthcare community. Many health policy issues may no longer be determined by
sound science and practice considerations, but rather by political factors. Changes in the health sector may lead to
unexpected divisions and alliances on health policy issues.
The intensity of economic competition in the health sector is likely to continue to increase because of the increasing
supply of healthcare personnel and because of the changes in the financing of care. Increased competition is likely to
cause realignments among key participants in the healthcare sector, often depending on the particular issue involved.
Dialogue and debate among the major stakeholders in the health system will be influenced by the tension between cost
containment and regulation; the interdependence of access, quality, and costs; the call for greater accountability; and
the slow but steady acceptance of the need for health reform.
The failure of health reform at the national policy level in 1994 did not avert the implementation of significant
improvements in both the public or the private components of the health sector. With or without major changes in
national health policies, the health system in the United States has been reforming itself incrementally for decades.
With the persistence of cost and access as the system’s twin critical problems, new approaches and models were both
needed and expected. The federal, as well as state, governments have moved to control the costs of Medicaid services,
primarily through attempts to enroll nondisabled Medicaid populations into capitated managed care programs. The
rapid conversion of Medicaid services to managed care operations and the growth of private managed care
organizations pose new issues for the delivery of clinical preventive and public health services.11 These changes will
likely result in fewer clinical preventive and treatment services being provided through public health agencies, but the
extent and impact of these shifts is uncertain.
In any event, the underlying investment strategy of the U.S. health system appears to have changed little over
recent decades, with more than 95% of the available resources allocated for treatment services, approximately 4% for
essential public health services, and a scant 1% for population-based public health services. Without additional
investment in prevention and public health approaches, the long-term prospects for controlling costs within the U.S.
health system are bleak. The health reform package enacted in 2010 was a significant step toward universal coverage
and meaningful health reform, especially in terms of reducing barriers to access for the 45 million Americans on the
fringes of the system and who otherwise would continue to incur excessive costs when they inappropriately accessed
needed services. Universal access remains a prerequisite for eventual control of costs. Although the Affordable Care
Act addressed a variety of health insurance gaps and abuses, it did relatively little to shift the balance in the U.S.
health system from treatment to prevention. Table 3-3 offers a scorecard on the implementation of key Affordable
Care Act (also known as Obamacare) components through 2014.
Although progress along the road to reform has been painfully slow, there is evidence that a paradigm shift is
already under way. The Pew Health Professions Commission, among other authorities, argues that the American
healthcare system of the 21st century will be quite different from its 1990s counterpart. The 21st century health
system will be
• More managed, with better integration of services and financing
• More accountable to those who purchase and use health services
• More aware of and responsive to the needs of enrolled populations
• More able to use fewer resources more effectively
• More innovative and diverse in how it provides for health
• More inclusive in how it defines health
• Less focused on treatment and more concerned with education, prevention, and care management
• More oriented to improving the health of the entire population
• More reliant on outcomes data and evidence14
These gains, however, will likely be accompanied by pain. The number of hospitals may decline by as much as 50%
and the number of hospital beds by even more than that. There will be continued expansion of primary care in
community and other ambulatory settings; this will foster replication of services in different settings, a development
likely to confuse consumers. These forces also suggest major traumas for the health professions, with projected
deficits of some professions, such as nurses and dentists, and surpluses of others, such as physicians and
pharmacists.14 An estimated 100,000–150,000 excess physicians, mainly specialists, could be joined by several hundred
thousand excess nurses as the hospital sector consolidates and by as many as 40,000 excess pharmacists as drug
dispensing is automated and centralized. The massive fragmentation among 200 or more allied health fields will likely
cause consolidation into multiskilled professions to meet the changing needs of hospitals and other care settings. One
of the few professions likely to flourish in this environment will be public health, with its focus on populations,
information-driven planning, collaborative responses, and broad definition of health and health interventions.
Where these forces will move the health system is not yet known. To blend better the contributions of preventive
and treatment-based approaches, several important changes are needed. There must be a new and more rational
understanding of what is meant by “health services.” This understanding must include a broad view of health
promotion and health protection strategies and must afford these equal standing with treatment-based strategies.
Once and for all, health services must be seen to include services that focus on health, as well as those that focus on ill
health. The health status of a population is determined by a complex set of considerations which include social
determinants that reflect the fundamental causes of many societal ills operating within a social-ecological model of
health and illness. Those considerations are very much the focus of the population-focused public health and
prevention interventions. A second and companion change needed is to finance this enhanced basic benefit package
from the same source, rather than funding public health and most prevention from one source (government resources)
and treatment and the remaining prevention activities from private sources (business, individuals, insurance). With
these changes, a gradual reallocation of resources can move the system toward a more rational and effective
investment strategy.
OUTSIDE-THE-BOOK THINKING 3-5
Which problems and issues of the health system are improved by the Affordable Care Act? Which are not? What forces
are most likely to fuel further movement toward major health system reform in America?
TABLE 3-3 Timeline and Implementation Status of Selected Affordable Care Act Health Reform Provisions
Year
Affordable Care Act Provision
= in effect
* = delayed or not yet implemented
2010
Requires the federal government to create a process, in conjunction with states, where insurers have to
justify unreasonable premium increases. Provides grants to states for reviewing premium increases.
Appropriates $5 billion for fiscal years 2010 through 2014 and $2 billion for each subsequent fiscal year to
support prevention and public health programs.
Provides a $250 rebate to Medicare beneficiaries who reach the Part D coverage gap in 2010. Further
subsidies and discounts that ultimately close the coverage gap begin in 2011.
Provides tax credits to small employers with no more than 25 employees and average annual wages of less
than $50,000 that provide health insurance for employees. Phase I (2010–2013): tax credit up to 35% (25%
for nonprofits) of employer cost; Phase II (2014 and later): tax credit up to 50% (35% for nonprofits) of
employer cost if purchased through an insurance Exchange for two years.
Imposes additional requirements on nonprofits hospitals to conduct community needs assessments and
develop a financial assistance policy and impose a tax of $50,000 per year for failure to meet these
requirements.
Creates a state option to provide Medicaid coverage to childless adults with incomes up to 133% of the
federal poverty level. (States will be required to provide this coverage in 2014.)
Creates a temporary program to provide health coverage to individuals with preexisting medical conditions
who have been uninsured for at least six months. The plan will be operated by the states or the federal
government.
Creates the National Prevention, Health Promotion, and Public Health Council to develop a national
prevention, health promotion, and public health strategy.
Extends dependent coverage for adult children up to age 26 for all individual and group policies.
Prohibits individual and group health plans from placing lifetime limits on the dollar value of coverage,
rescinding coverage except in cases of fraud, and from denying children coverage based on preexisting
medical conditions or from including preexisting condition exclusions for children. Restricts annual limits on
the dollar value of coverage (and eliminates annual limits in 2014).
Requires new health plans to provide at a minimum coverage without cost-sharing for preventive services
rated A or B by the U.S. Preventive Services Task Force, recommended immunizations, preventive care for
infants, children, and adolescents, and additional preventive care and screenings for women.
Permanently authorizes the federally qualified health centers and NHSC programs and increases funding for
FQHCs and for the NHSC for fiscal years 2010–2015.
2011
Requires health plans to report the proportion of premium dollars spent on clinical services, quality, and other
costs and provide rebates to consumers if the share of the premium spent on clinical services and quality is
less than 85% for plans in the large group market and 80% for plans in the individual and small group
markets.
Provides a 10% Medicare bonus payment for primary care services; also, provides a 10% Medicare bonus
payment to general surgeons practicing in health professional shortage areas.
Eliminates cost-sharing for Medicare-covered preventive services that are recommended (rated A or B) by the
U.S. Preventive Services Task Force and waives the Medicare deductible for colorectal cancer screening
tests; authorizes Medicare coverage for a personalized prevention plan, including a comprehensive health
risk assessment.
Creates a new Medicaid state option to permit certain Medicaid enrollees to designate a provider as a health
home and provides states taking up the option with 90% federal matching payments for two years for health
home-related services.
2011
Provides 3-year grants to states to develop programs to provide Medicaid enrollees with incentives to
participate in comprehensive health lifestyle programs and meet certain health behavior targets.
* Provides grants for up to five years to small employers that establish wellness programs.
• Funds have yet to be awarded due to budget debates related to the Prevention and Public Health Fund
Requires disclosure of the nutritional content of standard menu items at chain restaurants and food sold from
vending machines.
2012
Allows providers organized as accountable care organizations (ACOs) that voluntarily meet quality thresholds
to share in the cost savings they achieve for the Medicare program.
Requires private individual and group health plans to provide a uniform summary of benefits and coverage
(SBC) to all applicants and enrollees. The intent is to help consumers compare health insurance coverage
options before they enroll and understand their coverage once they enroll.
Requires enhanced collection and reporting of data on race, ethnicity, sex, primary language, disability status,
and for underserved rural and frontier populations.
2013
Provides a one percentage point increase in federal matching payments for preventive services in Medicaid
for states that offer Medicaid coverage with no patient cost sharing for services recommended (rated A or B)
by the U.S. Preventive Services Task Force and recommended immunizations.
Increases Medicaid payments for primary care services provided by primary care doctors to 100% of the
Medicare payment rate for 2013 and 2014 (financed with 100% federal funding).
Creates the Consumer Operated and Oriented Plan (CO-OP) to foster the creation of nonprofit, member-run
health insurance companies.
Extends authorization and funding for the Children’s Health Insurance Program (CHIP) through 2015
(current authorization is through 2013).
2014
Expands Medicaid to all individuals not eligible for Medicare under age 65 (children, pregnant women,
parents, and adults without dependent children) with incomes up to 138% FPL and provides enhanced
federal matching payments for new eligibles.
Allows all hospitals participating in Medicaid to make presumptive eligibility determinations for all Medicaid-
eligible populations.
Requires U.S. citizens and legal residents to have qualifying health coverage (there is a phased-in tax penalty
for those without coverage, with certain exemptions).
• States were given latitude to let people renew insurance policies that fail to meet the law’s benefits
standards, so that consumers may buy such policies until October 2016 and keep them for one year after
that.
2014
Creates state-based American Health Benefit Exchanges and Small Business Health Options Program (SHOP)
Exchanges, administered by a governmental agency or nonprofit organization, through which individuals and
small businesses with up to 100 employees can purchase qualified coverage. Exchanges will have a single
form for applying for health programs, including coverage through the Exchanges and Medicaid and CHIP
programs.
• Online enrollment via SHOPs delayed until November 2014 although small businesses could get coverage
directly from an insurer or an insurance agent or broker before online enrollment becomes available.
• Implementation of requirement that SHOPs offer two plans delayed until 2015.
Provides refundable and advanceable tax credits and cost sharing subsidies to eligible individuals. Premium
subsidies are available to families with incomes between 133–400% of the federal poverty level to purchase
insurance through the Exchanges, while cost sharing subsidies are available to those with incomes up to
250% of the poverty level.
Requires guarantee issue and renewability of health insurance regardless of health status and allows rating
variation based only on age (limited to a 3 to 1 ratio), geographic area, family composition, and tobacco use
(limited to 1.5. to 1 ratio) in the individual and the small group market and the Exchanges.
Prohibits annual limits on the dollar value of coverage.
Creates an essential health benefits package that provides a comprehensive set of services, limiting annual
cost-sharing to the Health Savings Account limits ($5,950/individual and $11,900/family in 2010). Creates
four categories of plans to be offered through the Exchanges, and in the individual and small group markets,
varying based on the proportion of plan benefits they cover.
* Permits states the option to create a Basic Health Plan for uninsured individuals with incomes between 133-
200% FPL who would otherwise be eligible to receive premium subsidies in the Exchange.
• Implementation delayed until 2015.
* Assesses a fee of $2,000 per full-time employee, excluding the first 30 employees, on employers with more
than 50 employees that do not offer coverage and have at least one full-time employee who receives a
premium tax credit. Employers with more than 50 employees that offer coverage but have at least one full-
time employee receiving a premium tax credit, will pay the lesser of $3,000 for each employee receiving a
premium credit or $2,000 for each full-time employee, excluding the first 30 employees.
• Implementation date moved to: January 1, 2015 for employers with 50—99 employees.
• Implementation date moved to January 1, 2016 for employers with 100 or more employees.
Permits employers to offer employees rewards of up to 30%, potentially increasing to 50%, of the cost of
coverage for participating in a wellness program and meeting certain health-related standards; establishes
10-state pilot programs to permit participating states to apply similar rewards for participating in wellness
programs in the individual market.
2016
* Permits states to form healthcare choice compacts and allows insurers to sell policies in any state
participating in the compact.
• Scheduled implementation date: January 1, 2016
2018
* Imposes an excise tax on insurers of employer-sponsored health plans with aggregate expenses that exceed
$10,200 for individual coverage and $27,500 for family coverage.
• Scheduled implementation date: January 1, 2018
Modified from Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured and Health Care Marketplace Project. Available at
http://kff.org/interactive/implementation-timeline/. Accessed March 10, 2014.
Organizations and systems that are unable to achieve their primary objectives and outcomes often justify their
existence in terms of how well they do the things they are doing. Our health system is a prime example of this
phenomenon. In such cases, the original outcome (here, improved health status) is displaced by a focus on how well
the means to that end (the availability of complex and sophisticated services) are being executed. Processes displace
outcomes as the prime purpose or mission for that entity. Instead of “doing the right things” to affect health status, the
system focuses on “doing things right” (regardless of whether they actually affect population health status). This
outcome displacement allows the United States to boast having the best medical care services in the world while
having an inadequate health system.
CONCLUSION
Every day in America, decisions are made that influence the health status of individuals and populations. The
aggregate of these decisions and the activities necessary to carry them out constitute our health system. It is
important to view interventions as linked with health and illness states, as well as with the dynamic processes and
multiple factors that move an individual from one state to another. Preventive interventions act at various points and
through various means to prevent the development of a disease state or, if it occurs, to minimize its effects to the
extent possible. These interventions differ in their linkages with public health practice, medical practice, and long-
term care, as well as in their focus on individuals or groups. The framework represents a rational one, reflecting
known facts concerning each of its aspects and their relationships with each other.
As this chapter has described, the U.S. health system focuses mainly on disease states and strategies for restoring,
as opposed to promoting or protecting, health. It directs the vast majority of human, physical, and financial resources
to tertiary prevention, particularly to acute treatment. It focuses disproportionately on individually oriented secondary
and tertiary medical care. In so doing, it raises questions as to whether these policies are effective and ethical.
Characterized in the past largely by federalism, pluralism, and incrementalism, the health sector in the United
States is finally undergoing fundamental change due in large part to the massive resources it consumes. We are now
realizing that this investment strategy is not producing results commensurate with its costs. Health indicators,
including those characterizing large disparities in outcomes and access among important minority groups, are not
responding to more resources being deployed in the usual ways. How to control costs while moving toward universal
access, consistent quality, and improved outcomes will challenge the U.S. healthcare system through the first quarter
of the 21st century.
REFERENCES
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3. Leavell HR, Clark EG. Preventive Medicine for the Doctor in His Community. 3rd ed. New York: McGraw-Hill; 1965.
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University of California Center for Health Professions; 1995.
CHAPTER 4
Law, Government, and Public Health
LEARNING OBJECTIVES
Given the network of health agencies at the federal, state, and local level as well as partnering organizations
in the voluntary and private sectors, analyze the authorities, functions and roles of health organizations at the
different governmental levels and in different sectors in ensuring population health. Key aspects of this
competency expectation include being able to
• Identify strategies used by governments to influence the health status of their citizens
• Describe how various forms of law contribute to government’s ability to influence health
• Identify the various federal health agencies and describe their general purpose and major activities
• Identify different approaches to organizing health responsibilities within state government
• Describe common features of local health departments in the United States
• Discuss implications of different approaches among states to carrying out public health’s roles
Public health is not limited to what governmental public health agencies do, although this is a widely held
misperception. Still, particular aspects of public health rely on government. For example, the enforcement of laws
remains one of those governmental responsibilities important to the public’s health and public health practice. Yet, law
and the legal system are important for public health purposes above and beyond the enforcement of laws and
regulations. Laws at all levels of government bestow the basic powers of government and distribute these powers
among various agencies, including public health agencies. Law represents governmental decisions and their
underlying collective social values, providing the basis for actions that influence the health of the public.
Decisions and actions that take place outside the sphere of government also influence the health of the public,
sometimes even more than those made by our elected officials and administrative agencies. Private sector and
voluntary organizations play key roles in identifying factors important for health and advancing actions to promote and
protect health for individuals and groups. Public health involves collective decisions and actions; it is often
governmental forums that raise issues, make decisions, and establish priorities for action. Many governmental actions
reflect the dual roles of government often portrayed on official governmental seals and vehicles of local public safety
agencies—to protect and to serve. As they relate to health, the genesis of these two roles lies in separate, often
conflicting, philosophies and duties of government. This chapter will examine how these roles are organized in the
United States. This examination particularly emphasizes the relationships among law, government, and public health,
seeking answers to the following questions:
• What are the various roles for government in serving the public’s health?
• What is the legal basis for public health in the United States?
• How are public health responsibilities and roles structured at the federal, state, and local levels?
To review the organization and structure of governmental public health, this chapter will begin with federal public
health roles and activities, to be followed, in turn, by those at the state and local levels. The focus is primarily on form
and structure, rather than function. In most circumstances, it is logical for form to follow function. Here, however, it is
necessary to understand the legal and organizational framework of governmental public health as part of the context
for public health practice. The framework established through law and governmental agencies is a key element of
public health’s infrastructure and one of the basic building blocks of the public health system. This structure is a
product of our uniquely American approach to government.
AMERICAN GOVERNMENT AND PUBLIC HEALTH
Former Speaker of the U.S. House of Representatives, Tip O’Neill, frequently observed, “all politics is local.” If this is
so, public health must be considered primarily a local phenomenon, as well, because politics are embedded in public
health processes. After all, public health represents collective decisions as to which health outcomes are unacceptable,
which factors contribute to those outcomes, which unacceptable problems will be addressed in view of resource
limitations, and which participants need to be involved in addressing the problems. These are political processes, with
different viewpoints and values being brought together to determine which collective decisions will be made. All too
often, the term politics carries a very different connotation, one frequently associated with overtones of partisan
ideologies. However, political processes are necessary and productive, and perhaps the best means devised by humans
to meet our collective needs.
The public health system in the United States is a product of many forces that have shaped governmental roles in
health. The framers of the U.S. Constitution did not plan for the federal government to deal directly with health or, for
that matter, many other important issues. The word health does not even appear in that famous document, relegating
health to the group of powers reserved to the states and the people. The Constitution explicitly authorized the federal
government to promote and provide for the general welfare (in the Preamble and Article I, Section 8) and to regulate
commerce (also in Article I, Section 8). Federal powers evolved slowly in the area of health on the basis of these
explicit powers and subsequent U.S. Supreme Court decisions that broadened federal authority by determining that
additional powers are implied in the explicit language of the Constitution.
The initial duties to regulate international affairs and interstate commerce led the federal government to
concentrate its efforts on preventing the importation of epidemics and assisting states and localities, upon request,
with their episodic needs for communicable disease control. The earliest federal health unit, the Marine Hospital
Service, was established in 1798, partly to serve merchant seamen and partly to prevent importation of epidemic
diseases; it evolved over time into the U.S. Public Health Service (PHS).
The power to promote health and welfare, however, did not always translate into the ability to act. The federal
government acquired the ability to raise substantial financial resources through the authority to levy a federal tax on
income, which was provided by the 16th Amendment in the early 20th century. The ability to raise vast sums generated
the capacity to address health problems and needs through transferring resources to state and local governments in
various forms of grants-in-aid. Despite its powers to provide for the general welfare and regulate commerce, the
federal government could not act directly in most health matters; it could act only through states as its primary
delivery system. After 1935, the power and influence of the federal government grew rapidly through its financial
influence over state and local programs, such as the Hospital Services and Construction (Hill-Burton) Act of 1946 and,
after 1965, through its emergence as a major purchaser of health care through Medicare and Medicaid. As for a public
health presence at the federal level, the best-known and most widely respected federal public health agency, now
known as the Centers for Disease Control and Prevention (CDC), was not established until 1946.1
The emergence of the federal government as a major influence in the health system displaced states from a position
they had held since before the birth of the American republic. States were sovereign powers before agreeing to share
their powers with the newly established federal government; their sovereignty included powers over matters related to
health emanating from two general sources. First, they derived from the police powers of states, which provide the
basis for government to limit the actions of individuals in order to control and abate hazards and nuisances. A second
source for state health powers lay in the expectation for government to serve those individuals unable to provide for
themselves. This expectation had its roots in the Elizabethan Poor Laws and carried over to states in the new American
form of government. Despite this common heritage, states assumed these roles quite differently and at different points
in time because the evolution of states themselves during the 19th century took place unevenly.
States developed structures and organizations needed to use their police powers to protect citizens from
communicable diseases and environmental hazards, primarily from wastes, water, and food. State health agencies
developed first in Massachusetts, then across the country, during the latter half of the 19th century. When federal
grants became available, especially after 1935, states eagerly sought out federal funding for maternal and child health
services, public health laboratories, and other basic public health programs. In so doing, states surrendered some of
their autonomy over health issues. Priorities were increasingly dictated by federal grants tied to specific programs and
services.
Each state has the ultimate authority to create the political subunits that serve the residents of a particular
jurisdiction. In this manner, counties, cities, and other forms of municipalities, townships, boroughs, parishes, and the
like are established. Special-purpose districts for every conceivable purpose—from library services and mosquito
control to emergency medical services and education—have also abounded. The powers delegated to or authorized for
all of these local jurisdictions are established by state legislatures for health and other purposes. Although many big-
city health departments were established prior to the establishment of their respective state health agencies, states
are free to use a variety of approaches to structuring public health roles at the local level. Because most states use the
county form of subdividing the state, counties became the primary local governmental jurisdictions with health roles
after 1900.
State constitutions and statutes impart the authority for local governments to influence health. This authority
comes in two forms: those responsibilities of the state specifically delegated to local governments and additional
authorities allowed through home rule powers. Home rule options permit local jurisdictions to enact a local
constitution or charter and to take on additional authority and powers, such as the ability to levy taxes for local public
health services and activities.
Counties generally carry out duties delegated by the state. More than two-thirds of U.S. counties have a county
commission form of government, with anywhere from 2 to 50 elected county commissioners (supervisors, judges, and
other titles are also used).2 These commissions carry out both legislative and executive branch functions, although
they share administrative authority with other local elected officials, such as county clerks, assessors, treasurers,
prosecuting attorneys, sheriffs, and coroners. Some counties—generally, the more populous ones—have a county
administrator accountable to elected commissioners, and a small number of counties (less than 5%) have an elected
county executive.
Local governments in U.S. cities were first on the scene in terms of public health responses, as noted in our
discussion of the history of public health. Big-city health agencies remain an important force in the public health
system in the United States. However, after about 1875 when states became more extensively involved, the relative
role of municipal governments began to erode. Both local and state governments were enticed by the availability of
federal funding, finding it preferable to take what they could get from a higher level of government rather than
generating their own revenue to finance needed services.
Many forces have been at work to alter the initial relationships among the three levels of government for health
roles, including
• Gradual expansion and maturation of the federal government
• Staggered addition of new states and variability in the maturation of state governments
• Population growth and shifts over time
• Ability of the various levels of government to raise revenues commensurate with their expanding needs
• Growth of science and technology as tools for addressing public health and medical care needs
• Rapid growth of the U.S. economy
• Expectations and needs of American society for various services from their government3,4
The last of these factors is perhaps the most important. For the first 150 years of U.S. history, there was little
expectation that the federal government should intervene in the health and welfare needs of its citizenry. The massive
need and economic turmoil of the Great Depression years drastically altered this longstanding value as Americans
began to turn to government to help deal with current needs and future uncertainties.
The complex public health network that exists today evolved slowly, with several shifts in relative roles and
influence. Economic considerations and societal expectations, both reaching a critical point in the 1930s, set the tone
for the rest of the 20th century. In general, power and influence were initially greatest at the local level, residing there
until states began to develop their own machinery to carry out their police power and general welfare roles. States
then served as the primary locus for these health roles until the federal government began to use its vast resource
potential to meet changing public expectations in the 1930s. Federal grant programs for public health and, eventually,
personal healthcare service programs soon drove state actions, especially after the 1960s. It was then that several new
federal health and social service programs were targeted directly to local governments, bypassing states. At the same
time, a new federal-state partnership for the medically indigent (Medicaid) was established to address the national
policy concern over the plight of the medically indigent.
Political and philosophical shifts since about 1980 altered roles once again.3 Debates over federal versus state roles
continued throughout the decades that followed, initially resulting in some diminution of federal influence and
enhancement of states’ rights. However, the Affordable Care Act in 2010 opened the door to further expansion of the
federal role in the health arena. In the end, the federal government has acquired the ability to influence the health
system through its fiscal muscle power, as well as its research, regulatory, technical assistance, and training roles.
PUBLIC HEALTH LAW
One of the chief organizing forces for public health lies in the system of law. Law has many purposes in the modern
world, and many of these are evident in public health laws. Unfortunately, there is no one repository where the entire
body of law, even the body of public health law, can be found. This has occurred because laws are products of the legal
system, which, in the United States, includes a federal system and 50 separate state-based legal systems. These
developed at different times in response to somewhat different circumstances and issues. Common to each is some
form of a state constitution, a considerable amount of legislation, and a substantial body of judicial decisions. If there
is any road map through this maze, it lies in the federal and state constitutions, which establish the basic framework
dividing governmental powers among the various branches of government in ways that allow each to create its own
legal structures.
As a result, four different types of law can be distinguished by virtue of their form or authority:
• Constitutionally based law
• Legislatively based law
• Administratively based law
• Judicially based law
A brief description of each of these forms of law follows.
Types of Law
Constitutional law is ultimately derived from the U.S. Constitution, the legal foundation of the nation, in which the
powers, duties, and limits of the federal government are established. States basically gave up certain powers (e.g.,
defense, foreign diplomacy, printing money), ceding these to the federal government while retaining all other powers
and duties. Health is not one of those powers explicitly bestowed upon the federal government. States, in turn, have
developed their own state constitutions, often patterned after the federal framework, although state constitutions tend
to be more clear and specific in their language, leaving less room and need for judicial interpretation. State
constitutions provide the broad framework from which states determine which activities will be undertaken and how
those activities will be organized and funded. These decisions and actions come in the form of state statutes.
Statutory (legislatively based) law includes all of the acts and statutes enacted by Congress and the various state
and local legislative bodies. This collection of law represents a wide range of governmental policy choices, including
• Simple expressions of preferences in favor of a particular policy or service (such as the value of home visits by
public health nurses)
• Authorizations for specific programs (such as the authority for local governments to license restaurants)
• Mandates or requirements for an activity to occur or, alternatively, to be prohibited (such as requiring all
newborns to be screened for specific metabolic diseases or prohibiting smoking in public places)
• Providing resources for specific purposes (such as the distribution of medications to patients with acquired
immune deficiency syndrome)
If the legislative intent is for something to occur, the most effective approaches are generally to require or prohibit
an activity.
The basic requirement for statutory-based laws is that they must be consistent with the U.S. Constitution and, for
state and local statutes, with state constitutions as well. State laws also establish the various subunits of the state and
delineate their responsibilities for carrying out state mandates, as well as the limits of what they can do. At the local
level, the legislative bodies of these subunits (e.g., city councils and county commissions) enact ordinances and
statutes setting forth the duties and authorizations of local government and its agencies. Laws affecting public health
are created at all levels in this hierarchy, but especially at the state and local levels. Among other purposes, these laws
establish state and local boards of health and health departments, delineate the responsibilities of these agencies,
including their programs and budgets, and establish health-related laws and requirements. Many of these laws are
enforced by governmental health agencies.
Administrative law is law promulgated by administrative agencies within the executive branch of government.
Rather than enact statutes that include extensive details of a professional or technical nature and to allow greater
flexibility in their design and subsequent revision, administrative agencies are provided with the authority to establish
law through rule-making processes. These rules, administrative law, carry the force of law and represent a unique
situation in which legislative, judicial, and executive powers are carried out by one agency. Administrative agencies
include cabinet-level departments, as well as other boards, commissions, and other entities that are granted this
power through an enactment of the legislative body.
The fourth type of law is judicial law, also known as common law. This includes a wide range of tradition, legal
custom, and previous decisions of federal and state courts. To ensure fairness and consistency, previous decisions are
used to guide judgments on similar disputes. This form of law becomes especially important in areas in which laws
have not been codified by legislative bodies. In public health, nuisances (unsanitary, noxious, or otherwise potentially
dangerous circumstances) are one such area in which few legislative bodies have specified exactly what does and what
does not constitute a public health nuisance. In this situation, the common law for nuisances is derived from previous
judicial decisions. These determine under what circumstances and for what specific conditions a public health official
can take action, as well as the actions that can be taken.
OUTSIDE-THE-BOOK THINKING 4-1
What is the legal basis for public health activities in the United States? What differences are there in the public health
powers of federal, state, and local governments?
Purposes of Public Health Law
Two broad purposes for public health law can be described: protecting and promoting health and ensuring the
protection of rights of individuals in the processes used to protect and promote health. Public health powers ultimately
derive from the U.S. Constitution, which bestows the authority to regulate commerce and provide for the general
welfare, and from the various state constitutions, which often provide clear but broad authorities, based largely on the
police power of the state. States often have reasonably well-defined public health codes. However, there is
considerable diversity in their content and scope, despite similarities in their basic sources of power and authority.
Many public health laws are enacted and enforced under what is known as the state’s “police power.” This is a
broad concept that encompasses the functions historically undertaken by governments in protecting the health, safety,
welfare, and general well-being of their citizens. A wide variety of laws derive from the police power of the state, a
power that is considered one of the least limitable of all governmental powers. The police power of the state can be
vested in an administrative agency, such as a state health agency, which becomes accountable for the manner in which
these responsibilities are executed. In these circumstances, its use is a duty, rather than a matter of choice, although
its form is left to the discretion of the user.
The courts have upheld laws that appear to limit severely or restrict the rights of individuals where these were
found to be reasonable, rather than arbitrary and capricious attempts to accomplish government’s ends. The state’s
police power is not unlimited, however. Interference with individual liberties and the taking of personal property are
considerations that must be balanced on a case-by-case basis. At issue is whether the public interest in achieving a
public health goal outweighs the public interest in protecting civil liberties. Public health laws requiring vaccinations
or immunizations to protect the community have generally withstood legal challenges claiming that they infringed
upon the rights of individuals to make their own health decisions. A precedent-setting judicial opinion upheld a
Massachusetts ordinance authorizing local boards of health to require vaccinations for smallpox to be administered to
residents if deemed necessary by the local boards.5 Such decisions argue that laws that place the common good ahead
of the competing rights of individuals should govern society. Similarly, courts have weighed the power of the state to
appropriate an individual’s property or limit the individual’s use of it if the best interests of the community make such
an action desirable. In some circumstances, equitable compensation must be provided. Issues of community interest
and fair compensation are commonly encountered in dealing with public health nuisances in which an individual’s
private property can be found to be harmful to others.
OUTSIDE-THE-BOOK THINKING 4-2
What is meant by a state’s police power, and how is that used in public health?
The various forms of law and the changing nature of the relationships among the three levels of government have
created a patchwork of public health laws. Despite its relatively limited constitutionally based powers, the federal
government can preempt state and local government action in key areas of public health regulation involving
commerce and aspects of communicable disease control. States also have authority to preempt local government
actions in virtually all areas of public health activity. Although this legal framework allows for a clear and rational
delineation of authorities and responsibilities, a quite variable set of arrangements has arisen. Often, the higher level
of government chooses not to exercise its full authority and shifts that authority to a lower level of government. This
can be accomplished in some instances by delegating or requiring, and in other instances by authorizing (with
incentives), the lower level of government to exercise authorities of the higher level. This has made for a complex set
of relationships among the three levels of government and for 50 variations of the theme to be played in the 50 states.
These relationships and their impact on the form and structure of governmental public health agencies will be evident
in subsequent sections of this chapter.
There have been many critiques of the statutory basis of public health in the United States. A common one is that
public health law, not unlike law affecting other areas of society, simply has not kept pace with the rapid and extensive
changes in science and technology. Laws have been enacted at different points in time in response to different
conditions and circumstances. These laws have often been enacted with little consideration as to their consistency
with previous statutes and their overall impact on the body of public health law. For example, many states have
different statutes and legal frameworks for similar risks, such as general communicable diseases, sexually transmitted
diseases (STDs), and human immunodeficiency virus infections. Confidentiality and privacy provisions, which trace
their origins to the vow in the Hippocratic oath not to reveal patient’s secrets, are often inconsistent from law to law,
and enforcement provisions vary as well. Beyond these concerns, public health laws often lack clear statements of
purpose or mission and are not clearly linked to modern public health core function and essential public health
services frameworks.
In view of these criticisms, recommendations have been advanced calling for a complete overhaul and recodification
of public health law. Recommendations for improvement of the public health codes often call for
• Stronger links with the overall mission and core functions of public health
• Uniform structures for similar programs and services
• Confidentiality provisions to be reviewed and made more consistent
• Clarification of police power responsibilities to deal with unusual health risks and threats
• Greater emphasis on the least restrictive means necessary to achieve the law’s intent through use of
intermediate sanctions and compulsive measures, based on proven effectiveness
• Fairer and more consistent enforcement and administrative practices
Although these recommendations have been advanced for several decades, little progress has been made at either
the federal or state level. At times, states have sought to recodify public health statutes by relocating their placement
in the statute books, rather than dealing with the more basic issues of reviewing the scope and allocation of their
public health responsibilities so that these are clearly presented and assigned among the various levels of government.
The intricacies of public health law often help drive the inner workings of federal, state, and local public health
agencies. We will now turn to the form and structure of these agencies.
GOVERNMENTAL PUBLIC HEALTH
Federal Health Agencies
The U.S. Public Health Service (PHS) serves as the focal point for health concerns at the federal level. Although there
have been frequent reorganizations affecting the structure of PHS and its placement within the massive Department of
Health and Human Services (DHHS), the restructuring completed in 1996 was the most significant in recent decades.
The changes were undertaken as part of the federal Reinvention of Government Initiative to bring expertise in public
health and science closer to the Secretary of DHHS. In the restructuring, the line authority of the Assistant Secretary
for Health over the various agencies within PHS was abolished, with those agencies now reporting directly to the
Secretary of DHHS, as illustrated in Figure 4-1. The Assistant Secretary for Health became the head of the Office of
Public Health and Science (OPHS), a new division reporting to the Secretary that also includes the Office of the
Surgeon General. Each of the former PHS agencies became a full DHHS operating division. These eight operating
agencies, the OPHS, and the regional health administrators for the 10 federal regions of the country now constitute
the PHS. In effect, PHS has become a functional rather than an organizational unit of DHHS. In 2003, several activities
related to emergency preparedness and response were moved into the newly established Department of Homeland
Security. An Office of Public Health Emergency Preparedness and Response remained at DHHS to coordinate
bioterrorism and other public health emergency activities managed by various PHS agencies. These duties were later
consolidated under a new Assistant Secretary for Preparedness and Response.
FIGURE 4-1 U.S. Department of Health and Human Services Organization Chart, 2014
Courtesy of U.S. Department of Health and Human Services, 2014.
PHS agencies address a wide range of public health activities, from research and training to primary care and
health protection, as described in Table 4-1. The key PHS agencies are
• Health Resources and Services Administration (HRSA)
• Indian Health Service
• Centers for Disease Control and Prevention (CDC)
• National Institutes of Health (NIH)
TABLE 4-1 U.S. Public Health Service Agencies
Health Resources and Services Administration (HRSA)
HRSA helps provide health resources for medically underserved populations. The main operating units of HRSA are the
Bureau of Primary Health Care, Bureau of Health Professions, Maternal and Child Bureau, and the HIV/AIDS Bureau. A
nationwide network of community and migrant health centers, augmented by primary care programs for the homeless
and residents of public housing, serve more than 10 million Americans each year. HRSA also works to build the
healthcare workforce and maintains the National Health Service Corps. The agency provides services to people with
AIDS through the Ryan White Care Act programs. It oversees the organ transplantation system and works to decrease
infant mortality and improve maternal and child health. HRSA was established in 1982 by bringing together several
existing programs. HRSA has nearly 2,000 employees, most at its headquarters in Rockville, Maryland.
Indian Health Service (IHS)
IHS is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health
services to members of federally recognized tribes grew out of the special government-to-government relationship
between the federal government and Indian tribes. This relationship, established in 1787, is based on Article I, Section 8
of the Constitution, and has been given form and substance by numerous treaties, laws, Supreme Court decisions, and
Executive Orders. IHS is the principal federal healthcare provider and health advocate for Native Americans, and its goal
is to raise their health status to the highest possible level. IHS currently provides health services to approximately 3
million American Indians and Alaska Natives who belong to more than 564 federally recognized tribes in 35 states. IHS
was established in 1924; its mission was transferred from the Interior Department in 1955. Agency headquarters are in
Rockville, Maryland. IHS has more than 15,000 employees.
Centers for Disease Control and Prevention (CDC)
Working with states and other partners, CDC provides a system of health surveillance to monitor and prevent disease
outbreaks, including bioterrorism events and threats, and maintains national health statistics. CDC also provides for
immunization services, supports research into disease and injury prevention, and guards against international disease
transmission, with personnel stationed in more than 54 foreign countries. CDC was established in 1946; its headquarters
are in Atlanta, Georgia. CDC has 11,000 employees.
National Institutes of Health (NIH)
Begun as a one-room Laboratory of Hygiene in 1887, NIH today is one of the world’s foremost medical research centers
and the federal focal point for health research. NIH is the steward of medical and behavioral research for the nation. Its
mission is science in pursuit of fundamental knowledge about the nature and behavior of living systems and the
application of that knowledge to extend healthy life and reduce the burdens of illness and disability. In realizing its goals,
NIH provides leadership and direction to programs designed to improve the health of the nation by conducting and
supporting research in the causes, diagnosis, prevention, and cure of human diseases; in the processes of human growth
and development; in the biological effects of environmental contaminants; in the understanding of mental, addictive and
physical disorders; and in directing programs for the collection, dissemination, and exchange of information in medicine
and health, including the development and support of medical libraries and the training of medical librarians and other
health information specialists. Although the majority of NIH resources sponsor external research, there is also a large in-
house research program. NIH includes 27 separate health institutes and centers; its headquarters are in Bethesda,
Maryland. NIH has approximately 19,000 employees.
Food and Drug Administration (FDA)
FDA ensures that the food we eat is safe and wholesome, that the cosmetics we use won’t harm us, and that medicines,
medical devices, and radiation-transmitting products such as microwave ovens are safe and effective. FDA also oversees
feed and drugs for pets and farm animals. Authorized by Congress to enforce the Federal Food, Drug, and Cosmetic Act
and several other public health laws, the agency monitors the manufacture, import, transport, storage, and sale of more
than $1 trillion worth of goods annually. FDA has over 15,000 employees. Among its staff, FDA has chemists,
microbiologists, and other scientists, as well as investigators and inspectors who visit more than 16,000 facilities a year
as part of their oversight of the businesses that FDA regulates. FDA, established in 1906, has its headquarters in Silver
Spring, Maryland.
Substance Abuse and Mental Health Services Administration (SAMHSA)
SAMHSA was established by Congress under Public Law 102-321 on October 1, 1992, to strengthen the nation’s
healthcare capacity to provide prevention, diagnosis, and treatment services for substance abuse and mental illnesses.
SAMHSA works in partnership with states, communities, and private organizations to address the needs of people with
substance abuse and mental illnesses as well as the community risk factors that contribute to these illnesses. SAMHSA
serves as the umbrella under which substance abuse and mental health service centers are housed, including the Center
for Mental Health Services (CMHS), the Center for Substance Abuse Prevention (CSAP), and the Center for Substance
Abuse Treatment (CSAT). SAMHSA also houses the Office of the Administrator, the Office of Applied Studies, and the
Office of Program Services. SAMHSA headquarters are in Rockville, Maryland; the agency has about 600 employees.
Agency for Toxic Substances and Disease Registry (ATSDR)
Working with states and other federal agencies, ATSDR seeks to prevent exposure to hazardous substances from waste
sites. The agency conducts public health assessments, health studies, surveillance activities, and health education
training in communities around waste sites on the U.S. Environmental Protection Agency’s National Priorities List.
ATSDR also has developed toxicity profiles of hazardous chemicals found at these sites. The agency is closely associated
administratively with CDC; its headquarters are also in Atlanta, Georgia. ATSDR has more than 400 employees.
Agency for Health Care Research and Quality (AHRQ)
AHRQ supports cross-cutting research on healthcare systems, healthcare quality and cost issues, and effectiveness of
medical treatments. Formerly known as the Agency for Health Care Policy and Research, AHRQ was established in 1989,
assuming broadened responsibilities of its predecessor agency, the National Center for Health Services Research and
Health Care Technology Assessment. The agency has about 300 employees; its headquarters are in Rockville, Maryland.
• Food and Drug Administration
• Substance Abuse and Mental Health Services Administration
• Agency for Toxic Substances and Disease Registry
• Agency for Healthcare Research and Quality (AHRQ)
PHS agencies comprise only a small part of DHHS. Other important operating divisions within DHHS include the
Administration for Children and Families, the Administration for Community Living, and the massive Centers for
Medicare and Medicaid Services (CMS). In addition, there are several administrative and support units for
management and the budget.
Beyond DHHS, health responsibilities have been assigned to several other federal agencies, including the federal
Environmental Protection Agency (EPA) and the Departments of Homeland Security, Education, Agriculture, Defense,
Transportation, and Veterans Affairs, just to name a few. The importance of some of these other federal agencies
should not be underestimated in terms of their roles and resources devoted to health purposes. Health-specific
agencies at the federal level are a relatively new phenomenon. The first cabinet-level federal human services agency of
any kind was the Federal Security Agency in 1939, and PHS itself remained a unit of the Treasury Department until
1944. This historical trivia demonstrates that federal engagement in public health is a relatively recent phenomenon.
The federal government is now the largest purchaser of health-related services, with spending on health
representing more than one-fourth of the total federal budget. Figure 4-2 compares total national health expenditures
with health expenditures attributed to the federal government and to state and local governments. Escalating costs for
healthcare services seriously constrain efforts to reduce the federal budget deficit, and there is little public or political
support for additional taxes for health purposes.
FIGURE 4-2 Total National Health Expenditures, and Federal and State/Local Government Expenditures for
Health-Related Purposes, United States, 1980–2012
Data from Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2013. Hyattsville, MD: NCHS;
2014.
It is no simple task to describe the federal budget development and approval process that determines funding levels
for federal health programs. Although one-fourth of the federal budget supports health activities, the major share is
spent on Medicare and Medicaid. These and other entitlement programs, such as Social Security, comprise two-thirds
of the federal budget; this spending is mandatory and cannot be easily controlled. The remaining one-third represents
discretionary spending; half of this is related to national defense purposes. Spending for discretionary programs is
more readily controlled. Nondefense discretionary spending for health purposes competes with a wide array of
programs, including education, training, science, technology, housing, transportation, and foreign aid and is declining
as a proportion of all federal spending.
Decisions authorizing and funding health programs are made in an annual budget approval process. The current
process is a complex one that establishes ceilings for broad categories of expenditures and then reconciles individual
programs and funding levels within those ceilings in omnibus budget reconciliation acts. For discretionary programs,
Congress must act each year to provide spending authority. For mandatory programs, Congress may act to change the
spending that current laws require. The result is a mixture of substantive decisions as to which programs will be
authorized and what they will be authorized to do, together with budget decisions as to the level of resources to be
made available through 13 annual appropriations bills. In recent years federal law has imposed a cap on total annual
discretionary spending and requires that spending cuts must offset increased mandatory spending or new
discretionary programs. This budgetary environment presents major challenges for new public health initiatives and,
not infrequently, threatens continued funding for programs that have been operating for decades.
The organization of federal health responsibilities within DHHS is quite complex fiscally and operationally. In
federal fiscal year 2015, the overall DHHS budget is about $1 trillion.6 DHHS has nearly 73,000 employees and is the
largest grant-making agency in the federal government, with some 60,000 grants each year. DHHS manages more
than 300 programs through its 11 operating divisions. The major share of the DHHS budget supports the Medicare
and Medicaid programs within HCFA. PHS activities account for less than one-tenth of the DHHS budget.
FIGURE 4-3 Fiscal Year 2015 U.S. Public Health Service Agency Program-Level Budgets
Data from the Fiscal Year 2015 Budget, U.S. Department of Health and Human Services, 2014.
Budgets for PHS operating divisions in federal fiscal year 2015 range from $30 billion for NIH to $400 million for
AHRQ as shown in Figure 4-3. Just over 50% of all PHS funds support NIH research activities, and another $32 billion
support the remaining PHS agencies with HRSA and CDC together accounting for about $18 billion, which represents
only 2% of total DHHS resources and about 0.5% of all federal spending.
As previously described, federal grants-in-aid have long been the prime strategy and mechanism by which the
federal government generates state and local action toward health priorities. A variety of approaches to grant making
have been used over recent decades. These can be categorized by the extent of restrictions or flexibility imparted to
grantees. The greatest flexibility and lack of requirements are associated with revenue-sharing grants. Block grants,
including those initiated in the early 1980s, consolidate previously categorical grant programs into a block that
generally comes with fewer restrictions than the previous collection of categorical grants. Formula grants are awarded
on the basis of some predetermined formula, often based at least partly on need, which determines the level of funding
for each grantee. Project grants are more limited in availability and are generally intended for a specific
demonstration program or project.
OUTSIDE-THE-BOX THINKING 4-3
What are the primary federal roles and responsibilities for public health in the United States? How do those roles and
responsibilities comport with Public Health Service (PHS) agency budget requests for federal fiscal year 2015?
In addition to being a prime strategy to influence services at the state and local level, federal grants also serve to
redistribute resources to compensate for differences in the ability of states to fund and operate basic health services.
They have also served as a useful approach to promoting minimum standards for specific programs and services. For
example, federal grants for maternal and child health promoted personnel standards in state and local agencies that
fostered the growth of civil service systems across the country. Other effects on state and local health agencies will be
apparent as these are examined in the following sections.
State Health Agencies
Several factors place states at center stage when it comes to health. The U.S. Constitution gives states primacy in
safeguarding the health of their citizens. From the mid-19th century until the 1930s, states largely exercised that
leadership role with little competition from the federal government and only occasional conflict with the larger cities.
Federal funding turned the tables on states after 1935, reaching its peak influence in the 1960s and 1970s. At that
time, numerous federal health and human service initiatives (such as model cities, community health centers, and
community mental health services) were funded directly to local governments and even to community-based
organizations. This practice greatly concerned state officials and served to damage tenuous relationships among the
three levels of government. The relative influence of states began to grow once again after 1980, with federal actions
restoring some powers and resources to states and their state health agencies. Although states were finding it
increasingly difficult to finance public health and medical service programs, they demanded more autonomy and
control over the programs they managed, including those operated in partnership with the federal government.
Ironically, local governments were making demands on state governments similar to those that states were making on
the federal government. States have found themselves uncomfortably in the middle between the two other levels of
government as states are one step removed from both the resources needed to address the needs of their citizens and
the demands and expectations of the local citizenry.
States carry out their health responsibilities through many different state agencies, although the overall
constellation of health programs and services within all of state government is roughly similar across states. In a
typical state, there are often two dozen or more state agencies that carry out health responsibilities or activities.
Somewhere in the maze of state agencies is an identifiable lead agency for public health. These official health agencies
are often freestanding cabinet-level departments reporting to the governor of the state. In more than one-half of the
states, the state health agency also reports to a state board of health or similar entity, although the prevalence of this
reporting relationship is declining. Another approach to the organizational placement of state health agencies finds
them within a multipurpose human service agency, often with the state’s social services and substance abuse
responsibilities. State health agencies are freestanding agencies in nearly 30 states and are part of multipurpose
health and/or human services agencies in the others.7
The official with statutory authority to carry out public health laws and declare public health emergencies is
generally the state health officer whose responsibilities also include serving as director of the state health department.
In some states, however, this statutory authority resides with other public officials, such as the governor or director of
the superagency in which the state health department is a component, or with the state board of health.
As identified in a recent profile of state public health agencies compiled by the Association of State and Territorial
Health Officials (ASTHO), key activities performed by state public health agencies include:
• Running statewide prevention programs like tobacco quit lines, newborn screening programs, and disease
surveillance.
• Ensuring a basic level of community public health services across the state, regardless of the level of resources
or capacity of local health departments.
• Providing the services of professionals with specialized skills, such as disease outbreak specialists and
restaurant and food service inspectors, who bring expertise that is otherwise hard to find, too expensive to
employ at a local level, or involves overseeing local public health functions.
• Collecting and analyzing statewide vital statistics, health indicators, and morbidity data to target public health
threats and diseases such as cancer.
• Directing statewide investigations of disease outbreaks, environmental hazards such as chemical spills and
hurricanes, and other public health emergencies.
• Monitoring the use of funds and other resources to ensure they are used effectively and equitably throughout the
state.
• Conducting statewide health planning, improvement, and evaluation.
• Licensing and regulating health care, food service, and other facilities.7
FIGURE 4-4 Selected Organizational Responsibilities of State Health Agencies, 2005
Data from Association of State and Territorial Health Officials. Washington, DC: ASTHO; 2006.
The range of responsibilities for the official state health agency varies considerably in terms of specific programs
and services. Staffing levels and patterns also show a wide range, reflecting the diversity in agency responsibilities.
The data presented on state health agencies in this chapter are derived from recent surveys of state health officials
conducted by ASTHO.7
Figure 4-4 illustrates the variability in state health agencies’ responsibilities for programs. In 2005, for example,
90% of the official state health agencies administered the Supplemental Food Program for Women, Infants, and
Children, vital statistics systems, public health laboratories, and tobacco prevention and control programs. Less than
one-half of the state health agencies administered the state Medicaid Program, mental health and substance abuse
services, and health professional licensing. Many state health agencies administered programs for environmental
health services, most frequently involving food and drinking water safety; however, only 20% of the state health
agencies served as the environmental regulatory agency within their state, which often includes responsibility for
clean air, resource conservation, clean water, superfund sites, toxic substance control, and hazardous substances.
Table 4-2 and Figure 4-5 summarize a wide range of state health agency characteristics and activities. SHAs have
made significant progress in completing the three prerequisites for accreditation—state health assessments, state
health improvement plans, and agency-wide strategic plans—since 2010 despite budget restrictions and staff
reductions.
State health agency responsibilities are anything but fixed in stone. Recent decades witnessed several changes in
their public health responsibilities, including more state health agencies taking on preparedness responsibilities and
expanding their health planning and development roles. On the other hand, fewer state health agencies are carrying
out environmental health and institutional licensing functions and some have transferred responsibility for natural
disaster preparedness. Notably, all-hazards preparedness and response is now one of the most prevalent of these
emerging roles.
TABLE 4-2 Vital Statistics for State Health Agencies (SHAs)
Data from Association of State and Territorial Health Officials, Profile of State Health – Volume 3. Washington, DC: ASTHO; 2014.
FIGURE 4-5 Selected Characteristics of State Health Agencies, 2012
Data from Association of State and Territorial Health Officials, Profile of State Health – Volume 3. Washington, DC: ASTHO; 2014.
In some states regional or district offices carry out state responsibilities and assist local health departments (LHDs).
Staff members assigned to district offices often provide consultation and technical assistance to local health agencies
especially for purposes of medical oversight, budgetary management, inspectional activities and code enforcement,
provision of education and training, and general planning and coordination for activities such as emergency
preparedness. More than 50% of the 100,000 full-time equivalent (FTE) employees of state health departments
perform their duties from regional, district, or local sites.
With public health responsibilities allocated differently across the various states, data on state public health
expenditures are difficult to interpret. These data do not allow for meaningful comparison across states because of the
variation in responsibilities assigned to the official state health agency. Importantly, these data often fail to
differentiate between population-based public health activities and personal health services.
OUTSIDE-THE-BOOK THINKING 4-4
Access the Web sites of any two U.S. state health departments and compare and contrast the two state-local public health
systems in terms of their structure, general functions, specific services, resources, and other important features. Your
focus should be on the state-local public health systems in these two states, rather than only the state health agencies!
The organizational placement and specific responsibilities of state health agencies largely determine the size of
their budgets and workforce. In order to identify state government expenditures for all public health activities, it is
necessary to examine the budgets of multiple state agencies. Data on state health expenditures for fiscal year 2003
indicate that states spent about $10 billion from state sources on population-based public health activities. In addition,
states expended another $9 billion of federal funding to support population-based services. Environmental protection,
injury prevention, and infrastructure activities were more likely to be funded from state sources. On the other hand,
funding for emergency preparedness and chronic disease prevention activity was more likely to come from federal
sources. State and federal funds equally supported prevention of epidemics and spread of disease.
In most states, more than a dozen state agencies carry out environmental health roles. This pattern replicates the
web of environmental responsibilities among federal agencies, creating a complex system often poorly understood by
the private sector and general public. Driving the organization of state responsibilities are several key federal
environmental statutes that include
• Clean Air Act
• Clean Water Act
• Comprehensive Environmental Response, Competition, and Liability Act and Superfund Amendments and
Reauthorization Act
• Federal Insecticide, Fungicide, and Rodenticide Act
• Resource Conservation and Recovery Act
• Safe Drinking Water Act
• Toxic Substance Control Act
• Food, Drug, and Cosmetic Act
• Federal Mine Safety and Health Act
• Occupational Safety and Health Act
The focus of federal statutes on specific environmental media (water, air, waste) has fostered the assignment of
environmental responsibilities to a variety of state agencies other than official state health agencies. The implications
of this diversification are important for public health agencies. State health agencies are becoming less involved in
environmental health programs; only a handful of states utilize their state health agency as the state’s lead agency for
environmental concerns. This role has largely shifted to state environmental agencies, although other state agencies
are also involved, resulting in state-level environmental strategies shifting from a health-oriented approach to a
regulatory approach. Despite their diminished role in environmental concerns, state health agencies continue to
address a very diverse set of environmental health issues and maintain epidemiologic and quantitative risk assessment
capabilities not available in other state agencies. Linking this important expertise to the workings of other state
agencies is a particularly challenging task.8
The wide variation in organization and structure of state health responsibilities suggests that there is no standard
or consistent pattern to public health practice among the various states. An examination of enabling statutes and state
public agency mission statements provides further support for this conclusion. One study found that only 11 of 43 state
agency mission statements address the majority of the concepts related to public health purpose and mission in the
Public Health in America document.9 When state public health enabling statutes are examined for consistency with the
essential public health services framework (also found in the Public Health in America document), the majority of
essential public health services could be identified in only one-fifth of the states. The most frequently identified
essential public health services reflected traditional public health activities, such as enforcement of laws, monitoring
of health status, diagnosing and investigating health hazards, and informing and educating the public. The essential
public health services least frequently referenced in these enabling statutes reflect more modern concepts of public
health practice, including mobilizing community partnerships, evaluating the effects of health services, and research
for innovative solutions. Only a few states were found to have both enabling statutes and state health agency mission
statements highly congruent with the concepts advanced in core functions/essential public health services framework.
State-based public health systems blend the roles of the state health agency and the LHDs in that state. In more
than 40 states, all areas of the state are served by an LHD. Where there is no LHD to provide public health services,
the state health agency usually provides basic public health coverage. Increasingly, states are using regional or district
structures to provide oversight and support for LHDs. In more than two thirds of states, local boards of health also
provide direction and oversight of local public health activities.
In sum, states face many challenges related to the fragmentation of public health roles and responsibilities among
various state agencies. Central to these are two related challenges: how to coordinate public health’s core functions
and essential services effectively and how to leverage changes within the health system to instill greater emphasis on
population-based preventive services. These are related aims.
Local Health Departments
In the overall structuring of governmental public health responsibilities, LHDs are where the “rubber meets the road.”
These agencies are established to carry out the critical public health responsibilities embodied in state laws and local
ordinances and to meet other needs and expectations of their communities. Although some cities had local public
health boards and agencies prior to 1900, the first county health department was not established until 1911. At that
time, Yakima County, Washington, created a permanent county health unit, based on the success of a county sanitation
campaign to control a serious typhoid epidemic. The number of LHDs grew rapidly during the 20th century, although
in recent decades, expansion has been tempered by consolidations.
LHDs should not be considered separately from the state network in which they operate. It is important to
remember that states, through their state constitutions and legislatures, establish the types and powers of local
governmental units that can exist in that state. In this arrangement, the state and its local subunits, however defined,
share responsibilities for health and other state functions. How health duties are shared in any given state depends on
a complex set of factors that include state and local statutes, history, need, and expectations.
Local health agencies relate to their state public health systems in one of three general patterns. In most states,
LHDs are formed and managed by local government, reporting directly to some office of local government, such as a
local Board of Health, county commission, or city or county executive officer. In this decentralized arrangement, LHDs
often have considerable autonomy although they may be required to carry out specific state public health statutes.
In some states, oversight of LHDs is shared between the state health agency and local government through the
power to appoint local health officers or to approve an annual budget. In other states with decentralized LHDs, some
areas of the state lack coverage because the local government chooses not to form a local health agency and the state
must provide services in those uncovered areas. This mixed arrangement occurs occasionally in about 20% of the
states.
Another 30% of the states use a more centralized approach, in which local health agencies are directly operated by
the state or there are no LHDs and the state provides all local health services. Classifying these arrangements as
decentralized, centralized, or mixed is useful from the perspective of the state-local public health system. From the
perspective of the LHD and the population it serves, however, the LHD is either a unit of local government or a unit of
state government or both.
LHDs are established by governmental units, including counties, cities, towns, townships, and special districts, by
one of two general methods. The legislative body may create an LHD through enactment of a local ordinance or a
resolution, or the citizens of the jurisdiction may create a local board and agency through a referendum. Both patterns
are common. Resolution health agencies are often funded from the general funds of the jurisdiction, whereas
referendum health agencies often have a specific tax levy available to them. There are advantages and disadvantages
to either approach. Resolution health agencies are simpler to establish and may develop close working relationships
with the local legislative bodies that create them. Referendum agencies reflect the support of the local electorate and
may have access to specific tax levies that preclude the need to compete with other local government funding sources.
Counties represent the most common form of subdividing states. In general, counties are geopolitical subunits of
states that carry out various state responsibilities, such as law enforcement (sheriffs and state’s attorneys) and public
health. Counties largely function as agents of the state and carry out responsibilities delegated or assigned to them. In
contrast, cities are generally not established as agents of the state. Instead, they have considerable discretion through
home rule powers to take on functions that are not prohibited by state law. Cities can choose to have a health
department or to rely on the state or their county for public health services. City health departments often have a
wider array of programs and services because of this autonomy. As described previously, the earliest public health
agencies developed in large urban centers, prior to the development of either state health agencies or county-based
LHDs. This status also contributes to their sense of independence and autonomy. These considerations, as well as the
increased demands and expectations to meet the needs of those who lack adequate health insurance, have made many
city-based, especially big city-based, LHDs more complex than other LHDs.
Both cities and counties have resource and political bases. Both rely heavily on property and sales taxes to finance
health and other services, and both struggle under the limitations of these funding sources. Political resistance to
increasing taxes is the major limitation for both. Relatively few counties and cities have imposed income taxes, the
form of taxation relied upon by federal and state governments.
Counties play a critical role in the public sector, the extent and importance of which is often overlooked. The
overwhelming majority of LHDs are organized at the county level, serving a single county, a city-county, or several
counties. As a result, counties provide a substantial portion of the community prevention and clinical preventive
services offered in the United States. Counties provide care for tens of millions at a cost of tens of billions from their
tax revenues through thousands of sites that include hospitals, nursing homes, clinics, health departments, and mental
health facilities. Counties play an explicit role in treatment, are legally responsible for indigent health care in over 30
states, and pay a portion of the nonfederal share of Medicaid in about 20 states. In addition, counties purchase health
care for several million county employees.10
The National Association of County and City Health Officials (NACCHO) tracks public health activities of LHDs; the
most recent survey of LHDs took place in 2013.10 Data provided in this chapter are derived from this 2013 survey, as
well as from several earlier surveys.
One limitation of information on LHDs is that there is neither a clear nor a functional definition of what constitutes
a LHD. The most widely used definition calls for an administrative and service unit of local government, concerned
with health, employing at least one full-time person, and carrying responsibility for health of a jurisdiction smaller than
the state. By this definition, more than 3,000 local health agencies operate in 3,042 U.S. counties. The number of LHDs
varies widely from state to state; Rhode Island has none, whereas neighboring Connecticut and Massachusetts each
report more than 100 LHDs.
More than two-thirds of LHDs are single-county health agencies, and over 80% operate out of a county base (single
county, multicounty, or city-county).10 Other LHDs function at the city, town, or township levels; some state-operated
units also serve local jurisdictions. Although precise numbers are uncertain, it appears that the total number of LHDs
has been increasing, from about 1,300 in 1947 to about 2,000 in the mid-1970s to somewhere near 3,000 today.
Authoritative reports going back nearly 70 years have proposed consolidation of small LHDs because of perceived
lack of efficiency and coordination of services, inconsistent administration of public health laws, and the inability of
small LHDs to raise adequate resources to carry out their prime functions effectively. Consolidations at the county
level would appear to be the most rational approach, but only limited progress has been achieved in recent decades.
Most LHDs are relatively small organizations; as illustrated in Figure 4-6, 61% serve populations of 50,000 or
fewer while 34% of LHDs serve populations of 50,000–499,999. Only 5% of LHDs serve populations of 500,000 or more
residents.10 Fully 90% of the U.S. population is served by an LHD in the medium and large population categories.
Table 4-3 summarizes basic descriptive information on LHDs.
OUTSIDE-THE-BOOK THINKING 4-5
Describe the basic structure of a typical local health department (LHD) in the United States in terms of type and size of
jurisdiction served, budget, staff, and agency head. (The NACCHO Web site may be useful here!) How does this compare
with the LHD serving your community?
Some states set qualifications for local health officers or require medical supervision when the administrator is not
a physician. About four-fifths of LHDs employ a full-time health officer. Health officers have a mean tenure of about 9
years. Approximately 15% are physicians. Fewer than one-fourth of LHD directors have graduate degrees in public
health.
Local boards of health are associated with most LHDs; in 2013, 70% of LHDs reported working with a local board of
health. About 35 states provide for some form of local boards of health. There are an estimated 3,200 local boards of
health; about 85% reported an affiliation with an LHD. However, 15% exist independently of any LHD; this pattern is
most common in Massachusetts, Pennsylvania, New Hampshire, Iowa, and New Jersey.
Virtually all local boards of health establish local health policies, fees, ordinances, and regulations. Figure 4-7
indicates that most local boards of health also recommend and/or approve budgets, establish community health
priorities, and hire the director of the local health agency. In recent decades, the roles of local boards of health have
shifted away from policy making to more advisory duties as local governments have become more directly involved
with oversight of their LHDs.
Similar to the situation with state health agencies, data on LHD expenditures lack currency and completeness.
Annual LHD expenditures in 2013 ranged from less than $10,000 to over $1 billion. One-half of LHDs had budgets of
$1 million or less, and 22% had budgets over $5 million. Total expenditures increase with size of population. LHDs
located in metropolitan areas had substantially higher expenditures than their nonmetropolitan area counterparts. The
median per capita LHD expenditure level in 2013 was $34 excluding clinical services.
FIGURE 4-6 Small, Medium, and Large LHDs; Percentage of all LHDs and Percentage of Population Served,
United States, 2013
Data from National Association of County and City Health Officials. 2008 National Profile of Local Health Departments. Washington, DC: NACCHO;
2009.
LHDs derived their funding from several sources: local funds (26%), the state (37%, including 17% that were
federal funds passing through the state), direct federal funds (2%), Medicaid and Medicare reimbursements (15%),
fees (12%), and other sources (8%). Metropolitan LHDs and those serving smaller populations are more dependent on
local sources of funding, while LHDs in nonmetropolitan areas and those serving larger populations rely more on state
sources.
Revenue from virtually all sources for LHDs had been increasing until the economic recession that began in 2008.
The number of FTE workers shows the same pattern. The economic downturn didn’t reverse course until 2012 and
2013—well after the official end of recession.
The number of FTE employees also increases with the size of the population served. Only 11% of LHDs employ 125
or more persons, and 68% have 24 or fewer employees. The number of employees and the number of different
occupations and professions are related to LHD population size. Clerical staff, nurses, sanitarians, managers, health
educators, and nutritionists are the most common occupational categories.
There is considerable variability in the services provided by LHDs. Top priority areas for LHDs overall are
communicable disease control, environmental health, and child health. LHDs serving both large and small populations
report similar priorities, although community outreach replaces environmental health as a top priority for the largest
local health jurisdictions (those over 500,000 population). Slight differences in priorities are also apparent between
metropolitan and nonmetropolitan area LHDs. LHDs in metropolitan areas often include inspections as a high priority,
while nonmetropolitan LHDs are more likely to include family planning and home healthcare services as priorities.
Many LHDs provide a common core battery of services that generally includes adult and childhood immunizations,
communicable disease control, community assessment, community outreach and education, environmental health
services, epidemiology and surveillance programs, food safety and restaurant inspections, health education, and
tuberculosis testing. Less commonly, LHDs provide services related to primary care and chronic disease, including
cardiovascular disease, diabetes, and glaucoma screening; behavioral and mental health services; programs for the
homeless; substance abuse services; and veterinary public health.12
LHDs do not always provide these services themselves; increasingly, they contract for these services or contribute
resources to other agencies or organizations in the community. Community partners for LHDs include state health
agencies, other LHDs, hospitals, other units of government, nonprofit and voluntary organizations, academic
institutions, community health centers, the faith community, and insurance companies. LHDs increasingly interact with
managed care organizations, although most do not have either formal or informal agreements governing these
interactions. Where agreements existed, they were more likely to be formal, to cover clinical and case management
services, and to involve the provision (rather than the purchase) of services.
TABLE 4-3 Vital Statistics for Local Health Departments (LHDs)
Data from National Association of County and City Health Officials, 2013 National Profile of Local Health Departments. Washington, DC:
NACCHO; 2014.
FIGURE 4-7 Selected Functions of Local Boards of Health
Data from 2013 National Profile of Local Health Departments, NACCHO, 2014.
INTERGOVERNMENTAL RELATIONSHIPS
In terms of public health roles, no level of government predominates. The relationships between and among the three
levels of government have changed considerably over time in terms of their relative importance and influence. This is
especially true for the federal and local roles. The federal government had little authority and little ability to influence
health priorities and interventions until after 1930. Since that time, it has exercised its influence primarily through
financial leverage on both state and local governments, as well as on the private medical care system. The massive
financing role of the federal government has moved it to a position of preeminence among the various levels of
government in actual ability to influence health affairs. This is evident in the federal share of total national health
expenditures and the federal government’s role in implementing the Affordable Care Act. However federal public
health spending represents only about 1% of total federal health spending, one-fourth less than in 2005 (Figure 4-8).
This suggests that the relative federal commitment to public health has declined somewhat over recent decades. The
federal proportion of total public health activity spending shows a similar pattern (Figure 4-9), declining from 20% in
2010 to 15% in 2012. Figure 4-10 traces public health activity spending from 1980 to 2012.
In recent decades, political initiatives have sought to diminish the powerful federal role and return some of its
authority back to the states. However, little in the form of meaningful transfer of authority or resource control has
taken place through 2014. It is likely that the federal government’s fiscal muscle will sustain its current upper hand in
its relationships with state and local government.
FIGURE 4-8 Federal Public Health Activity Spending as a Percentage of Total Federal Health Spending, United
States, 1960–2012
Data from Centers for Medicare and Medicaid Services, National Health Accounts (NHA), selected years, 1960–2012.
FIGURE 4-9 Federal Public Health Activity Spending as a Percentage of Total Public Health Activity Spending,
United States, 1960–2012
Data from Centers for Medicare and Medicaid Services, National Health Accounts (NHA), selected years, 1960–2012.
Local government has experienced the greatest and most disconcerting change in relative influence over the 20th
century. Prior to 1900, local government was the primary locus of action, with the development of both population-
based interventions for communicable disease control and environmental sanitation and locally provided charity care
for the poor. However, the massive problems related to simultaneous urbanization and povertization of the big cities
spawned needs that could not be met with local resources alone. States often viewed local governments in general and
LHDs in particular as their delivery system for programs and services. In any event, the power of states and the
growing influence of financial incentives through grant programs of both federal and state government acted to alter
local priorities. Priorities were being established by higher levels of government more often than through local
determinations of needs. Although the demands and expectations were being directed at local governments, key
decisions were being made in state capitals and in Washington, DC. Unfortunately there are signs that local
governments across the country are looking for opportunities to reduce their health roles for both clinical services and
population-based interventions where they can. The perception is that the responsibility for clinical services lies with
federal and state government or the private sector and that even traditional public health services can be effectively
outsourced. How these actions will comport with the widespread belief that services are best provided at the local
level raises serious questions regarding new roles of oversight and accountability that are not easily answered. Local
governments have lost control over priorities and policies; they bridle under the regulations and grant conditions
imposed by state and federal funding sources. As costs increase, grant awards fail to keep pace; however, even with
Obamacare wholly or partly uninsured individuals will continue to look to local government for services. These rising
expectations and increasing costs are occurring at a time when local governments are unable and unwilling to seek
additional tax revenues. The complexities of organizing and coordinating community-wide responses to modern public
health problems and risks also push local government to look elsewhere for solutions.
FIGURE 4-10 Federal and State/Local Public Health Activity Spending, United States, 1980–2012
Data from Centers for Medicare and Medicaid Services, National Health Accounts (NHA), selected years, 1980–2012.
OUTSIDE-THE-BOOK THINKING 4-6
What is the basis for the historic and ongoing tension between the powers of the federal government and the powers of
states in public health matters?
States were slow to assume their extensive powers in the health arena but have been major players since the latter
half of the 19th century. Although the growing influence of the federal government since 1930 displaced states as the
most important level of government, their relative role has strengthened since about 1980. Still, states have become
secondary players in the health sector. Most states lack the means, political as well as statutory, to intervene
effectively in the portion of the health sector located within their jurisdictional boundaries. This is further complicated
by their tradition of imitating the federal health bureaucracy whenever possible through the decentralization of health
roles and responsibilities throughout dozens of administrative agencies. Coordination of programs, policies, and
priorities has become exceedingly difficult within state government. Still, the widely disparate circumstances from
state to state make for laboratories of opportunity in which innovative approaches can be developed and evaluated.
The relationship between state and local government in public health has traditionally been tenuous and difficult.
Just as the federal government views the states, states themselves have come to view local governments as just
another way to get things done. As a result, states have turned to other parties, such as community-based
organizations, and have begun to deal directly with them, leaving local government on the sidelines. This undervaluing
of LHDs, when coupled with competing priorities, such as education, public safety, and transportation, within local
governments, presents major challenges for the future of public health services in the U.S. Instead of becoming
stronger allies, these forces are working to pull apart the fabric of the national public health network.
These ever-changing and evolving relationships call into question whether the governmental public health network
can be strengthened through a more centralized approach involving greater federal leadership and direction.11 With a
continued emphasis on decentralization, some states may truly be laboratories of innovation and offer creative
solutions. There are many examples of creative policies and programs at the state level, but there are also many
examples of state creativity being stifled by the federal government. The history of state requests for waivers of
Medicaid requirements is a case in point. Many states waited several years or more for federal approval of the waivers
necessary to begin innovative programs, and some of the more creative proposals were actually rejected. Still, it can
be argued that state political processes are more reflective of the different political values that must be reconciled for
progressive policies to develop.
CONCLUSION
Public health activities in the United States are coordinated by a network of state and local public health agencies
working in partnership with the federal government. This framework is precariously balanced on a legal foundation
that gives primacy for health concerns to states, a financial foundation that allows the federal government to promote
consistency and minimum standards across 50 diverse states, and a practical foundation of LHDs serving as the point
of contact between communities and their three-tiered government. Over time, the relative influence of these partners
has shifted dramatically because of changing needs, resources, and public expectations. The challenges to this
dynamic organizational structure are many. There are increasing calls for government to turn over many public
programs to private interests and growing distrust of government, in general. These developments make it easy to
forget that many of the public health achievements of the past century would not have been possible without a serious
commitment of resources and leadership by those in the public sector. In any event, it is clear that the organizational
structure of public health—its form—intimately reflects the structure of government in the United States. The extent to
which public health’s form facilitates or impedes its effective functioning is the focus of an upcoming chapter.
REFERENCES
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University Press; 1995.
4. Pickett G, Hanlon JJ. Public Health Administration and Practice. 9th ed. St. Louis, MO: Mosby; 1990.
5. Jacobson v Massachusetts. 197 US 11 (1905).
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8. Burke TA, Shalauta NM, Tran NL, Stern BS. The environmental web: a national profile of the state infrastructure for environmental health and
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CHAPTER 5
Twenty-First Century Community Public Health
Practice
LEARNING OBJECTIVES
Given an ecological perspective of the varied influences on the health of populations, develop a community
health improvement strategy that identifies community priorities and mobilizes community resources to
effectively address agreed-upon priorities. Key aspects of this competency expectation include being able to
• Explain the governmental presence in health concept
• Identify and describe public health’s core functions and essential services
• Describe how the core functions/essential public health services framework is operationalized in various community
health assessment and improvement activities
• Trace the development of public health practice standards over the past century
• Discuss how community health assessment, community health improvement planning, and organizational strategic
planning serve as the pillars of modern public health practice standards and the accreditation of public health
organizations
The Institute of Medicine’s (IOM) landmark report in 1988, The Future of Public Health, stimulated important changes
in the U.S. public health system.1 The IOM report rearticulated the mission, substance, and core functions of public
health and challenged the public health community to think more strategically, plan more collectively, and perform
more effectively. Exciting opportunities afforded by broader participation through engaging communities and other
stakeholders, heightened public expectations for addressing threats and emergencies, and the potential for better
integration of public health and medical care activities have energized these efforts. These developments brought
change to the public health system while offering new hope for achieving improved health outcomes through public
health practice. This chapter examines the link between public health’s functions and public health practice, focusing
on the organizing concepts for modern public health practice and how these have advanced new standards for public
health practice. Key questions to be addressed in this chapter are as follows:
• What have been public health’s main functions over the past century?
• What are the core functions of public health today?
• How are these functions translated into practice?
• What are the current standards for community public health practice?
Improvement science asserts that results reflect the systems that produce them. In other words, every system is
perfectly designed to achieve the exact results it gets. This somewhat elliptical wisdom underscores a major challenge
confronting efforts to enhance the results of public health practice: Improving health outcomes calls for improving the
basic processes of public health practice. However, as some additional reasoning from the improvement scientists
warns, to improve something, we must be able to control it; to control it, we must be able to understand it; and to
understand it, we must be able to measure it. Measurement relies on operational definitions for the concepts of
interest. Improving the performance of public health functions is an agenda that defines, measures, understands, and
controls the processes that constitute public health practice.
For nearly 100 years, the public health community has been grappling with this agenda, with only limited success
along the way.2 For much of the 20th century, an adequate conceptual framework for defining the public health system
was lacking. As a result, past efforts generally focused on measuring aspects of the public health system that only
indirectly or partially characterized the functions carried out in public health practice. This limited opportunities for
understanding, controlling, and improving public health practice and health outcomes. Nonetheless, these efforts
paved the way for developments that were subsequently jump-started by the 1988 IOM report.
PUBLIC HEALTH FUNCTIONS AND PRACTICE BEFORE 1990
Over much of the past century, the mission and purpose of public health (what it is) and its functions (how it addresses
its mission) were viewed as synonymous with the provision of public health services. In fact, public health’s services
were frequently characterized as its functions. Public health was known more by its deeds than its intent. As a result,
early efforts to describe and measure public health practice focused primarily on measuring aspects of important
public health services.
The earliest attempts to define and measure public health practice in the United States date back to 1914. Before
that time, public health functions were primarily those identified in the broad statutes of state and local governments,
centering on the prevention and control of infectious diseases. In 1914, however, a survey catalogued the various
services of state health agencies, as well as their role in fostering the development of local health departments (LHDs).
This study concluded that even though public health agencies were carrying out a wide variety of programs and
services they were missing their mark. Much of what was being done through public health agencies had little effect
on community health status, and there was actually much that these agencies could have been doing that would have
reduced mortality and morbidity.3 Public health practice was evaluated using a scoring system that placed greater
weight on some public health activities and services than on others, allowing a basis for comparisons across agencies.
Key elements of this approach were soon incorporated into local public health assessment initiatives orchestrated by
the American Public Health Association (APHA).
In 1921, the first report of APHA’s Committee on Municipal Health Department Practice called for the systematic
collection and analysis of information on local public health practice to support the development of standards for LHDs
serving the nation’s largest municipalities. The committee had determined that LHDs and the communities they served
would benefit from standards that would ensure a consistent level of public health services from one jurisdiction to
another. The committee also sought to identify characteristics of LHD practice that produce the best results. An
elaborate survey instrument and process were established; more than 80 big-city health departments were reviewed in
the initial effort.
The need to examine public health practice outside the nation’s large cities, especially in the growing number of
county-based LHDs, was soon apparent. In 1925, the committee was reconstituted as the Committee on Administrative
Practice to assess more broadly the status of public health practice in the United States. The new committee
developed the first version of an “Appraisal Form” to be used as a self-assessment tool by local health officers. The
intent was to measure the immediate results attained from local public health services. Examples of these immediate
results follow:
• Birth and death records adequately catalogued and analyzed
• Various vaccinations provided for specific age groups
• Health problems in school-aged children identified and treated
• Tuberculosis cases hospitalized and treated
• Laboratory tests performed4
Successive iterations of the Appraisal Form appeared through the 1920s and 1930s; these were well received by the
public health community, although there were occasional concerns that quantity was being emphasized over quality.
Local health officers were able to compare their ratings with those of other public health agencies. The basis for
comparison was a numerical rating score, based on aggregated points awarded across key administrative and service
areas. Comparative ratings were used to improve health programs, advocate for resources, summarize health agency
activities in annual reports, and engage other health interests in the community. Agency ratings often attracted
considerable public interest, resulting in both good and bad publicity for local agencies. Despite the initial intent to
emphasize immediate results, however, the major focus of the ratings remained on measuring the more concrete
aspects of public health practice, such as staff, clinic sites, patient visits, and the number of services rendered.
In 1943, a new instrument, the “Evaluation Schedule,” which was scored centrally by the APHA Committee on
Administrative Practice, replaced the self-assessment approach used in the Appraisal Form. The scores for health
agencies of varying size and type were widely disseminated so that individual LHDs could directly compare their
performance in meeting community needs with that of their peers. Table 5-1 lists some of the key performance
measures included in the 1947 version of the Evaluation Schedule.
TABLE 5-1 Public Health Practice Performance Measures from 1947 Evaluation Schedule
1. Hospital beds: percentage in approved hospitals
2. Practicing physicians: population per physician
3. Practicing dentists: population per dentist
4. Water: percentage of population in communities over 2,500 served with approved water
5. Sewerage: percentage of population in communities over 2,500 served with approved sewerage systems
6. Water: percentage of rural schoolchildren served with approved water supplies
7. Excreta disposal: percentage of rural schoolchildren served with approved means of excreta disposal
8. Food: percentage of food handlers reached by group instruction program
9. Food: percentage of restaurants and lunch counters with satisfactory facilities
10. Milk: percentage of bottled milk pasteurized
11. Diphtheria: percentage of children under 2 years given immunizing agent
12. Smallpox: percentage of children under 2 years given immunizing agent
13. Whooping cough: percentage of children under 2 years given immunizing agent
14. Tuberculosis: newly reported cases per death, 5-year period
15. Tuberculosis: deaths per 100,000 population, 5-year period
16. Tuberculosis: percentage of cases reported by death certificate
17. Syphilis: percentage of cases reported in primary, secondary, and early latent stage
18. Syphilis: percentage of reported contacts examined
19. Maternal: puerperal deaths per 1,000 total births, 5-year rate
20. Maternal: percentage of antepartum cases under medical supervision seen before the sixth month
21. Maternal: percentage of women delivered at home under postpartum nursing supervision
22. Maternal: percentage of births in hospital
23. Infant: deaths under 1 year of age per 1,000 live births, 5-year rate
24. Infant: deaths from diarrhea and enteritis under 1 year per 1,000 live births, 2-year rate
25. Infant: percentage of infants under nursing supervision before 1 month
26. School: percentage of elementary children with dental work neglected
27. Accidents: deaths from motor accidents per 100,000 population, 5-year rate
28. Health department budget: cents per capita spent by health department
Data from American Public Health Association, Committee on Administrative Practice. Evaluation Schedule for Use in Study and Appraisal of
Community Health Programs. New York, NY: APHA; 1947.
To develop a blueprint for a national network of LHDs that would provide every American with public health
coverage, the Committee on Administrative Practice established a Subcommittee on Local Health Units. The
subcommittee’s major report (widely known as the Emerson Report) in 1945 was a landmark for recommendations
regarding local public health practice. The Emerson Report became the postwar plan for public health in the United
States. The report’s far-reaching recommendations called for a minimum population base of 50,000 people for each
LHD and included state-by-state proposals for networks of LHDs that would cover all Americans while reducing the
number of LHDs by about 50% through consolidation of smaller units.5
The Emerson Report gave increased prominence to six basic services believed to represent local government’s
public health responsibilities to its citizens: vital statistics, environmental sanitation, communicable disease control,
maternal and child health services, public health education, and public health laboratory services.5,6 This was not a
new formulation for local public health services. Rather, it was essentially the same package of services that had been
considered the standard of practice among LHDs for several decades. Over time, these services had become widely
known as the six basic functions of public health (“Basic Six”); Table 5-2 describes the Basic Six. With the added
impetus of the Emerson Report, these six activities became the cornerstone for structuring local public health
practice. Although the report’s extensive recommendations never became national public policy, they promoted
positive changes in many states.
TABLE 5-2 Basic Six Services of Local Public Health
1. Vital statistics—collection and interpretation.
2. Sanitation.
3. Communicable disease control, including immunization, quarantine, and other measures such as identifying
communicable disease carriers and distributing vaccines to physicians as well as doing immunizations directly.
4. Maternal and child health (MCH), consisting of prenatal and postpartum care for mothers and babies and supervision
of the health of schoolchildren. In some places, immunization of children was handled by the MCH program.
5. Health education, including instruction in personal and family hygiene, sanitation and nutrition, given in schools, at
neighborhood health center classes, and in home visits.
6. Laboratory services to physicians, sanitarians, and other interested parties.
Data from Shonick W. Government and Health Services: Government’s Role in the Development of U.S. Health Services 1930–1980. New York:
Oxford University Press; 1995.
The Committee on Administrative Practice stimulated considerable interest in local public health practice. After
about 1950 and continuing into the 1980s, there were repeated efforts to reexamine and redefine the boundaries of
local public health practice. This search for mission redefinition is evident in a series of APHA policy statements from
1950 to 1970.6 In a 1950 APHA statement on LHD services and responsibilities, the Basic Six were presented as
desirable minimal services, and several new “optimal” responsibilities were identified: recording and analysis of health
data, health education and information, supervision and regulation, provision of direct environmental health services,
administration of personal health services, and coordination of activities and services within the community. Another
APHA policy statement in 1963 added seventh and eighth services to the Basic Six: operation of health facilities and
area-wide planning and coordination. Then, in 1970, APHA adopted another policy statement, expanding on these
concepts and calling for increased involvement of state and LHDs in coordinating, monitoring, and assessing the
adequacy of health services in their jurisdictions. The evolution of these various characterizations of public health
practice is traced in Table 5-3.
In the closing decades of the 20th century, important new expectations for local public health practice emerged.
Inadequate access to medical care was increasingly identified as a significant impediment to promoting and improving
community health. This resulted in local health departments increasingly serving a safety net function. This expanded
direct service provision role moved LHDs into new territory, beyond the boundaries of the expanded six functions that
characterized public health practice throughout the first half of the 20th century. There was considerable debate as to
whether this new role was appropriate, as well as whether LHDs should play leadership roles within their communities
in integrating medical and community health services. The movement into medical care was controversial from its
inception. Hanlon, in examining the future of LHDs in 1973, urged official public health agencies to withdraw from the
business of providing personal health services (whether preventive or therapeutic) and instead to “concentrate upon
[their] important and unique potential as community health conscience and leader”7(p901) in promoting the
establishment of sound social policy. Despite these admonitions, direct medical care services increased among LHDs
throughout the 1960s, 1970s, and 1980s, largely as a result of new federal and state grant programs. LHDs were
becoming significant providers of safety-net medical services, joining public hospitals and community health centers in
this important role.
Quietly emerging through these developments was a unique concept that began to shift the emphasis from the
services of public health to its mission and functions. This concept, often characterized as a governmental presence at
the local level (AGPALL), emerged in the 1970s in the process of fashioning model standards for communities to
participate in establishment of the 1990 national health objectives.8 As described in Table 5-4, AGPALL asserts that
local government, acting through various means, is ultimately responsible and accountable for ensuring that minimum
standards are met in the community. Every locality is served by a unit of government that has responsibility for the
health of that locality and population. This responsibility can be executed through an organization other than the
official public health agency, but government, through its presence and interest in health, is responsible to see that
necessary, agreed-on services are available, accessible, acceptable, and of good quality.
TABLE 5-3 Expansion of the Basic Six Public Health Services, 1920–1980
Initial “Basic Six”
• Vital statistics
• Sanitation
• Communicable disease control
• Maternal and child health
• Health education
• Laboratory services
“Optimal” Services in 1950s
• Basic Six as minimal level
• Analysis and recording of health data
• Health education and information
• Supervision and regulation
• Provision of direct environmental health services
• Administration of personal health services
• Coordination of activities and services within the community
Added in 1960s
• Operation of health facilities
• Area-wide planning and coordination
Added in the 1970s
• Coordinating, monitoring, and assessing the adequacy of health services
Data from Shonick W. Government and Health Services: Government’s Role in the Development of U.S. Health Services 1930–1980. New York:
Oxford University Press; 1995.
TABLE 5-4 Governmental Presence at the Local Level
The concept of governmental presence at the local level is based upon a multifaceted, multitiered governmental
responsibility for ensuring that standards are met—a responsibility that often involves agencies in addition to the public
health agency at any particular level. Regardless of the structure, every community must be served by a governmental
entity charged with that responsibility, and general-purpose government must assign and coordinate responsibility for
providing and ensuring public health and safety services. Where services in any area covered by standards are readily
available, government may also (but need not also) be involved in delivery of such services. Conversely, where there is a
gap in service availability, it is the responsibility of government to have, or to develop, the capacity to deliver such
services. Where county and municipal responsibilities overlap, agreements on division of responsibility are necessary.
In summary, government at the local level has the responsibility for ensuring that a health problem is monitored and that
services to correct that problem are available. The state government must monitor the effectiveness of local efforts to
control health problems and act as a residual guarantor of services where community resources are inadequate,
recognizing of course that state resources are also limited.
Reproduced from the U.S. Conference of City Health Officials, National Association of County Health Officials, Association of State and
Territorial Health Officials, American Public Health Association, and U.S. Department of Health, Education and Welfare, Public Health Service,
Centers for Disease Control. Model Standards for Community Preventive Health Services [Preamble to original model standards]. Public Health
Service: Atlanta, GA; 1978.
The AGPALL concept emphasizes the leadership and change agent dimensions of community public health practice;
however, exercising leadership to serve the community’s health is neither simple nor straightforward. The complexities
of 20th century health problems and their contributing factors often called for collaborative, rather than command-
and-control solutions. Key to identifying and solving important community health problems is the ability to engage
diverse interests and build constituencies. The AGPALL concept suggests that modern public health practice involves
more than the provision of services. This broader view of public health’s functions was powerfully reinforced by the
IOM report.
PUBLIC HEALTH FUNCTIONS AND PRACTICE AFTER 1990
The forecast for the public health system provided in the 1988 IOM report (appropriately titled The Future of Public
Health) was more dismal than many had expected. After all, the infrastructure of the national public health system had
grown substantially throughout the century, especially in terms of LHD coverage of the population. There was
widespread acceptance that appropriate community services should include chronic disease prevention and medical
care, in addition to the basic six services. Also, importantly, health status had never been better. Nevertheless, the
HIV/AIDS epidemic had emerged, and there was no shortage of intractable health and social issues being placed on
the public health agenda. Resources to meet these challenges were greatly limited, in part because of the insatiable
appetite of the medical care delivery system for every available health dollar. These forces acted together to dissipate
public appreciation and support for public health, and the IOM feared that public health would not be able to
overcome these challenges without a new vision that would engender the support of the public, policy makers, the
media, the medical establishment, and other key stakeholders.
The vision articulated in the IOM report was grounded in a broader view of public health functions than had existed
in the past. Throughout earlier decades, the services provided by public health agencies had come to be viewed by
many as public health’s functions. In identifying three core functions, the IOM report suggested that the function to
serve—whether described in terms of specific services or as the more abstract concept of assurance—incompletely
characterizes the unique role of public health in our society. Public health interventions represent the products of
carrying out public health’s core functions, rather than the functions themselves. The IOM examination explicated
three public health core functions: assessment, policy development, and assurance.1
Assessment calls for public health to regularly and systematically collect, assemble, analyze, and make
available information on the health of the community, including statistics on health status, community health
needs, and epidemiologic and other studies of health problems. Not every agency is large enough to conduct
these activities directly; intergovernmental and interagency cooperation is essential. Nevertheless, each
agency bears the responsibility for seeing that the assessment function is fulfilled. This basic function of
public health cannot be delegated.1(p7)
Policy development calls for public health to serve the public interest in the development of comprehensive
public health policies by promoting the use of the scientific knowledge base in decision making about public
health and by leading in developing public health policy. Agencies must take a strategic approach, developed
on the basis of a positive appreciation for the democratic political process.1(p8)
Assurance calls for public health to ensure their constituents that services necessary to achieve agreed on
goals are provided, either by encouraging actions by other entities (private or public), by requiring such
action through regulation or by providing services directly. Each public health agency is to involve key policy
makers and the general public in determining a set of high-priority personal and community-wide health
services that government will guarantee to every member of the community. This guarantee should include
subsidization or direct provision of high-priority personal health services for those unable to afford them.1(p8)
This new core function framework resonated widely within the public health community; its broader
characterization of the important functions of public health led to the definition and measurement of their operational
aspects, facilitating assessment of their performance. Several key aspects of the assessment, policy development, and
assurance functions are processes that identify and address health problems; others are processes (e.g., services and
other interventions) generated to ensure that these problems are addressed. To explicate the core functions and
provide a framework for characterizing modern public health practice, a work group representing the national public
health organizations developed the essential public health services framework.9 Since 1995, virtually all national and
state public health initiatives have adopted the essential public health services framework as the foundation for efforts
to characterize, measure, and improve the performance of public health practice. Unfortunately, the use of the term
services in the essential public health services framework can be a source of confusion. Although they are not services
in the same sense that most people view clinical services (e.g., immunizations) or community preventive services (e.g.,
fluoridating water), the essential public health services are important processes that operationalize the core functions
—assessment, policy development, and assurance—into actionable elements of public health practice.
Public health strives to identify health problems and their causative factors, develop strategies to address these
problems, and see that these strategies are implemented in a way that achieves the desired goals. Whereas a
comprehensive description for public health practice is yet to be agreed on, the best depiction of what contemporary
public health practice is all about can be found in the mission, vision, and functions outlined in the Public Health in
America statement.10 This one-page document articulates a vision (healthy people in healthy communities), a mission
(promoting physical and mental health and preventing disease, injury, and disability), and statements of what public
health practice does and how it accomplishes these ends. As presented in Table 5-5, these statements offer a
framework for establishing and measuring practice standards for public health systems, organizations, and workers.
The processes embodied in the essential public health services and their links to the three core functions are critical to
an understanding of modern public health practice.
OUTSIDE-THE-BOOK THINKING 5-1
Review the organization of health responsibilities in the state of your choice and describe how public health’s core
functions and essential services are distributed among various offices and agencies of state government beyond the state
health department.
TABLE 5-5 Relationship of Public Health in America Statement to Public Health Practice
Public Health in America Elements
Relationship to Public Health
Practice
Vision: Healthy people in healthy communities
Mission: Promote physical and mental health and prevent disease, injury, and
disability
Vision and mission statements for
public health practice
Public Health
• Prevents epidemics and the spread of disease
• Protects against environmental hazards
• Prevents injuries
• Promotes and encourages healthy behaviors
• Responds to disasters and assists communities in recovery
• Ensures the quality and accessibility of health services
Statements of the broad categories
of outcomes affected by public
health practice; sometimes viewed
as what public health does
Essential Public Health Services
1. Monitor health status to identify community health problems
2. Diagnose and investigate health problems and health hazards in the community
3. Inform, educate, and empower people about health issues
4. Mobilize community partnerships to identify and solve health problems
5. Develop policies and plans that support individual and community health efforts
6. Enforce laws and regulations that protect health and ensure safety
7. Link people with needed personal health services and ensure the provision of
health care when otherwise unavailable
8. Ensure a competent public health and personal healthcare workforce
9. Evaluate effectiveness, accessibility, and quality of personal and population-
based health services
10. Research for new insights and innovative solutions to health problems
Statements of the processes of
public health practice that affect
public health outcomes;
sometimes viewed as how public
health does what it does
Data from Public Health Functions Steering Committee. Public Health in America. Washington, DC: PHS; 1994.
Assessment in Public Health
Two important processes (or essential public health services) characterize the assessment function of public health: (1)
monitoring health status to identify community health problems and (2) diagnosing and investigating health problems
and health hazards in the community.
Monitoring health status to identify community health problems encompasses:
• Accurate, ongoing assessment of the community’s health status
• Identification of threats to health
• Determination of health service needs
• Attention to the health needs of groups that are at higher risk than the total population
• Identification of community assets and resources that support the public health system in promoting health and
improving quality of life
• Use of appropriate methods and technology to interpret and communicate data to diverse audiences
• Collaboration with other stakeholders, including private providers and health benefit plans, to manage
multisectoral integrated information systems
Diagnosing and investigating health problems and health hazards in the community encompass:
• Access to a public health laboratory capable of conducting rapid screening and high-volume testing
• Active infectious disease epidemiology programs
• Technical capacity for epidemiologic investigation of disease outbreaks and patterns of infectious and chronic
diseases and injuries and other adverse health behaviors and conditions
Policy Development for Public Health
The assessment function and its related processes provide a foundation for policy development and its key processes,
including (1) informing, educating, and empowering people about health issues; (2) mobilizing community
partnerships to identify and solve health problems; and (3) developing policies and plans that support individual and
community health efforts.
Informing, educating, and empowering people about health issues encompass:
• Community development activities
• Social marketing and targeted media public communication
• Provision of accessible health information resources at community levels
• Active collaboration with personal healthcare providers to reinforce health promotion messages and programs
• Joint health education programs with schools, churches, work sites, and others
Mobilizing community partnerships to identify and solve health problems encompasses:
• Convening and facilitating partnerships among groups and associations (including those not typically considered
to be health related)
• Undertaking defined health improvement planning process and health projects, including preventive, screening,
rehabilitation, and support programs
• Building a coalition to draw on the full range of potential human and material resources to improve community
health
Developing policies and plans that support individual and community health efforts encompasses:
• Leadership development at all levels of public health
• Systematic community-level and state-level planning for health improvement in all jurisdictions
• Development and tracking of measurable health objectives from the community health plan as a part of a
continuous quality improvement strategy
• Joint evaluation with the medical healthcare system to define consistent policy regarding prevention and
treatment services
• Development of policy and legislation to guide the practice of public health
OUTSIDE-THE-BOOK THINKING 5-2
How are the essential public health services related to public health’s three core functions? How are these
operationalized in public health practice?
Assurance of the Public’s Health
Whereas assessment and policy development set interventions into motion, the assurance function keeps them on
track through five important processes: (1) enforcing laws and regulations that protect health and ensure safety; (2)
linking people to needed personal health services and ensuring the provision of health care when otherwise
unavailable; (3) ensuring a competent public health and personal healthcare workforce; (4) evaluating effectiveness,
accessibility, and quality of personal and population-based health services; and (5) researching for new insights and
innovative solutions to health problems.
Enforcing laws and regulations that protect health and ensure safety encompasses:
• Enforcement of sanitary codes, especially in the food industry
• Protection of drinking water supplies
• Enforcement of clean air standards
• Animal control activities
• Follow-up of hazards, preventable injuries, and exposure-related diseases identified in occupational and
community settings
• Monitoring quality of medical services (e.g., laboratories, nursing homes, and home healthcare providers)
• Review of new drug, biologic, and medical device applications
Linking people to needed personal health services and ensuring the provision of health care when otherwise
unavailable (sometimes referred to as outreach or enabling services) encompass:
• Assurance of effective entry for socially disadvantaged people into a coordinated system of clinical care
• Culturally and linguistically appropriate materials and staff to ensure linkage to services for special population
groups
• Ongoing care management
• Transportation services
• Targeted health education/promotion/disease prevention to high-risk population groups
Ensuring a competent public and personal healthcare workforce encompasses:
• Education, training, and assessment of personnel (including volunteers and other lay community health workers)
to meet community needs for public and personal health services
• Efficient processes for licensure of professionals
• Adoption of continuous quality improvement and lifelong learning programs
• Active partnerships with professional training programs to ensure community-relevant learning experiences for
all students
• Continuing education in management and leadership development programs for those charged with
administrative/executive roles
Evaluating effectiveness, accessibility, and quality of personal and population-based health services encompasses:
• Assessing program effectiveness
• Providing information necessary for allocating resources and reshaping programs
Researching for new insights and innovative solutions to health problems encompasses:
• Full continuum of innovation, ranging from practical, field-based efforts to fostering change in public health
practice to more academic efforts to encourage new directions in scientific research
• Continuous linkage with institutions of higher learning and research
• Internal capacity to mount timely epidemiologic and economic analyses and conduct health services research
The important processes embodied in the essential public health services framework underscore the complexities of
public health practice. The essential public health services framework is relevant to both programs and organizations
and is evident in virtually any public health intervention (although to different degrees), constituting what might be
considered generic public health practice. The core functions and essential services framework demonstrate that
public health practice is more than a collection of programs and services; it embodies the AGPALL concept and the
tools to carry out that role.
COMMUNITY HEALTH ASSESSMENT AND IMPROVEMENT TOOLS
The delineation of core functions and essential public health services fortified the foundation for public health
practice.11 Over the two decades after the appearance of the IOM report, several important new tools for public health
practice came onto the scene to build on this foundation.
Mobilizing for Action through Planning and Partnerships
Among the early post-IOM report initiatives, the Assessment Protocol for Excellence in Public Health (APEXPH),
developed by the National Association of County and City Health Officials (NACCHO), in collaboration with other
national public health organizations, had an extensive and positive influence on public health practice.12 Even greater
reach and impact are expected from the second generation of this tool, Mobilizing for Action through Planning and
Partnerships (MAPP).13
OUTSIDE-THE-BOOK THINKING 5-3
Determine whether your LHD has completed a community health assessment and/or improvement process. If it has, what
approaches and tools were used? What were the products and results? If it has not, why?
The original APEXPH was a tool for organizational self-assessment and improvement for LHDs, as well as a simple
and effective community needs assessment process. APEXPH provided a means for LHDs to enhance their
organizational capacity and strengthen their leadership role in their communities. APEXPH guided health department
officials in two principal areas of activity: (1) assessing and improving the organizational capacity of the agency, and
(2) working with the local community to improve the health status of its citizens. There were three principal parts to
this process:12
1. An organizational capacity assessment—self-assessed key aspects of operations, including authority to operate,
community relations, community health assessment, public policy development, assurance of public health
services, financial management, personnel management, and program management, resulting in an
organizational action plan that set priorities for correcting perceived weaknesses.
2. A community health assessment process—guided formation of a community advisory committee that identified
health problems requiring priority attention and then set health status goals and programmatic objectives. The
aim was to mobilize community resources in pursuit of locally relevant public health objectives consistent with
the Healthy People objectives.
3. Completing the cycle—ensured that the activities from the organizational and community processes were
effectively carried out and that they accomplished the desired results through policy development, assurance,
monitoring, and evaluation activities.
After its appearance in 1991, APEXPH steadily gained acceptance with the majority of all LHDs using all or part of
APEXPH during the 1990s. Although the decade’s experience with APEXPH was highly positive, opportunities for
strengthening the tool became apparent. Heightened interest in community health improvement efforts, widespread
acceptance of the essential public health services as the framework for public health practice, the need to strategically
engage a wider range of community interests, and the opportunity to formalize and activate local public health
systems converged to suggest that an even more strategic approach to community health improvement was needed.
The development of MAPP addressed these needs in the form of a robust tool of public health practice that could be
used by communities with effective LHD leadership to create a local system that ensures the delivery of health
services essential to protecting the health of the public.13 Distinguishing features of MAPP include:
• Incorporation of strategic planning concepts—to assist LHDs in more effectively engaging their communities,
securing resources, and managing the process of change. Visioning, contextual environment assessment,
strategic issue identification, and strategy formulation principles are among the strategic planning concepts
embedded in MAPP.
• Grounding in local public health practice—to ensure that the process is practical, flexible, and user friendly. The
instruments rely heavily on the previous experiences and successes of typical communities through vignettes,
case studies, and other examples.
• A focus on the local public health system—to broaden community health improvement efforts by recognizing and
including all public and private organizations contributing to public health at the local level.
Because public health involves more than what public health agencies do, MAPP provides a framework for
actualizing this assertion through:
• A common approach for assessing local public health systems—to promote consistent quality of public health
practice from community to community and state to state. The essential public health services framework
provides the measures used to assess local public health systems consistent with other national and state efforts
to promote a basic set of public health performance standards.
• Expansion of the basic indicators for health status—to reflect better the demographic and socioeconomic
determinants of health, community assets, environmental and behavioral risks, and quality of life. MAPP includes
a core set of measures for all communities and an extended menu of additional measures for use, where
appropriate.
• Recognition that community themes and strengths play an important role in community health improvement
efforts—to balance overreliance on data and expert opinion, provide new insights into factors affecting
community health, and increase buy-in and active participation as stakeholders feel their concerns and opinions
are important to the process.
The model developed for MAPP incorporates interrelated and interactive components. To be practical for use in
widely diverse communities and to meld basic strategic planning concepts with public health and community health
improvement concepts, MAPP is both simple and complex, as illustrated in Figure 5-1. There is no fixed or even
preferred sequencing of its components. The boundaries of the model identify the four assessments that comprise the
MAPP process; these are usually completed after visioning has taken place but before strategic issues are identified in
the steps indicated in the center of the model. Each element of the model is briefly described here:
• Organizing for success/partnership development—involves establishing values and outcomes for the process and
determining the scope, form, and timing for planning process, as well as its participants.
• Visioning—involves developing a shared vision of the ideal future for the community, which serves to provide the
process with focus, purpose, direction, and buy-in.
• Four MAPP assessments—these inform the planning process and drive the identification of strategic issues. All
are critical to the success of the process, although there is no prescribed order in which they need to be
undertaken. The four strategic assessments are described below:
1. Community themes and strengths assessment—involves the collection of inputs and insights from throughout
the community in order to understand issues that residents feel are important.
FIGURE 5-1 MAPP Model
Reproduced from National Association of County and City Health Officials; 2000.
2. Local public health assessment—involves an analysis of mission, vision, and goals through the use of
performance measures for the essential public health services. Both strengths and areas for improvement are
identified.
3. Community health status assessment—involves an extensive assessment of indicators in 11 domains, including
asset mapping and quality of life; environmental health; socioeconomic, demographic, and behavioral risk
factors; infectious diseases; sentinel events; social and mental health; maternal and child health; health
resource availability; and health status indicators.
4. Forces of change assessment—identifies broader forces affecting the community, such as technology and
legislation.
• Identify strategic issues—involves fundamental policy questions for achieving the shared vision, arising from the
information developed in the previous phases. Some are more important than others and require action.
FIGURE 5-2 MAPP as a Road Map for Community Public Health Systems
Reproduced from National Association of County and City Health Officials; 2000.
• Formulate goals and strategies—involves developing and examining options for addressing strategic issues,
including questions of feasibility and barriers to implementation. Preferred strategies are selected.
• The action cycle—involves implementation, evaluation, and celebration of achievements after LHD leaders have
selected and agreed-upon strategies.
As depicted in Figure 5-2, MAPP offers a virtual road map for community public health systems. Widespread use of
MAPP began in 2001, and after only a few years, its impact was apparent in an evaluation of early adopters.14 LHDs,
other local government agencies, hospitals, and social service providers were the most frequent community
participants in the MAPP process, as shown in Figure 5-3. Educational institutions, nonprofit organizations,
community residents, local businesses and employers, and civic interest groups were the most frequently identified
new partners. Managed care organizations, health professional organizations, environmental agencies, and
neighborhood organizations were substantially less likely to be engaged in the MAPP process. LHDs reported that the
most frequent results from MAPP were the strengthened existing partnerships, an increased understanding of
community health problems, and greater community engagement.
Other Community Health Assessment and Improvement Tools
In addition to the essential public health services framework and the APEXPH/MAPP processes, the IOM report
stimulated several other important initiatives to promote core function-related performance, especially for the
assessment and policy development functions. One of the first community health planning tools to be widely used was
the Planned Approach to Community Health (PATCH), a process for community organization and community needs
assessment that emphasizes community mobilization and constituency building. PATCH focuses on orienting and
training community leaders and other community participants in all aspects of the community needs assessment
process and includes excellent documentation and resource materials. Although originally developed by the Centers
for Disease Control and Prevention (CDC) to focus on chronic health conditions and stimulate health promotion and
disease prevention interventions, PATCH is flexible enough to be used in a wide variety of community health needs
assessment applications.
FIGURE 5-3 Top Participant Categories for Communities Using MAPP
Data from Lenihan DP, Landrum LB, Turnock BJ. An Evaluation of MAPP and NPHPS in Local Health Jurisdictions. Chicago, IL: Illinois Public
Health Institute; 2006.
Yet another important tool for addressing public health core functions and their associated processes is the Model
Standards framework.8 The steps outlined for community implementation of the Model Standards process link many of
the various core function-related tools; these steps represent, in effect, a pathway for organizations to participate in
community health improvement activities. The steps include:
1. Assessment of organizational role. Communities are organized and structured differently. As a result, the
specific roles of local public health organizations will vary from community to community. This essential first step
is to reexamine organizational purpose and mission and develop a long-range vision through strategic planning
involving its internal and external constituencies. The resulting mission statement and long-range vision serve to
guide the organization (leadership and board, as well as employees) and to define it for its community partners.
This critical step should be completed before the remaining steps can be successfully addressed. Part 1 of
APEXPH and the expanded strategic planning elements of MAPP are useful in accomplishing this task.
2. Assessment of organizational capacity. After a mission and role have been defined, it is necessary to examine an
organization’s capacity to carry out its role in the community. This calls for an assessment of the major
operational elements of the organization, including its structure and performance for specific tasks. This type of
organizational and local public health system self-assessment is best carried out through broad participation from
all levels. Both APEXPH and MAPP include hundreds of indicators that can be used in this capacity assessment.
These indicators can be modified or eliminated if they are deemed inappropriate, and additional indicators can
also be used. This step serves to identify strengths and weaknesses relative to the mission and role.
3. Development of a capacity-building plan. The development of a capacity-building plan incorporates the
organization’s strengths and prioritizes its weaknesses so that the most important are addressed first. As in any
plan, specific objectives for addressing these weaknesses are developed, responsibilities are assigned, and a
process for tracking progress over time is established. Again, APEXPH and MAPP are valuable tools for
accomplishing this task.
4. Assessment of community organizational structure. Having looked internally at its capacity and ability to
exercise its leadership role for identifying and addressing priority health needs in the community, the public
health organization must assess the key stakeholders and necessary participants for a community-wide needs
assessment and intervention initiative. This is often a long-term and continuous process in which the relationship
of all important community stakeholders and partners (e.g., the health agency, community providers of health-
related services, community organizations, community leaders, interest groups, the media, and the general
public) is assessed. This step determines how and under whose auspices community health planning will take
place within the community. Both APEXPH/MAPP and PATCH processes support the successful completion of this
step.
5. Organization of community. This step calls for organizing the community so that it represents a strong
constituency for public health and will participate collaboratively in partnership with the health agency. Specific
strategies and activities will vary from community to community but will generally include hearings, dialogues,
discussion forums, meetings, and collaborative planning sessions. The specific roles and authority of community
participants should be clarified so that the process is not perceived as one driven largely by the health agency
and so-called experts. Both APEXPH/MAPP and PATCH are useful for completing this step.
6. Assessment of community health needs. The actual process of identifying health problems of importance to the
community is one that must carefully balance information derived from data sets with information derived from
the community’s perceptions of which problems are most important. Often, community readiness to mitigate
specific problems greatly increases the chances for success, as well as support for the overall process within the
community. In addition to generating information on possible health problems, this step gathers information on
resources available within the community. This step serves to provide the information necessary for the
community’s most important health problems to be identified. The community needs assessment tools provided in
both APEXPH/MAPP and PATCH are useful in accomplishing this step.
7. Determination of local priorities and community health resources. After important health problems are
identified, decisions must be made as to which are most important for community action. This step requires broad
participation from community participants in the process so that priorities will be viewed as community rather
than agency-specific priorities. Debate and negotiation are essential for this step, and there are many approaches
to coming to consensus around specific priorities. Both APEXPH/MAPP and PATCH support this step.
8. Selection of outcome objectives. After priorities are determined, the process must establish a target level to be
achieved for each priority problem. For this step, the Model Standards process is especially useful in linking
community priorities to national health objectives and establishing targets that are appropriate for the current
status and improvement possible from a community intervention. This step also calls for negotiation within the
community because deployment and reallocation of resources may be needed to achieve the agreed-upon target
outcomes. In addition to Model Standards, both APEXPH/MAPP and PATCH can be useful in accomplishing this
step.
9. Development of intervention strategies. This step is one of determining strategies and methods of achieving the
outcome objectives established for each priority health problem. This can be quite difficult and, at times,
contentious. For some problems, there may be few or even no effective interventions. For others, there may be
widely divergent strategies available, some of which may be deemed unacceptable or not feasible. After
agreement is reached as to strategies and methods, responsibilities for implementing and evaluating
interventions will be assigned. With community-wide interventions, overall coordination of efforts may also need
to be addressed as part of the intervention strategy.
10. Implementation of intervention strategies. After the establishment of goals, objectives, strategies, and methods,
specific plans of action for the intervention are developed, and specific tasks and work plans are developed. Clear
delineation of responsibilities and time lines is essential for this step.
11. Continuous monitoring and evaluation of effort. The evaluation strategy for the intervention will track
performance related to outcome objectives, as well as process objectives and activity measures over time. If
activity measures and process objectives are being accomplished, there should be progress toward achieving the
desired outcome objectives. If this does not occur, the selected intervention strategy needs to be reconsidered
and revised.
OUTSIDE-THE-BOOK THINKING 5-4
What features are similar among MAPP, PATCH, CHIP, and Model Standards? What features differ? What role do these
tools play in carrying out public health’s core functions at the local level?
In 1996, and again in 2002, the IOM revisited issues addressed in its 1988 report, concluding that different
organizations, leadership, and political and economic realities were transforming how public health carried out its
core functions and essential services.15,16 On one hand, market-driven health care was forcing public health to clarify
and strengthen its public role in a predominantly private health system. On the other, public health was increasingly
identifying and working with a variety of entities within the community that shape community health and well-being.
Another important IOM report in 1997 advanced an expanded community health improvement planning (CHIP) model
that extended the tools developed earlier in the decade and the steps described previously here.17 Its main features are
its expanded perspective on the wide variety of factors that influence health, its support for broad participation by
community stakeholders, and its emphasis on the use of performance measures to ensure accountability of partners
and track progress over time.
Community health assessments leading toward community health improvement plans increased in quantity as well
as quality during the 25 years between 1988 and 2013. A survey conducted by NACCHO in 2013 found that more than
two-thirds of local health jurisdictions (LHJs) nationwide had conducted a community health assessment in the past 5
years (58% within the past 3 years) and only 11% either had not completed one or were not planning one in the near
future. Similar results were reported for community health improvement plans and organizational strategic plans,
although at somewhat lower levels.18 Those LHDs not planning to conduct assessments, CHIPs, and strategic plans
were primarily the smallest local health jurisdictions with few full-time employees. State health agencies have also
been active in completing state health assessments, statewide health improvement plans, and agency-wide strategic
plans, as demonstrated in Figure 5-4. State agency commitment to these planning activities provides an additional
impetus for LHDs.
In most communities, LHDs serve as the primary instigators of community health assessments or serve as the lead
agency or full partner in a community-wide coalition that assumes responsibility for the assessment. A provision of the
Affordable Care Act health reform legislation requires nonprofit hospitals to engage in community health assessments
at least every 3 years and encourages hospitals to collaborate with public health agencies where possible. Figure 5-5
documents that two-thirds of LHDs either had already been collaborating with their local hospitals by 2013 or were in
discussions to incorporate hospitals into their existing community health assessment efforts.
Community Engagement
Communities remain the battlefields on which public health threats are met and public health challenges are
addressed in the 21st century. There was steady growth in the armamentarium of community public health practice
during the late 20th century in the form of community health assessment and improvement tools based on the core
functions and essential public health services framework. Community health improvement is grounded in the
realization that more doctors, more clinics, and more sophisticated diagnostic and treatment advances will not
alleviate the major health problems facing Americans. Instead, the greatest gains will come from what people do or do
not do for themselves, individually and collectively. Acting collectively can take place at many levels; at the community
level, it often works best.
FIGURE 5-4 State Health Agency (SHA) and Local Health Department (LHD) Participation in Health
Assessment, Health Improvement Planning, and Strategic Planning Activities, United States, 2012 and 2013
Adapted from National Association of County and City Health Officials. 2013 National Profile of Local Health Departments. Washington, DC:
NACCHO; 2014 and Association of State and Territorial Health Officials. Profile of State Health, Volume Three, 2012. Washington, DC: ASTHO;
2014.
The notion of community is an elusive concept. Generally, communities are aggregates of individuals who share
common characteristics or other bonds. One person can be part of many different communities. One definition views
community as the associative, self-generated gathering of common people who have sufficient resources in their lives
to cope with life’s demands and not suffer ill health. This definition of community focuses on the capacity of
communities to achieve their health goals through the effective use of their own assets. It differs considerably from the
view of communities as locations in which health problems reside and health services are delivered. Rather than
focusing on the level of individual actions and behaviors, it recognizes the importance of social determinants of health
and of the environmental and policy levels for public health responses. Community public health practice revolves
around engaging communities to work collectively on their own behalf. Community engagement is the process of
working collaboratively with groups of people who are affiliated by geographic proximity, special interests, or similar
situations, with respect to issues affecting their well-being. Although community engagement is a relatively recent
phenomenon for many governmental public health organizations, health education specialists have been using these
principles for decades, based on the simple guiding principle of starting where the people are.19
FIGURE 5-5 Collaboration between LHDs and Nonprofit Hospitals on Community Health Assessments, United
States, 2013
Data from National Association of County and City Health Officials. 2013 National Profile of Local Health Departments. Washington, DC: NACCHO;
2014.
This positive approach emphasizes that all communities have assets. All too often, communities have been viewed
solely in terms of their needs and problems. The implication of these different perspectives is important. If
communities are viewed from their needs, the policies and interventions will be based on needs. If they are to be
viewed from their assets, the policies and interventions will be based on the community’s capacities, skills, and assets.
Community health improvement seldom occurs from the actions of outside interests; the most successful community
development efforts are driven by the commitment of those investing themselves and their resources in the effort.
Identifying community assets is possible through approaches that catalog and actually map the basic building blocks
that will be used to address important community health problems.20 Primary building blocks include those community
assets that are most readily available for community health improvement, including both individual and organizational
assets. Individual assets include the skills, talents, and experiences of residents, individual businesses, and home-
based enterprises, as well as personal income. Organizational assets include associations of businesses, citizen
associations, cultural organizations, communications organizations, and religious organizations. Secondary building
blocks are private, public, and physical assets, which can be brought under community control and used for
community improvement purposes. These include private and nonprofit organizations (higher educational institutions,
hospitals, social service agencies), public institutions and services (public schools, police, libraries, fire departments,
parks), and physical resources (vacant land, commercial and industrial structures, housing, energy, and waste
resources).
In addition to community engagement and asset-mapping strategies, performance measurement offers another tool
for community health improvement activities. Performance measures are also not new to public health practice. The
use of performance measures to track progress toward community or national health objectives and to monitor
programs has long been standard practice. The CHIP proposed by the IOM in its report on performance monitoring,
however, takes performance measurement to a new level. In these processes, performance measures serve to hold
communities (acting through stakeholders and partnerships) accountable for actions for which they have accepted
responsibility.17 This supports the development of a shared vision and a collaborative and integrative approach to
community problem solving for the purpose of improving health status. It offers a pathway for stakeholders and
partners to assume responsibility collectively and to marshal their resources and assets in pursuit of agreed-upon
objectives.
The CHIP model incorporates a problem identification and prioritization cycle, followed by an analysis and
implementation cycle. This second cycle develops, implements, and evaluates health intervention strategies that
address priority community health problems. The distinguishing feature of this approach is the emphasis on
measurement to link performance and accountability on a community-wide basis, rather than solely on the LHD or
another public entity. Several recommendations were developed to operationalize the community health improvement
concept, including:
• Communities should base a health improvement process on a broad definition of health and a comprehensive
conceptual model of how health is produced within the community.
• A CHIP should develop its own set of specific, quantitative performance measures, linking accountable entities to
the performance of specific activities expected to lead to the production of desired health outcomes in the
community.
• A CHIP should seek a balance between strategic opportunities for long-term health improvement and goals that
are achievable in the short term.
• Community conditions guiding CHIPs should strive for strategic inclusiveness, incorporating individuals, groups,
and organizations that have an interest in health outcomes; can take actions necessary to improve community
health; or can contribute data and analytic capabilities needed for performance monitoring.
• A CHIP should be centered in a community health coalition or similar entity.17
Numerous useful tools and guides are available via the Internet to support the expanded community health
improvement efforts in models such as CHIP, MAPP, and similar initiatives. Prominent among these tools are CDC’s
Principles of Community Engagement, the Community Tool Box (developed by the University of Kansas), and the
Healthy People 2020 Tool Kit (produced by the Public Health Foundation).21-23
The maturation of community-driven models of public health practice was fostered in part by the National Turning
Point Initiative.24 Funded jointly by the Kellogg Foundation and Robert Wood Johnson Foundation, Turning Point sought
to transform and strengthen the public health infrastructure at the state and local levels, in effect, reforming public
health practice. More than twenty states participated in Turning Point through statewide and local partnerships that
brought together a broad spectrum of health interests to develop a shared vision and strategic plans to improve
statewide public health systems. The collaborations in the various Turning Point sites varied significantly, nurturing
and developing many different models for systems change.
The Healthy Communities framework represents another successful model for community health improvement,
using health as a metaphor for a broader approach to building community.25 Because health cuts across lines of race,
ethnicity, class, culture, and sector, the focus on a healthy community enables the entire community to collaborate in
community renewal. Healthy Communities is based on the belief that change in public policies and actions will occur
only when people act together to participate directly in the public work of our society and problems occur. A key to
success involves community institutions using their organizational skills, relationships, in-kind resources, and
credibility to engage the rest of the community in mobilizing the creativity and resources of the community to improve
health and well-being. Focusing on systems change, Healthy Communities seeks to build broad citizen participation
that encourages new players and honors diversity. It looks to build true collaborations between business, government,
nonprofit organizations, and citizens stimulating the community and political will to act together.
Community-based health policy development is also receiving greater attention in these collaborations and
partnerships. Public policy serves as a guide to influence governmental decisions and action at any jurisdictional level,
thereby affecting what would otherwise occur.26 For the health and well-being of communities, policies indicate broad
directions toward important goals, cutting across many different stakeholders and affecting large populations. Policies
focus on both goals and the means to achieve those goals, often affecting the decisions and actions of individual
organizations. At the community level, health policy has many options, such as more and better health services to
address unmet needs in the community or advocacy for broader support to improve the conditions influencing health
in the community. Increasingly, community-driven public health initiatives are tackling the broader social and
community factors, even as they seek to ensure that gaps in services are somehow met.
Little research is available to elucidate the value of community-driven health policy development initiatives. There
is some evidence that widespread initiation of CHIPs increases the frequency with which key policy development
components take place. Policy development may be the public health core function most heavily impacted by CHIPs.
The increase in performance of specific practices related to the core functions has been greatest for those related to
policy development, and generally, the baseline level of measures of policy development lags behind that of assessment
and assurance where CHIPs have not been implemented.
Together, these strategies, initiatives, and tools can make substantial contributions to improving public health
practice in the United States. In addition, there is reason to believe that improvement is needed in view of assessments
of performance that were completed over recent decades.
OUTSIDE-THE-BOOK THINKING 5-5
You are the administrator of a typical county-based LHD in a largely rural state. Your newly elected county board
chairman has ordered you to come up with new health-related initiatives that will improve the health of the county’s
residents. How would you approach this charge?
STRATEGIC PLANNING, STANDARDS, AND ACCREDITATION
Community health assessments, and community health improvement plans offer public health organizations an
opportunity to reexamine their mission, vision, and goals and to better align their strategic direction with community
needs and priorities. Strategic planning has become a third pillar of modern public health practice that is now
institutionalized in a process that accredits state and local public health agencies through the Public Health
Accreditation Board.
Strategic planning has long been recognized as an effective management practice and tool among private sector
organizations. More recently, the practice has become widely established among nonprofit and public sector
organizations. Strategic planning encompasses a series of key steps from laying the groundwork through
implementing, evaluating, and revising the plan. Preplanning calls for identifying key stakeholders, assessing the
availability of necessary information, and developing a plan, process, and timeline for the strategic planning project.
These preparatory activities provide a foundation for the critically important step of developing clear statements of
mission, vision, and values.
Many strategic planning processes begin with the identification of core values for the organization with the input of
key stakeholders and after careful consideration of both formal and informal mandates for the organization. An initial
mission statement is then developed as well as a vision statement that articulates where the organization wants to be
in the future. The vision statement is critical here, as it characterizes the difference between where an organization is
and where it wants to be. This sets the stage for the identification of strategic issues that must be addressed for the
vision to be achieved. Figure 5-6 illustrates the key components of an organizational strategic planning process.
Examination of strategic issues depends in part on the availability of relevant information. Existing reports and data
may or may not be useful. Additional data and information are often needed, as are appropriate methods of
summarizing data and information for the analysis step that follows.
FIGURE 5-6 Strategic Planning Process
Many methods are used to analyze data for strategic planning purposes, although one commonly used approach is
the SWOT/SWOC Analysis. In this method, strengths, weaknesses, opportunities, and threats (or challenges) are
identified as quadrants of an analysis matrix. Making these dimensions explicit facilitates the identification of
emerging trends, cross-cutting themes, and ultimately, key strategic issues and priorities.
It is these key strategic issues and priorities that drive the strategic plan in the form of its strategies, goals and
objectives, timelines, accountabilities, and evaluation framework. These are captured in a strategic planning document
that is widely communicated to staff and stakeholders.
As the plan is implemented, activities and objectives are monitored closely using quality improvement practices that
emphasize outcomes, yet foster flexibility to shift strategies when results dictate the need to do so. Revisions and
updates for the original strategic plan should be viewed as the rule, rather than the exception. It is equally important
that results be shared widely among staff and stakeholders.
Strategic plans for public health organizations benefit greatly from preexisting community health assessments and
community health improvement plans. Together, these three tools define the minimal requirements for an effective
public health organization. It should not be surprising that these three elements comprise the basic prerequisites for
PHAB accreditation. Public health organizations without a community health assessment, community health
improvement plan, and strategic plan simply aren’t living up to the standards and expectations of 21st century
community public health practice.
Accreditation of state and local public health organizations has been a controversial idea for decades. For many
years, the public health community did not view the observation, “If you’ve seen one health department, you’ve seen
one health department” as disparaging. For some, it was a badge of honor in that health departments should differ
from each other due to their unique populations, political structures, and community health needs. As discussed
earlier in this chapter, public health was long viewed as the programs and services provided, which understandably
differed from one community or state to another. After the IOM report in 1988, however, a view that core functions
rather than programs and community services defined a public health organization promoted a view that health
departments should in fact be more alike than different. These commonalities offered a template for common
standards to be developed and applied through national or state strategies to promote their widespread adoption.
Standards are basically explicit performance expectations. Progress towards the development of public health
practice standards came quickly after 1990. At the national level, CDC collaborating with the major national public
health practice organizations developed the National Public Health Performance Standards Program.27 These
standards were based on the 10 essential public health services framework and designed so that they could be used in
several applications that would synergize their adoption. These national standards could be used by health
departments for self-assessment and improvement. The standards or a subset of the standards could also be used for
national surveillance purposes to determine how many health departments or what proportion of the population were
being served by a health department meeting some level of these standards. The standards framework could also be
adopted or adapted by states, which would then require or incentivize their LHDs to meet the standards. Finally, some
external entity could apply the standards through a national voluntary accreditation program.
NACCHO extended and focused the content of the national public health performance standards in the development
of a panel of standards, again based largely on the essential public health services framework, that constituted an
operational definition of a functional local health department.28 Relatively soon thereafter with substantial financial
support from the Robert Wood Johnson Foundation, NACCHO and the other national public health practice
organizations collaborated to explore the feasibility and ultimately established a national voluntary program for public
health agency accreditation.
The standards and process for the national program were developed by the Public Health Accreditation Board over
several years.29 The PHAB standards focused on the same catalog of concepts captured in the NPHPS program and the
operational definition of a functional local health department. Once again the 10 essential public health services
served as organizing domains. The accreditation process calls for an extensive self-assessment activity before an on-
site verification and review by a site visit team. Notably, public health agencies must demonstrate completion of a
CHA, CHIP, and strategic plan in order to even submit an application for accreditation.
In 2013, PHAB announced the initial cohort of accredited public health agencies. Additional approvals steadily
followed as many agencies sought to be early adopters. Surveys of local and state health agencies, document that
demand for accreditation is already substantial. As indicated in Figure 5-7, by early 2014, nearly one-half of LHDs
had either been accredited or entered the pipeline for accreditation by submitting an application or letter of intent, or
by indicating that they planned to submit a letter of intent or apply through their state health agency.30 Only 17% of
LHDs indicated that they did not intend to seek accreditation, virtually guaranteeing that PHAB will be busy reviewing
applicants for years to come. Interest among state health agencies was even higher with 80% either already applying
or planning to apply as of later 2012.31
FIGURE 5-7 Level of Local Health Department Engagement with PHAB Accreditation, 2014 (n = 609)
Reproduced from National Association of County and City Health Officials. Local Health Department Accreditation: Findings from the 2014 Forces
of Change Study. Washington, DC: NACCHO; 2014.
CONCLUSION
For more than a century, public health has sought to measure its efforts through standards that reflected its mission to
promote and protect population health and well-being. The 1988 IOM report emphasized the need for stronger
assessment and policy development functions to complement the long-standing view that public health’s role is one of
assurance. The essential public health services framework operationalizes the core functions and serves as the
organizing construct for modern public health practice standards. For public health organizations, those standards are
achieved in part through community health assessments, community health improvement plans, and organizational
strategic plans. These activities are now recognized by the Public Health Accreditation Board as prerequisites for
recognition by that body, further establishing the core functions and essential public health services framework as the
bedrock of modern public health practice.
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Association of County and City Health Officials; 2000.
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Institute; 2006.
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Washington, DC: National Academy Press; 2003.
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CHAPTER 6
Public Health Emergency Preparedness and
Response
LEARNING OBJECTIVES
Given an emergency situation with public health implications (such as H1N1 influenza, massive flooding, or
bioterrorism threats), identify the critical components necessary for an effective response. Key aspects of this
competency expectation include being able to
• Differentiate among the various types of public health emergencies and disasters, including their definitions and
related terminology
• Describe why emergencies and disasters are problems in which the public health system must be an integral
participant across a range of activities
• Describe the roles, responsibilities and competencies expected of public health workers in emergency preparedness
and response
• Define terrorism and bioterrorism and identify category A, B, and C biologic agents and their unique characteristics
and relevance to bioterrorism events and threats, and
• Describe recent governmental public health initiatives for public health emergency preparedness and response
PUBLIC HEALTH ROLES IN EMERGENCY PREPAREDNESS AND RESPONSE
Public health crossed the threshold of the new century as an admittedly important but poorly understood contributor
to American society. Despite its contributions to population health status and quality of life throughout the 20th
century, the visibility and economic valuation of public health activities remained low. This situation changed rapidly
after the terrorist attacks on the World Trade Center and Pentagon on September 11, 2001, and the bioterrorism
events spreading anthrax through the United States postal system the following month. The nation responded quickly
in the aftermath of these events, elevating terrorism, bioterrorism preparedness, and emergency response to the top
of the national agenda. Within months, several billion dollars were made available to federal, state, and local public
health agencies for public health preparedness and response activities, with additional funding allocated annually
thereafter. This explosion of attention, resources, and expectations typifies the history of public health in America—a
dramatic health-related event spotlights a largely neglected public health infrastructure resulting in a rapid infusion of
resources to resuscitate the system.
This chapter describes the decisions made and actions taken to enhance public health emergency preparedness and
response, as well as some of the successes, failures, and lessons learned along the way. The intent is to chronicle why
and how public health emergency preparedness and response is emerging as one of the hallmarks of public health
practice in 21st century America. Toward that end, this chapter focuses on several key questions:
• What is public health preparedness?
• What are the key components of preparedness?
• Is the public health system adequately prepared?
• What is needed to become fully prepared?
The core functions and essential public health services framework for modern public health responses is organized
around six major functions:
• Preventing epidemics and the spread of disease
• Protecting against environmental hazards
• Preventing injuries
• Promoting and encouraging healthy behaviors
• Responding to disasters and assisting communities in recovery
• Ensuring the quality and accessibility of health services1
Although only one of these functions explicitly refers to public health’s role in responding to emergencies, all six
drive the public health approach to emergency preparedness and response. Public health emergency preparedness
and response efforts seek to prevent epidemics and the spread of disease, protect against environmental hazards,
prevent injuries, promote healthy behaviors, and ensure the quality and accessibility of health services. Each of these
is expected by the public and each is evident in effective preparedness and response related to public health
emergencies. Together they make preparedness and response a special and particularly critical component of modern
public health practice.
For public health emergencies, preparedness and response are inextricably linked.2 Preparedness is based on
lessons learned from both actual and simulated response situations. Effective response is all but impossible without
extensive planning and thoughtful preparation. Public health roles in health-related emergencies illustrate both facets.
Public Health Surveillance
Many public health emergencies are readily apparent, but others may not manifest themselves immediately. Effective
preparedness and response rely on monitoring disease patterns, investigating individual case reports, and using
epidemiologic and laboratory analyses to target public health intervention strategies. For example, foodborne illness
outbreaks may involve individuals who remain in the same location after being exposed, making it easier to identify a
common exposure pattern when these individuals seek medical care. Alternatively, an exposure at a convention or
family reunion is more difficult to detect because individuals may present for medical care far from the location of
exposure. Whether within the same community or in distant locations, it is often difficult for individual medical
practitioners to recognize that an outbreak or widespread epidemic is occurring. Prompt recognition and reporting of
cases to health authorities is a critical link in the public health chain of protection. New approaches to public health
surveillance include biosurveillance and syndromic surveillance, the early detection of abnormal disease patterns and
nontraditional early disease indicators, such as pharmaceutical sales, school and work absenteeism, and animal
disease events. Multiple large data sets can be mined and analyzed for nontraditional markers of disease, which can
lead to more rapid detection and response efforts.
OUTSIDE-THE-BOOK THINKING 6-1
What constitutes vulnerability in populations living in disaster-prone areas? Provide a concrete example from a disaster
that has drawn media attention in recent years.
Epidemiologic Investigation and Analysis
Once a disease event is reported, public health agencies can uncover unusual patterns that help identify outbreaks and
continuing risks. Public health professionals may use sophisticated analytic tools, such as pattern recognition
software
and geographic information systems, to determine patterns in disease cases. These surveillance activities help to
ensure that disease outbreaks are identified quickly and that appropriate response actions, such as the issuance of
health alerts for area providers and communication with response partners, are initiated. Many current disease
surveillance systems act in a passive manner (i.e., they rely on providers to initiate disease reports); however, public
health agencies are increasingly using active surveillance activities, such as when public health workers proactively
seek information from providers and other sources to monitor disease trends. In the event of an actual or threatened
public health emergency, active surveillance activities are deployed and/or expanded.
Surveillance activities trigger more extensive and focused epidemiologic investigations in order to determine the
identity, source, and modes of transmission of disease agents. Epidemiologic investigations seek to determine what is
causing the disease, how the disease is spreading, and who is at risk. Answers to these questions inform efforts to
mount rapid and effective interventions. Methods of obtaining epidemiologic information, often characterized as
disease detective activities, include contacting patients, obtaining detailed information on location and types of
possible exposures, and examining both clinical specimens (such as blood and urine) and environmental samplings
(such as food, water, air, and soil). Epidemiologic investigations require trained personnel and, in many cases, are
quite intensive in terms of the quantity and quality of human resources needed. Laboratory capacity to support these
investigations is critical.
Laboratory Investigation and Analysis
In many situations, laboratories provide the definitive identification of causative agents, both biological and chemical,
and through various fingerprinting activities link cases to a common source. Capabilities to identify rare or unusual
diseases are often not present in every community, necessitating linkages with higher level laboratories. Specimens
may be sent for analysis and confirmation to a regional or state public health laboratory or possibly even to a CDC
reference laboratory (laboratories are rated in terms of the level of safety they provide). Some specialized capabilities
found at these higher level laboratories include serotyping to determine the antigenic profile of a microorganism and
DNA fingerprinting to not only identify the type of microorganism causing an infectious disease but to also pinpoint
the particular strain of bacterium or virus involved. In this way, public health authorities can determine if reported
disease cases are part of the same outbreak, and therefore linked to a common source. Public health laboratories must
rely on specialized protective laboratory equipment and facilities because of the dangerous agents with which they
work. Some agents, such as smallpox, require special biocontainment equipment and procedures.
Intervention through Effective Countermeasures
The primary reason for collecting, analyzing, and sharing information on disease is to control that disease. Expending
resources for surveillance and analysis makes little sense if actions do not follow. Interventions that protect individuals
from risks associated with environmental hazards are many, including setting standards for health and safety,
inspecting food production and importation facilities, monitoring environmental conditions, abating conditions that
foster infectious disease (e.g., insect and animal control), and enforcing private-sector compliance with established
standards. Disease and injury risks associated with these biologic and chemical hazards, whether naturally occurring
or initiated by man, are reduced through rigorous monitoring and enforcement activities. Public health agencies also
play a substantial role in remediation of environmental hazards by decontaminating sites and facilities after they are
identified. The extent of remediation necessary can vary greatly, just as the nature and extent of the contamination
varies with different disease agents and their ability to remain viable outside a human host or animal/insect vector.
Risk Communication
Epidemiologic and laboratory investigations drive the initiation of actions intended to limit the spread of disease and
to prevent additional cases in the community. The range of possible actions can be quite broad, including restraining
the activities of individuals through isolation and quarantine and imposing temporary or permanent barriers around
sources of contamination (e.g., sealing buildings, closing restaurants, and cutting off water supplies). In severe and
unusual circumstances, special emergency powers may be put into effect limiting human and animal travel and/or
restricting certain types of business activity. In these situations, the importance of effective public education and
information activities to communicate risk to the public cannot be overstated. Commonly encountered examples
include notices to boil drinking water when contaminated water supplies are suspected and product recalls and food
safety advisories for potentially contaminated food products. The dissemination of information on mail handling
practices during the anthrax attacks in late 2001 served both public education and risk communication purposes.
Promoting and encouraging healthy behaviors during public health emergencies represents another public health
intervention strategy. It is not uncommon in the event of a natural disaster or terrorist attack for the most devastating
effects to take the form of social disruption and infrastructure damage. The psychological effects of fear and terror,
together with disruption of infrastructure components such as electricity, water, and safe housing, may create more
casualties than any initial terrorist’s biologic or chemical assault. Such conditions can also foster toxicity and
infectious disease threats, such as occurred with the mass evacuation of the area around the World Trade Center
leading to the abandonment of food supplies in surrounding homes and restaurants. Public health officials in New York
City took steps to secure these premises to avoid the proliferation of rodents and other pests that otherwise could have
resulted in secondary health threats.
Preparedness Planning
Organizing responses to emergencies is an important public health role that ensures the availability and accessibility
of medical and mental health services. Preparedness and planning cannot eliminate all biologic, chemical, radiation,
and mass casualty threats. But coordinated, community-wide planning for emergency medical and public health
responses ensures that emergency medical services and medical treatment services are deployed in a rapid and
effective manner. Such planning foresees the need for public health measures to be activated in order to ensure the
safety of responders and to prevent secondary effects caused by further disease transmission and injury risk. Planning
for these coordinated responses includes monitoring available response resources, establishing action protocols,
simulating emergency events to improve readiness, training public and private sector personnel, assessing
communication capabilities, supplies, and resources, and maintaining relationships with partner organizations to
improve coordination. Hazard vulnerability analyses are an especially important planning tool that rate and rank the
risk of specific emergencies for communities.
OUTSIDE-THE-BOOK THINKING 6-2
What are the basic functions that public health organizations perform in response to emergencies and disasters? When
and how should the organization identify these functions?
Community-Wide Response
Public sector agencies play an important, but not exclusive, role in community-wide responses to emergencies. In
many response situations, private sector medical care providers deliver the bulk of the triage and treatment services
needed when a mass casualty emergency occurs. Although less involved with direct care, public sector agencies play
key roles in coordinating and overseeing the delivery of services as well as communicating with providers, the media,
and the public. Supervision of decontamination and triage often falls to public health authorities. Countermeasures
such as antibiotics, antitoxins, and chemical antidotes as well as prophylactic medications and vaccines must be
obtained, deployed, and delivered. Public health plays an active role in situations necessitating deployment of
Strategic National Stockpile (SNS) pharmaceuticals, supplies, and equipment. In some situations, public health
professionals also provide direct medical care. Public health also contributes through mobilization of regional and
national assets and resources when local resources are overwhelmed. Some emergency situations, such as the anthrax
attacks of 2001, prompted public fear and overreactions resulting in mountains of unknown powdery substances being
tested and thousands of individuals unnecessarily initiating prophylactic antibiotic treatments. That situation and
others over recent years argue that the worried well can stress response systems even more than those actually
affected.
Unique Aspects of Bioterrorism Emergencies
Across the spectrum of possible public health emergency scenarios, bioterrorism threats represent a particularly
challenging form of public health emergency. Bioterrorism is the threatened or intentional release of biologic agents
(viruses, bacteria, or their toxins) for the purpose of influencing the conduct of government or intimidating or coercing
a civilian population to further political or social objectives. These agents can be released by way of the air (as
aerosols), food, water, or insects. Biologic agents with significant bioterrorism potential are listed in Table 6-1.
Category A includes organisms that pose a risk to national security because of several factors. These organisms can be
easily disseminated or transmitted from person to person, and they result in high mortality rates and have the
potential for major public health impact. In addition, these organisms are likely to cause public panic and social
disruption, thereby requiring special action for public health preparedness. Category B agents are the second highest
priority organisms. These are moderately easy to disseminate, result in moderate morbidity rates and low mortality
rates, and require specific enhancements of the CDC’s diagnostic capacity and enhanced disease surveillance. The
third highest priority agents fall into Category C and include emerging pathogens that could be engineered for mass
dissemination in the future because of availability, ease of production and dissemination, and potential for high
morbidity and mortality rates with major public health impact.
Biologic, chemical, radiation, and mass casualty threats that are intentionally inflicted differ from naturally
occurring disease and injury threats in a number of important aspects. Central to these differences, bioterrorism is a
criminal act requiring its prevention and response to include criminal justice, military, and intelligence agencies that
are not likely to be familiar with naturally occurring disease outbreaks. Law enforcement agencies, including the
Federal Bureau of Investigation, have lead responsibility for responding to a bioterrorism attack. In addition,
bioterrorism attacks may involve disease agents that occur infrequently in nature and with which neither public health
officials nor clinicians have had much experience. It is increasingly possible to genetically engineer chimeras to create,
for example, microorganisms that blend the pathogenic qualities of multiple disease agents. Because such organisms
do not exist in nature, they would be completely unknown to public health and medical experts. Attacks related to
biologic or chemical threats initiated by a bioterrorist would not likely follow known epidemiologic patterns,
diminishing the value of using past experience with disease transmission and manifestation to identify the source or
cause.
TABLE 6-1 Biologic Agents with Bioterrorism Potential
Category A
• Anthrax (Bacillus anthracis)
• Botulism (Clostridium botulinum toxin)
• Plague (Yersinia pestis)
• Smallpox (variola major)
• Tularemia (Francisella tularensis)
• Viral hemorrhagic fevers (filoviruses [e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo])
Category B
• Brucellosis (Brucella species)
• Epsilon toxin of Clostridium perfringens
• Food safety threats (e.g., Salmonella species, Escherichia coli O157:H7, Shigella)
• Glanders (Burkholderia mallei)
• Meloidosis (Burkholderia pseudomallei)
• Psittacosis (Chlamydia psittaci)
• Q fever (Coxiella burnetii)
• Ricin toxin from Ricinus communis (castor beans)
• Staphylococcal enterotoxin B
• Typhus fever (Rickettsia prowazekii)
• Viral encephalitis (alphaviruses [e.g., Venezuelan equine encephalitis, eastern equine encephalitis, western equine
encephalitis])
• Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum)
Category C
• Emerging infectious diseases such as Nipah virus and hantavirus
Reproduced from Centers for Disease Control and Prevention; 2010.
It is likely that bioterrorists would seek to be covert, expending great energy and attention to ensure the delayed
discovery of the disease to maximize the population’s exposure. Intentional outbreaks may develop in multiple
locations simultaneously, thereby straining local, state, and federal response efforts. With many emerging and
reemerging infectious disease threats (e.g., Ebola Virus, Sudden Acute Respiratory Syndrome, West Nile Virus,
hantavirus), it is increasingly difficult to predict the precise nature of the next public health emergency. It could result
from a chance mutation of a microorganism or it could result from the intentional act of terrorists. Multiple threats are
possible, necessitating preparedness and response systems that can address a wide variety of unknown and
unanticipated hazards. This concept of multiple threats and unknown hazards has led many terrorism experts to
advocate for a robust public health infrastructure capable of responding to many different forms of emergencies.
Protecting the public from infectious diseases and other threats is one of the major roles of public health in modern
society. This role took on a new meaning after the national security was threatened by the events of September 11,
2001, and the anthrax attacks that were initiated less than a month later. Figure 6-1 and Figure 6-2 summarize the
time lines and pathways for the most infamous bioterrorism attack in U.S. history. Initially focused on bioterrorism
threats and events, this new role of public health emergency preparedness and response for all types of emergencies
and disasters has emerged as central to what public health professionals and organizations are expected to perform in
21st century America.
Workplace Preparedness
Public health emergencies, including those related to terrorism, have many different visages and many different
venues. Yet most of the direct victims of terrorism in the United States in recent years have been people at work,
including the victims of the bombing of the federal building in Oklahoma City, those who died in the World Trade
Center and the Pentagon on September 11, 2001, and the victims who contracted anthrax transmitted through the
mail later in that same year.
Acts of terrorism intend to make people feel powerless and believe that they cannot take steps to prevent such
incidents or mitigate their consequences. But experience to date in battling other workplace safety risks suggests that
there are steps that can be taken by employers and employees. The workplace is, in effect, a key line of defense for
homeland security. This is recognized formally in the formation and scope of responsibilities for the new federal
Department of Homeland Security (DHS) as well as in the response of the business community after 2001 in taking
tangible steps to enhance security.
FIGURE 6-1 Epidemic Curve for 22 Cases of Bioterrorism-Related Anthrax, United States, 2001
Reprodcued from Jernigan DB, Raghunathan PL, Bell BP, et al. Investigation of bioterrorism-related anthrax, United States, 2002: epidemiologic
findings. Emerging Infectious Diseases. 2002; 8(10): 1019–1028.
FIGURE 6-2 Cases of Anthrax Associated with Mailed Paths of Implicated Envelopes and Intended Target Sites,
United States, 2001
Reprodcued from Jernigan DB, Raghunathan PL, Bell BP, et al. Investigation of bioterrorism-related anthrax, United States, 2002: epidemiologic
findings. Emerging Infectious Diseases. 2002; 8(10): 1019–1028.
NATIONAL PUBLIC HEALTH PREPAREDNESS AND RESPONSE COORDINATION
The terrorist events of 2001 resulted in a series of new national policies and priorities to safeguard American citizens
at home. One major development was the creation of the Department of Homeland Security (DHS) with extensive
authority and powers related to domestic terrorism and security. In accord with the Homeland Security Act of 2002,
several important public health functions were transferred into the new DHS in 2003, including the SNS of emergency
pharmaceutical supplies and medical equipment. Responsibilities for SNS were subsequently transferred from DHS to
CDC. The new federal agency immediately became part of the American everyday experience through activities
providing timely and detailed information about threat levels to the public, government agencies, first responders,
transportation hubs, and the private sector.
The establishment of a new federal agency, however, did not substantially alter the configuration of public health
responsibilities within the system of operational federalism described in our earlier examination of law, government,
and public health. Federal agencies are significant contributors, but public health remains largely a state
responsibility, with the bulk of this activity taking place at the local level. For public health emergencies, including
national disasters such as Hurricane Katrina in 2005 and bioterrorism events or threats, preparedness and
coordinated response across all levels of government are critical. Nonetheless, there are significant issues related to
intergovernmental relationships, resource deployment, and financing that make public health emergencies especially
difficult challenges for the public health system. The following sections examine key aspects of the structure,
operations, and issues in public health emergency preparedness and response at the national, state, and local levels.
Federal Agencies and Assets
Several dozen separate federal departments and agencies have roles in preparing for or responding to public health
emergencies, including bioterrorist attacks. Within this constellation of agencies, the Department of Health and
Human Services (DHHS) and DHS play the most important public health roles.
Prior to 2003, DHHS was the primary federal agency responsible for the medical and public health response to
emergencies (including major disasters and terrorist events). Beginning in 2003, DHHS now shares center stage with
the new DHS. DHHS discharges its responsibilities through several operating agencies, including the following:
• CDC: CDC works with state public health agencies to detect, investigate, and prevent the spread of disease in
communities. CDC provides support to state public health agencies in a variety of ways, including financial
assistance, training programs, technical assistance and expert consultation, sophisticated laboratory services,
research activities, and standards development. The Office of Public Health Preparedness and Response
coordinates efforts across the various CDC centers, institutes, and offices. CDC now has operational responsibility
for deployment of SNS resources during emergencies.
• Health Resources and Services Administration (HRSA): HRSA was the agency originally responsible for a state
grant program to facilitate regional hospital preparedness planning and to upgrade the capacity of hospitals and
other healthcare facilities to respond to public health emergencies until this program was transferred to the
Office of the Assistant Secretary for Preparedness and Response. HRSA is also generally responsible for
healthcare workforce development, including grant programs for curriculum development and continuing
education for health professionals on bioterrorism preparedness and response.
• Food and Drug Administration (FDA): FDA has responsibilities both for ensuring the safety of the food supply
and for ensuring the safety and efficacy of pharmaceuticals, biologics, and medical devices. FDA fulfills its food
safety responsibilities in partnership with the Department of Agriculture, which is responsible for the safety of
meat, poultry, and processed egg products.
• National Institutes of Health (NIH): NIH conducts and supports biomedical research, including research
targeted at the development of rapid diagnostics and new and more effective vaccines and antimicrobial
therapies.
• Office of the Assistant Secretary for Preparedness and Response (ASPR) within DHHS sets overall policy
direction and coordinates public health emergency preparedness and response activities across the various
DHHS agencies. This office now administers the hospital preparedness program, formerly managed by HRSA.
In 2003, 23 federal agencies, programs, and offices were fashioned into the new federal DHS. The new agency
sought to bring a coordinated approach to national security from emergencies and disasters, both natural and man-
made. DHS actively promotes an “all-hazards” approach to disasters and homeland security issues. The Federal
Emergency Management Agency (FEMA), formerly an independent agency, became one of the major branches of the
new DHS responsible for emergency preparedness and response, tasked with responding to, planning for, recovering
from, and mitigating against disasters under authority provided by the federal Stafford Act (Table 6-2).
Within DHS, the Emergency Preparedness and Response Directorate coordinates emergency medical response in
the event of a public health emergency, including the National Disaster Medical System and the Metropolitan Medical
Response Systems (these are described later in this chapter). Other major directorates (divisions) of the new DHS
include Border and Transportation Security, Science and Technology, Information Analysis and Infrastructure
Protection, and Management.
TABLE 6-2 Robert T. Stafford Disaster Relief and Emergency Assistance Act
The Congress hereby finds and declares that (1) because disasters often cause loss of life, human suffering, loss of
income, and property loss and damage; and (2) because disasters often disrupt the normal functioning of governments
and communities, and adversely affect individuals and families with great severity; special measures, designed to assist
the efforts of the affected States in expediting the rendering of aid, assistance, and emergency services, and the
reconstruction and rehabilitation of devastated areas, are necessary.
It is the intent of Congress, by this Act, to provide an orderly and continuing means of assistance by the Federal
Government to State and local governments in carrying out their responsibilities to alleviate the suffering and damage
which result from such disasters by—
(1) revising and broadening the scope of existing disaster relief programs;
(2) encouraging the development of comprehensive disaster preparedness and assistance plans, programs, capabilities,
and organizations by the States and by local government;
(3) achieving greater coordination and responsiveness of disaster preparedness and relief programs;
(4) encouraging individuals, States, and local governments to protect themselves by obtaining insurance coverage to
supplement or replace governmental assistance;
(5) encouraging hazard mitigation measures to reduce losses from disasters, including development of land use and
construction regulations; and
(6) providing Federal assistance programs for both public and private losses sustained in disasters.
P.L. 93-288, as amended.
Within DHS, the chief medical officer has primary responsibility for medical issues related to natural and manmade
disasters and terrorism. In the aftermath of Hurricane Katrina, the Pandemic and All-Hazards Preparedness Act
(PAHPA) of 2006 clarified the roles and responsibilities of DHS and DHHS. Several programs, including the National
Disaster Medical System, were moved from DHS to DHHS.
Other federal agencies also carry important responsibilities related to bioterrorism and public health emergency
preparedness. The Environmental Protection Agency responds to emergencies involving chemicals and other
hazardous substances. The Department of Defense indirectly supports public health preparedness through various
research efforts on biologic and chemical weapons, intelligence gathering related to terrorism threats, and civil
support functions in the event of an emergency that results in severe social unrest. The Department of Justice has lead
responsibility for assessing and investigating terrorist threats, including those related to bioterrorism, and provides
funds and assistance to emergency responders (police, fire, ambulance, and rescue personnel) at state and local levels.
The Department of Veterans Affairs purchases drugs and other therapeutics for the SNS and operates one of the
nation’s largest healthcare systems, which could provide critical surge capacity in the event of a mass casualty event.
Several other federal agencies, including the Departments of Transportation, Commerce, and Energy, also have
potential roles to play in preparing for and responding to a public health emergency.
National Incident Management System
Prior to the establishment of the new DHS, the management of large-scale health events was complicated by the
involvement of many different federal agencies. States have established a similar web of agencies to manage disasters
and other emergencies, with each developing its own form of an incident management system. In order to ensure
greater consistency across states and for interfaces between the federal government and states, a National Incident
Management System (NIMS) was prescribed by a presidential directive in 2003 to cover all incidents (natural and
unnatural) for which the federal government deploys emergency response assets. The Secretary of Homeland Security
is responsible for the development and implementation of NIMS. Its success depends in large part on the
establishment of consistent approaches within the states as to roles and responsibilities for both public health
agencies and the hospital community (including their supporting healthcare systems) in managing emergencies at the
state and regional levels and developing and deploying incident management plans at substate levels.
Bioterrorism and other public health incidents fall within the scope of NIMS. To this end, DHHS has the initial lead
responsibility for the federal government and deploys assets as needed within the areas of its statutory responsibility
(such as the Public Health Service Act and the Federal Food, Drug, and Cosmetic Act) while keeping the Secretary of
Homeland Security apprised regarding the course of the incident and nature of the response operations.
While NIMS is used for all events, the National Response Plan (NRP) is implemented for incidents requiring federal
coordination. The NRP is another key provision of the Homeland Security Act of 2002 and Homeland Security
Presidential Directive 5. The purpose of NRP is to align federal coordinating, structures, capabilities, and resources
into a unified, all-discipline, and all-hazards approach to domestic incident management. It is based on the premise
that incidents are typically managed at the lowest possible geographic, organizational, and jurisdictional level. NRP
does not alter or impede the ability of federal agencies to carry out their specific authorities under applicable laws,
executive orders, and directives. It establishes the coordinating structures, processes, and protocols required to
integrate the specific statutory and policy authorities of various federal departments and agencies in a collective
framework for action to include prevention, preparedness, response, and recovery activities. The NRP distinguishes
between events that require the secretary of DHS to manage the federal response for incidents of national significance
and the majority of incidents occurring each year that are handled by responsible jurisdictions or avenues through
other established authorities and existing plans.
Under the NRP, DHS assumes responsibility for coordinating federal response operations, including those involving
public health components, under certain conditions. DHS coordinates the federal government’s resources utilized in
response to or in recovery from terrorist attacks, major disasters, or other emergencies if and when any of the
following four conditions applies:
1. A federal department or agency acting under its own authority has requested the assistance.
2. The resources of state and local authorities are overwhelmed and federal assistance has been formally
requested by state and local authorities.
3. More than one federal department or agency has become substantially involved in responding to the incident.
4. DHS has been directed to assume responsibility for managing the domestic incident by the president.3
For states and local governments to gain full benefit from the emergency response assets of the federal
government, states must develop incident management systems that are interoperable with NIMS. Beginning in 2004,
adherence to and compatibility with NIMS became a condition of all grants and other awards from federal agencies for
any aspect of state or local emergency preparedness and response. NRP compliance was required as well after 2006.
The Pandemic and All-Hazards Preparedness Act (PAHPA) legislation of 2006 and 2013 reauthorized and
restructured key components of public health preparedness and response efforts in DHS and DHHS. PAHPA also
addressed lessons learned from the flawed federal response to Hurricane Katrina and growing concerns over a
possible global flu pandemic. Central to the restructuring of federal roles and responsibilities was the establishment of
a national health security strategy for public health emergency preparedness and response, including a full
assessment of federal, state, and local public health and medical capabilities. Key elements of the national health
security strategy in PAHPA focused on:
• Public health workforce enhancements including revitalization of the Commissioned Corps and loan repayment
programs to increase the number of public health professionals working in shortage areas;
• Vaccine tracking and distribution to improve effective distribution of seasonal flu vaccine supplies;
• Enhanced all-hazards medical surge capacity through use of mobile medical assets and federal facilities during
emergencies, expanding the Medical Reserve Corps and establishing a single nationwide network of systems for
the purpose of advance registration of volunteer health professionals;
• Biomedical research and development for vaccine and drug development to combat pandemic flu emergencies;
and
• Grants to state and local government to improve detection and response capabilities for pandemic flu.
Federal Emergency Medical Assets
Several national emergency response assets are available to state and local governments from the new DHS. These
include the National Disaster Medical System (NDMS), the Metropolitan Medical Response System (MMRS), and the
Strategic National Stockpile (SNS).
The NDMS now operates within the Office of Emergency Preparedness and Response within DHHS. NDMS brings
together medical services from DHHS, DHS, Defense, and Veterans Affairs to augment local emergency medical
services during a disaster or other large-scale emergency. The NDMS has several operational components, including
Disaster Medical Assistance Teams (DMATs), Disaster Mortuary Teams (DMORTs), Federal Coordinating Centers, and
Management Support Units.
DMATs are self-sustaining squads of licensed, actively practicing, volunteer professional and paraprofessional
medical personnel who provide emergency medical care at the site of a disaster or other emergency. DMAT teams
often triage, stabilize, and prepare patients for evacuation in mass casualty situations. They are sent into these
situations to supplement, rather than supplant or replace, local capacity. Once activated, these professionals are
federalized, allowing them to practice with their current professional licenses in any jurisdiction. DMORTs include
mortuary, dental, and forensic specialists who serve to augment the services of local coroners and medical examiners.
Portable temporary mortuaries for mass casualty situations are provided when needed. Management support units
provide command, coordination, and communication capabilities for DMATs and DMORTs and other federal assets.
Federal Coordinating Centers recruit hospitals to participate in the NDMS and recruit health workers for the DMATs
and DMORTs.
The MMRS, involving more than 100 metropolitan communities, integrates existing emergency response systems at
the local level, including emergency management, medical and mental health providers, public health agencies, law
enforcement, fire departments, emergency medical services, and the National Guard. The MMRS seeks to develop a
unified regional response to mass casualty events. MMRS was transferred from DHHS when the new DHS was
established in 2003.
The SNS ensures the availability and rapid deployment of life-saving pharmaceuticals, antidotes, other medical
supplies, and equipment necessary to counter the effects of nerve agents, biologic pathogens, and chemical agents.
The SNS stands ready for immediate deployment to any U.S. location in the event of a terrorist attack using a biologic
toxin or chemical agent directed against a civilian population. In the event of possible bioterrorist attack, a 12-hour
push package containing 50 tons of stockpile materials can be immediately dispatched to predetermined Receipt,
Store, and Storage sites identified in state bioterrorism response plans. There are twelve 12-hour push packages
centrally located around the U.S. for immediate deployment. Detailed deployment activities for SNS materials are
prescribed in state and local emergency response plans.
Federal Funding for Public Health Preparedness Infrastructure
Although multiple agencies provide federal funding for emergency preparedness, federal support for the public health
infrastructure at the state and local levels is provided largely from grants and cooperative agreements with CDC. In
1999, for the first time, CDC awarded more than $40 million for bioterrorism preparedness to states and cities for
enhanced laboratory and electronic communication capacity and another $32 million to establish a national
pharmaceutical stockpile to ensure availability of vaccines, prophylactic medicines, chemical antidotes, medical
supplies, and equipment needed to support a medical response to a biologic or chemical terrorist incident. At the time,
these appeared to be large sums. In the wake of September 11, 2001, and the anthrax attacks the following month,
increased concerns regarding homeland security led to a $2.1 billion FY 2002 appropriation for CDC’s antiterrorism
activities, over a 20-fold increase from FY 1999 levels. The FY 2002 supplemental appropriations nearly $1 billion for
grants to states and localities to upgrade state and local capacity. Roughly similar levels of funding were provided
throughout the first decade of the new century, although steady reductions marked the years of the second decade.
The state and local activities impacted by this funding are described in subsequent sections of this chapter.
STATE AND LOCAL PUBLIC HEALTH PREPAREDNESS AND RESPONSE
COORDINATION
State Agencies and Assets
Similar to the federal pattern, states rely on a variety of agencies to deliver public health emergency services. Also
similar to the federal model, these functions tend to be concentrated within a limited number of agencies at the state
level, with the state health department and state emergency management agency playing the most significant roles.
Most state health departments are freestanding agencies (i.e., not part of a larger human services agency), and many
have responsibility for emergency medical service systems within the state. However, most states have an
environmental health agency that is separate from the state health agency. Although these states may have an
environmental health section within the health agency, the environmental health agency is charged with monitoring
environmental contaminants and remediation of hazardous conditions. Nearly all states have a separate emergency
management agency (patterned after FEMA), and some states have established their own Departments of Homeland
Security. In responding to a public health emergency, the state public health agency works collaboratively with the
state emergency management agency as well as with the state environmental protection, law enforcement, public
safety, and transportation agencies and, in some instances, the National Guard.
States execute their powers and authority to act in public health emergencies through various state public health
laws. There are concerns that existing public health laws may be inadequate in some states because they are obsolete
and fragmented. A Model Public Health Emergency Powers Act was designed to assist states in examining and
enhancing their legal framework for public health emergencies. The model act addresses key issues related to
preparedness, surveillance, protection of persons, management of property, and public information and
communications.4
Considerable differences exist among states in the breadth and depth of services provided within their jurisdictions
and the degree to which public health service delivery responsibilities are delegated to local governments. In general,
however, state governments are ultimately responsible for ensuring adequate response to a public health emergency
and tend to play certain key roles in preparedness and response, regardless of how decentralized a particular public
health system might be. Except in the largest metropolitan local public health departments, local public health officials
rely on state personnel and capacity for a number of key functions, including advanced laboratory capacity,
epidemiologic expertise, and serving as a conduit for federal assistance.
OUTSIDE-THE-BOOK THINKING 6-3
Describe three or more provisions of public health statutes that are important elements of public health emergency
response plans.
States participate in an interstate agreement whereby one or more states can provide resources, equipment,
services, and other needed support to another state during an emergency incident. This mutual aid agreement, the
Emergency Management Assistance Compact (EMAC), covers licensing, credentialing, workers compensation, and
reimbursement, allowing personnel to focus on the emergency at hand. EMAC personnel integrate into the existing
structures of the requesting state. Of the more than 65,000 personnel deployed to Louisiana, Mississippi, and Alabama
for Hurricanes Katrina and Rita in 2005, nearly 4,000 were health and medical personnel.
Incident Command Systems
In order to manage resources effectively and facilitate decision making during emergencies, incident command
systems (ICS) are in wide use by police, fire, and emergency management agencies. Initially adopted for the fire
service, ICS eliminates many common problems related to communication, terminology, organizational structure, span
of control, and other differences across different disciplines and agencies in response to a critical incident. Critical
incidents include any natural or man-made event, civil disturbance, or any other occurrence of unusual or severe
nature that threatens to cause or actually causes the loss of life or injury to citizens and/or severe damage to property.
In managing critical incidents, clear goals and objectives are established and communicated to responders,
response plans are utilized, communications are effective, and resources are utilized in a timely and effective manner.
ICS should not be considered an additional set of procedures; rather the system must become part of routine
operations, with personnel fully trained in its use and standard operating procedures reflective of the capabilities
actually available.
One important key to effective ICS is the ability to size up the incident scene and make the initial call for resources.
This allows responders to get control of the incident rather than playing catch-up for the rest of the incident.
Appropriate initial size-up prevents unnecessary injury or loss of life, property or environmental damage, and negative
perceptions of the responding agencies.
Key components of ICS include
• Common terminology—Major organizational functions and units are named; in multiple incidents, each incident
is named. Common names are used for personnel, equipment, and facilities. Clear terms are used in radio
transmissions (e.g., codes, such as “10” codes, are not used).
• Modular organization—ICS develops “top down” from the first unit involved based on the specific incident’s
management needs. Each ICS is staffed with a designated incident commander (responsible for safety, liaison,
and information) with other functions (operations, planning, logistics, finance/administration) staffed as needed.
• Integrated communications—ICS uses a common communications plan and redundant two-way communications.
• A unified command structure—This is necessary when the incident is within a single jurisdiction with multiple
agencies involved, or the incident is multijurisdictional, or individuals representing different agencies or
jurisdictions share common responsibilities. All agencies involved contribute to the unified command process by
determining overall goals and objectives, planning jointly for tactical activities, conducting integrated tactical
operations, and maximizing the use of assigned resources.
• Consolidated action plans—Written action plans are necessary when the incident is complex and/or when several
agencies and/or jurisdictions are involved. Action plans include specific goals, objectives, and support-activities.
• A manageable span of control—The number of subordinates one supervisor can manage effectively should be
between three and seven, with five being optimal.
• Designated incident facilities—These include the command post from which all incident operations, direction,
control, coordination, and resource management are directed. Command posts can be fixed or mobile but need
adequate communications capabilities.
• Comprehensive resource management—This maximizes resource use, consolidates control, reduces
communications load, provides accountability, and reduces freelancing.
The emergency management team functions at the emergency operations center (EOC) where it coordinates
strategic decisions through the incident command structure. Ideally, the team should be isolated from the confusion,
media, and weather during the incident. EOC participants must have adequate authority and decision-making
capability. EOC decisions could include issuing curfews, circumventing normal bidding processes, emergency
appointments, permanent or temporary relocation, emergency demolition of unsafe properties, or implementation of
prophylaxis to populations. The EOC is supported operationally by incident command posts in the field, which are
responsible for tactical decisions as well as oversight and command of responders at the scene.
Effective emergency operations plans and standard operating procedures simplify decision making during
incidents. Training makes implementation of decisions easier for subordinates. When the level of preparation and
practice exercises is inadequate, emergency operations plans can become overwhelmed by common incidents and
unable to deal with those that are not fully anticipated. In such circumstances, decision making becomes complex and
challenging. A comprehensively planned and frequently exercised organizational system is necessary to overcome
these pitfalls.
As ICS has become increasingly accepted as an effective framework for responding to incidents, its use has
extended to other settings. For example, there has been much progress in development and deployment of hospital
emergency ICSs and tabletop exercises for hospitals. Several states have expanded on the ICS concept to develop
standardized emergency management systems that formally incorporate ICS, mutual aid agreements, and
multijurisdictional and interagency cooperation at the substate level, resulting in coordinated and unified decisions
throughout the state.
Local Agencies and Assets
The front line of response to public health emergencies is at the local level, where LHDs work collaboratively with
other first responders, such as fire and rescue personnel, emergency medical service providers, law enforcement
officers, hazardous materials teams, physicians, and hospitals in preparing for and managing the consequences of
health-related emergencies. Although the relationships between state and local public health agencies vary greatly
from state to state, and even from local jurisdiction to local jurisdiction within the same state, local government has
significant responsibilities for dealing with emergencies in virtually all states. First responders play key roles in:
• Recognizing public health emergencies, including those that result from terrorist attacks
• Identifying unique personal safety implications associated with the emergency situation
• Identifying security issues that are unique to the event or to the emergency medical system response
• Understanding basic principles of patient care based upon the type of emergency event encountered
Focusing on the services most directly related to emergency preparedness and response, the vast majority of LHDs
carry out activities related to epidemiology and surveillance, communicable disease control, food safety, and
restaurant inspections.5 Relatively few LHDs operate laboratory services, air quality, animal control, or water
inspections.
In those cases in which the LHD is not responsible for these services, they are typically delivered by another local
government agency (e.g., a fire department or environmental services agency), a private agency (hospital or
ambulance service), or the state. Even when services are offered by an LHD, they may be quite limited in terms of
scope or hours of availability. For example, although nearly one-half of LHDs report providing laboratory services,
these services may be quite limited in nature (e.g., to support tuberculosis and sexually transmitted disease testing).
Many LHDs that report having laboratory services are likely to rely on state public health labs for more specialized
diagnostic needs.
The state of readiness among LHDs has increased since 2001, when only about one-fourth of LHDs had completed a
comprehensive emergency response plan with another one-fourth indicating that planning was underway. Deployment
of LHD staff to assist in emergencies is limited by the size and qualifications of the agency’s workforce. More than one-
half of all LHDs have 20 or fewer staff members.5 Larger agencies generally have much higher staffing levels and a
more comprehensive range of expertise. Figure 6-3 illustrates the range of LHD activities related to emergency
preparedness and response in 2013. Nearly 60% of LHDs reported responding to an emergency event in the previous
year. Figure 6-4 demonstrates the percentage of LHDs responding to specific events or participating in drills and
exercises related to those emergencies. Table 6-3 catalogs the range and types of drills and exercises.
The configuration of LHDs within a state or in a multistate metropolitan area also varies across the country. Several
states organize local public health activities at a regional or district level. Other states have virtually hundreds of
LHDs that serve towns or townships, some in counties or districts served by a larger LHD. Some communities have no
LHD at all. Organizing preparedness and response efforts in these different circumstances presents special problems
in terms of multijurisdictional response, surge capacity, backup, and mutual aid agreements. Several capacity
assessment and enhancement tools are available from NACCHO and CDC to assist local assessment of readiness.6–8
Medical Reserve Corps are locally based volunteer response teams that can be deployed in emergency situations.
These multidisciplinary teams often have ongoing relationships with local public health agencies and other community
medical care providers that may include volunteer work on health promotion and screening projects or assistance with
mosquito control activities in communities where West Nile Virus presents a risk. During emergencies, Medical
Reserve Corps teams play predetermined roles such as providing local surge capacity for triage and medical care or
assisting with deployment of SNS materials. Several hundred communities already participate in the Medical Reserve
Corps program, either through start-up funding from the HRSA or through local resources.
FIGURE 6-3 Percentage of Local Health Departments with Selected Emergency Preparedness Activities in the
Past Year
Adapted from National Association of County and City Health Officials, 2013 National Profile of Local Health Departments. Washington, DC:
NACCHO; 2014.
FIGURE 6-4 Percentage of Local Health Departments Responding to a Specific All-Hazards Event or
Participating in a Drill or Exercise for that Event in the Past Year
Modified from National Association of County and City Health Officials, 2013 National Profile of Local Health Departments. Washington, DC:
NACCHO; 2014.
Education and training for frontline workers has been a continuing challenge for local agencies in order for them to
assess and address the training needs of key public health professionals, infectious disease specialists, emergency
department personnel, and other healthcare (including mental health) providers. Emergency preparedness
competencies (Table 6-4) for all public health workers serve as the focal point for these assessment, enhancement,
and recognition efforts. A more extensive panel of bioterrorism and emergency readiness competencies for various
categories of public health workers is also in wide use.9
Private Healthcare Providers and Other Partners
In nearly all communities, government agencies play a central role in preparing for and responding to public health
emergencies. Often overlooked, however, is the critical contribution made by private sector healthcare providers,
pharmaceutical manufacturers, agricultural producers, the food industry, and other private sector interests. An
important example is the role played by alert health professionals who are trained to recognize potential emergency
situations and report these suspicions to public health officials. Clinicians in Florida played a major role in first
identifying and then linking anthrax cases with bioterrorism in 2001. Hospital emergency rooms and physicians’
offices are where most individuals who have contracted an infectious disease or are exposed to dangerous chemicals
encounter their community’s emergency response system. That encounter should trigger an appropriate response if
the condition is one that represents a threat to others. Every state has incorporated requirements in state statute that
call for physicians, laboratories, and other health providers to notify public health officials when specific notifiable
diseases or conditions are encountered. Some states include a general provision that physicians should report
“unusual” infectious diseases. Despite these laws and regulations, compliance with disease reporting physicians
remains spotty for a variety of reasons. The requirements and the reporting procedures may not be understood by
some physicians. Others believe reporting is not worth the time and effort. Reporting from laboratories is more
complete, but concerns exist as to whether laboratories serving multiple jurisdictions are fully aware of differences in
requirements among the jurisdictions served.
TABLE 6-3 Types of Emergency Exercises
Exercise Activities that can be undertaken by an agency or group of agencies to test their readiness to
respond to emergencies or to evaluate the adequacy of their response plan and success of their
training program
Orientation seminar or
workshop
An exercise carried out to familiarize new staff with the agency’s emergency response activities
or current staff to new or changing information or procedures or to bring together response
agencies for better understanding and coordination
Drill An exercise limited to a specific response activity and conducted to instruct thoroughly through
repetition and practice
Tabletop An exercise conducted in a conference room setting with situations presented as verbal or
written problems or questions intended to generate discussion of actions to be taken based on
the emergency plan and standard operating procedures. Basic tabletop exercises use group
process to solve problems. Advanced play uses prescripted messages.
Functional An exercise usually conducted at the site where the event would normally take place such as the
command center and designed to evaluate the capabilities of the disaster response system.
Full scale An exercise designed to test a major portion of the emergency operations plan, evaluate the
operational capability of emergency responders in an interactive manner over an extended
period of time, and mobilize field personnel and resources.
Adapted from Center for Health Policy, Columbia University School of Nursing. Defining Emergency Exercises: A Working Guide to the
Terminology Used in Practicing Emergency Responses in Communities and Public Health Agencies. New York, NY: Columbia University School
of Nursing, Center for Health Policy; 2004.
In addition to playing an important role in identifying potential public health emergencies, healthcare providers
play a critical role in responding to the medical consequences of those emergencies, especially in mass casualty
situations. For the relatively rare disease threats associated with bioterrorism, healthcare providers often have only
limited experience dealing with these conditions and look to public health authorities for clinical guidance. Through
the development of community-wide emergency response plans, public health agencies, private sector delivery
systems, hospitals, physicians, pharmacies, nursing homes, and others are mobilized in the event of an emergency to
provide needed treatment to those affected by disease and to provide prophylactic care to those at risk for exposure to
disease. State and federal laws that confer tax-exempt status on hospitals typically require those institutions to provide
significant community benefit, including the provision of emergency medical services and participation in regional
emergency medical service planning. Funds for hospital preparedness, including staff training and preparedness
planning, are provided by DHHS and channeled through state health departments.
Other private sector interests also contribute to public health emergency preparedness. Although NIH makes
significant investments in the development of new vaccines and antimicrobial agents, pharmaceutical manufacturers
represent the primary source of funding for research and development. Efforts to encourage industry interest in the
development of vaccines and other countermeasures include incentives such as liability protections, antitrust waivers,
patent extensions, and long-term contracts. Similarly, activities to improve the safety and security of the food supply
will rely on the agricultural and food production industries to make necessary upgrades to their processes and to seek
innovative ways to minimize disease threats.
TABLE 6-4 Emergency Preparedness Core Competencies for All Public Health Workers
All Public Health Workers must be competent to
• Describe the public health role in emergency response in a range of emergencies that might arise (e.g., “The
department provides surveillance, investigation, and public information in disease outbreaks and collaborates with other
agencies in geological, environmental, and weather emergencies.”).
• Describe the chain of command in emergency response.
• Identify and locate the agency emergency response plan (or the pertinent portion of the plan).
• Describe his/her functional role(s) in emergency response and demonstrate his/her role(s) in regular drills.
• Demonstrate correct use of all communication equipment used for emergency communication (e.g., phone, fax, radio).
• Describe communication role(s) in emergency response—within the agency using established communication systems,
with the media, with the general public, and personal (with family, neighbors).
• Identify limits to own knowledge/skill/authority and identify key system resources for referring matters that exceed
these limits.
• Recognize unusual events that might indicate an emergency and describe appropriate action (e.g., communicate clearly
within chain of command).
• Apply creative problem solving and flexible thinking to unusual challenges within his/her functional responsibilities and
evaluate effectiveness of all actions taken.
Public Health Leaders/Administrators must also be competent to
• Describe the chain of command and management system (“incident command system”) or similar protocol for
emergency response in the jurisdiction.
• Communicate the public health information, roles, capacities, and legal authority to all emergency response partners—
such as other public health agencies, other health agencies, and other governmental agencies—during planning, drills,
and actual emergencies. (This includes contributing to effective community-wide response through leadership, team
building, negotiation, and conflict resolution.)
• Maintain regular communication with emergency response partners. (This includes maintaining a current directory of
partners and identifying appropriate methods for contacting them in emergencies.)
• Ensure that the agency (or the agency unit) has a written, regularly updated plan for major categories of emergencies
that respects the culture of the community and provides for continuity of agency operations.
• Ensure that the agency (or agency unit) regularly practices all parts of emergency response.
• Evaluate every emergency response drill (or actual response) to identify needed internal and external improvements.
• Ensure that knowledge and skill gaps identified through emergency response planning, drills, and evaluation are
addressed.
Public Health Professionals must also be competent to
• Demonstrate readiness to apply professional skills to a range of emergency situations during regular drills (e.g., access,
use, and interpret surveillance data; access and use lab resources; access and use science-based investigation and risk
assessment protocols; identify and use appropriate personal protective equipment).
• Maintain regular communication with partner professionals in other agencies involved in emergency response. (This
includes contributing to effective community-wide response through leadership, team building, negotiation, and conflict
resolution.)
• Participate in continuing education to maintain up-to-date knowledge in areas relevant to emergency response (e.g.,
emerging infectious diseases, hazardous materials, and diagnostic tests).
Public Health Technical and Support Staff must also be competent to
• Demonstrate the use of equipment (including personal protective equipment) and skills associated with his/her
functional role in emergency response during regular drills.
• Describe at least one resource for backup support in key areas of responsibility.
Data from Bioterrorism & Emergency Readiness Competencies for All Public Health Workers, Centers for Disease Control and Prevention, 2003.
Public Perceptions and Expectations
The flurry of activity to improve public health emergency preparedness and response capabilities is understandable.
The public is highly concerned over the possibility of terrorist attacks of all types. Fears of possible anthrax or
smallpox attacks are nearly as high as concerns of conventional explosives, airline hijacking or bombings, and attacks
using radioactive, toxic, or hazardous materials as weapons.10 Among these potential terrorist weapons, concerns
persist that smallpox will be used, related in part to the attention placed on smallpox at the national level with the
initiation of smallpox preparedness programs that include vaccinations for key medical and first responder personnel.
Although the public believes that the country is better prepared for a biologic or chemical attack than it was prior to
2002, the public perceives that the current level of preparedness is not high enough and more needs to be done. Public
health leaders have been concerned that the emphasis on bioterrorism would reduce efforts on other public health
problems and issues. Figure 6-5 and Figure 6-6 suggest that this concern may be unfounded as evidence suggests
that preparedness funding has actually served to strengthen key public health programs as well the public health
infrastructure in the United States.
FIGURE 6-5 Reported Change in Selected LHD Functions between 2002 and 2005 as a Result of Efforts to
Improve Emergency Preparedness
Data from National Associaiton of County and City Health Officials. 2005 National Profile of Local Health Departments. Washington, DC: NACCHO;
2006.
FIGURE 6-6 Percentage of States Reporting Stronger Infrastructure and Programs Because of Emergency
Preparedness Efforts
Data from Association of State and Territorial Health Officials (ASTHO). Profile of State Public Health, Volume One. Washington, DC: ASTHO; 2009.
State and Local Preparedness Grants
With the public health infrastructure increasingly viewed as a frontline defense against terrorism and homeland
security priority, federal funding for public health purposes increased dramatically beginning in 2002. To put this
increase into perspective, total governmental public health activity spending in 2000 was $43 billion, with the federal
government accounting for approximately $5 billion.11
Beginning in 2002, federal funding increased by more than $2 billion, with about one-half of that amount directed to
state and local governments for public health infrastructure improvements. Similar levels were funded through 2010
with reductions implemented thereafter. The infusion of this magnitude of resources afforded the opportunity to
address serious and longstanding gaps in public health protection and foster greater consistency and enhanced quality
throughout the national network of governmental public health agencies at the federal, state, and local levels.
Public health infrastructure funding was channeled to the states and several large cities (including New York,
Chicago, Los Angeles, and Washington, DC) through CDC. Each state received a minimum award of $5 million plus an
additional amount based on a population formula. Activities supported by these funds were to be consistent with
federal guidance. In several funding cycles, additional priorities were added, some without additional resources. In
2003 federal guidance incorporated specific smallpox preparedness and response capacities and allowed for costs
associated with smallpox preparedness to be covered by grant funds. In 2006, pandemic flu preparedness became a
priority with some additional one time funding provided. Amidst the evolution of broader federal policies on national
security, CDC guidance since 2011 has focused on increasing specific capabilities at the state and local level.
State and Local Emergency Preparedness Capabilities
In 2011, CDC implemented a systematic process for defining a set of public health preparedness capabilities to assist
state and local health departments with their strategic planning. The resulting public health preparedness capabilities
established national standards for public health preparedness capability-based planning in order to assist state and
local planners in identifying gaps in preparedness, determining the specific jurisdictional priorities, and developing
plans for building and sustaining capabilities.
CDC identified 15 public health preparedness capabilities (shown below in their corresponding domains) as the
basis for state and local public health preparedness:
Biosurveillance
• Public Health Laboratory Testing
• Public Health Surveillance and Epidemiological Investigation
Community Resilience
• Community Preparedness
• Community Recovery
Countermeasures and Mitigation
• Medical Countermeasure Dispensing
• Medical Materiel Management and Distribution
• Non-Pharmaceutical Interventions
• Responder Safety and Health
Incident Management
• Emergency Operations Coordination
Information Management
• Emergency Public Information and Warning
• Information Sharing
Surge Management
• Fatality Management
• Mass Care
• Medical Surge
• Volunteer Management12
The basic strategy was for each jurisdiction to determine the order of the capabilities it would pursue based upon
the jurisdictional risk assessment completed as part of the community preparedness capability. Jurisdictions were
strongly advised to ensure that they first were able to demonstrate capabilities within the biosurveillance, community
resilience, countermeasures and mitigation, incident management, and information sharing domains.
In order to delineate the public health aspects for each capability, CDC adopted the terminology and definitions
from the DHS Target Capabilities List, content from the Pandemic and All-Hazards Preparedness Act, and capabilities
from the National Health Security Strategy (NHSS) as a baseline. Aligning across national programs, the Pandemic
and All-Hazards Preparedness Act emphasizes the need to maintain consistency with other key national programs,
specifically the NHSS preparedness goals. PAHPA also directs that the NHSS be consistent with the DHS National
Preparedness Guidelines, a major component of which is the Target Capabilities List. The National Preparedness
Guidelines represent a standard for preparedness based on establishing national priorities through a capabilities-
based planning process. In addition to aligning with the National Preparedness Guidelines, CDC determined that the
public health preparedness capabilities should also be aligned with the essential public health services framework.
CDC conducted a mapping process which determined that several of the public health preparedness capabilities
aligned with multiple essential public health services. Thus, the state and local preparedness capabilities align with
both the DHS target capabilities and the HHS essential public health services, with a focus on public health
capabilities critical to preparedness (see Figure 6-7).
The public health preparedness capabilities represent a national public health standard for state and local
preparedness that better prepares state and local health departments for responding to public health emergencies and
incidents, and supports the accomplishment of the essential public health services. Each of the public health
preparedness capabilities identifies priority resource elements that are relevant to both routine public health activities
and essential public health services. While demonstrations of capabilities can be achieved through different means
(e.g., exercises, planned events, and real incidents), jurisdictions are encouraged to use routine public health activities
to demonstrate and evaluate their public health preparedness capabilities.
The content of each public health preparedness capability is based on evidence-informed documents, applicable
preparedness literature, and subject matter expertise gathered from across the federal government and the state and
local practice community. Each capability includes a definition of the capability and list of the associated functions,
performance measures, tasks, and resource considerations.
FIGURE 6-7 Public Health Emergency Preparedness Capabilities
Reproduced from Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response. Public Health Preparedness
Capabilities:
National Standards for State and Local Planning, March 2011. CDC; Atlanta, GA; 2011.
OUTSIDE-THE-BOOK THINKING 6-4
What is meant by the term “surge capacity,” and how is this addressed in public health emergency response plans?
Early Lessons
Effective state and local preparedness programs require hazard and vulnerability analyses, forecasts of the probable
health effects, analyses of the availability of needed resources, identification of vulnerable populations, and
development of detailed plans for both preparedness and response. Many factors influence the ability of states and
localities to complete these tasks. Public health preparedness is particularly challenging because public health and
public safety roles differ for federal, state, and local governments. The federal government has primary responsibility
for national security, while state and local governments carry the responsibility and financial burden for most other
public health responsibilities. At the local level, public health preparedness must be well coordinated with hospital
preparedness. Virtually all states now recognize the importance of exercises and drills and there have been a number
of national exercises involving the top officials of federal and state government.
Ideally, the infusion of resources to shore up the sagging public health infrastructure would foster positive
structural changes in public health systems at the state and local level. The early evidence supports this contention.
Yet federal funding is slowly eroding, with the average awards to LHDs in 2013 providing only $1.15 per capita and
with smaller LHDs receiving larger per capita awards than LHDs serving more populous communities.5
Despite fears that the increased focus on emergency preparedness would weaken other public health duties, this
has not occurred. Preparedness is now viewed as an important quality or attribute of an effective public health system
rather than as another priority program operating within its own silo. This is the essence of the philosophy that has
come to be known as the “dual use,” “multiple use,” or “all-hazards” strategy. Although still early in the process, some
things are clear.
The price for public health preparedness is high, regardless of how it is calculated. In crude dollar terms, its costs
reflect a significant increase in the federal investment in governmental public health services provided through
governmental public health agencies. This increase will need to be sustained indefinitely, because it primarily supports
information, communications, and workforce development systems that are ongoing in nature. And it will require
commensurate commitment and investment on the part of state and local governments. Otherwise, supplanting will
occur in one form or another and the opportunity for federal preparedness funds to leverage other resources will be
lost.
The price in terms of federalism and intergovernmental relationships will also be high. States will need to
encourage and accept stronger federal leadership on the one hand and generate a better understanding of local needs
and priorities on the other. These will need to be fashioned into effective local, regional, state, and multistate efforts in
ways that will challenge states to live up to their primary responsibility for the health of their citizens. All this must be
done while navigating through a treacherous obstacle course laden with political, economic, and bureaucratic
impediments to sustained progress.
The federal government must avoid the pitfall of merely throwing money at the problem, without fostering a
national vision of public health preparedness and nurturing the state-local public health systems that must carry out
that vision. This will require the federal agencies to be accountable for meaningful capacity and performance
standards, consistent credibility as to ends and means, integration both across focus areas and across federal
agencies, and leadership rather than either regulatory or advisory approaches to dealing with state-local public health
system issues.
Although these are formidable challenges, the opportunities are unprecedented. The boost in federal funding and
potential for federal leadership provide a unique opportunity to fashion a more coordinated national public health
system. Certainly, the public now expects this, and the price of not being prepared will be even higher.
OUTSIDE-THE-BOOK THINKING 6-5
Choose a public health discipline or occupational group (either your own or one that you are somewhat familiar with) and
describe the range of tasks that this discipline may be asked to perform in disaster preparedness and response.
CONCLUSION
Preparing for and responding to emergencies is a well-established role for public health agencies and their workers.
This role, highlighted in the Public Health in America statement1 as one of six critical responsibilities, has often been
viewed as one of responding to an occasional natural disaster such as an earthquake, hurricane, or flood. Large-scale
events that threaten public health and safety have seldom been intentionally inflicted, until recent examples to the
contrary, such as the anthrax mailings in 2001 and the bombings of the federal building in Oklahoma City in the 1990s
and the Boston Marathon in 2013. Geopolitical events in the international theater now raise the specter of increased
risk for terrorist acts, including bioterrorism, directed against the American population, underscoring the need for
sustained preparedness and response capacities at all levels of government.
The cycle of progress in public health preparedness has been remarkably consistent over several centuries in the
United States. A terrible epidemic or another form of health-related disaster or threat occurs. Public expectations call
for such an event to never occur again. Significant new resources are deployed to raise the level of preparedness and
protection. There is no immediate recurrence and the threat seems to dissipate over time. Preparedness, though still
important, becomes relatively less important. Eventually, a new threat or event appears, and the cycle repeats itself.
This recurring scenario raises the question as to whether current preparedness efforts represent a new and
different strategy that could interrupt this chain of events. Past preparedness efforts focused on a specific threat and
diminished as that specific threat diminished. Perhaps a more broadly focused preparedness campaign, one that is
valued because it battles many different threats, will fare differently.
REFERENCES
1. Public Health Functions Steering Committee. Public Health in America. Washington, DC: U.S. Public Health Service; 1995.
2. Landesmann LY. Public Health Management of Disasters: The Practice Guide. Washington, DC: American Public Health Association; 2001.
3. Presidential Homeland Security Directive No. 5, February 28, 2003.
4. The Center for Law and the Public’s Health. The Model State Emergency Health Powers Act. Baltimore, MD: Georgetown and Johns Hopkins
Universities; 2001.
5. National Association of County and City Health Officials. 2013 Profile of Local Health Departments. Washington, DC: NACCHO; 2014.
6. National Association of County and City Health Officials. Elements of Effective Local Bioterrorism Preparedness: A Planning Primer for Local
Health Departments. Washington, DC: National Association of County and City Health Officials; 2001.
7. National Association of County and City Health Officials. Local Centers for Public Health Preparedness: Models for Strengthening Local Public
Health Capacity. Washington, DC: National Association of County and City Health Officials; 2001.
8. Centers for Disease Control and Prevention. Local Emergency Preparedness and Response Inventory: A Tool for Rapid Assessment of Local
Capacity to Respond to Bioterrorism, Outbreaks of Infectious Disease, and Other Public Health Threats and Emergencies. Atlanta, GA: Centers
for Disease Control; 2001.
9. Columbia University School of Nursing, National Association of County and City Health Officials, and Centers for Disease Control and
Prevention. 2003. Bioterrorism and Emergency Readiness Competencies for All Public Health Workers.
https://training.fema.gov/EMIWeb/downloads/BioTerrorism%20and%20Emergency%20Readiness . Accessed October 7, 2014.
10. Lake, Snell, Perry. & Associates. Americans Speak Out on Bioterrorism and U.S. Preparedness to Address Risk. Princeton, NJ: Robert Wood
Johnson Foundation; December 2002.
11. Centers for Medicare and Medicaid Services. National Health Accounts.
12. Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response. Public Health Preparedness Capabilities:
National Standards for State and Local Planning, March 2011. CDC; Atlanta, GA; 2011.
CHAPTER 7
Public Health Workforce
LEARNING OBJECTIVES
Given the current status of public health activities in the United States, identify and explain how various
occupations, positions, and roles in the public health workforce contribute to carrying out public health’s core
functions and essential services. Key aspects of this competency expectation include being able to
• Describe the size, composition, and distribution of the current public health workforce
• Identify and discuss competency frameworks for routine and emergency public health practice
• Identify information sources for examining key dimensions of the current and future public health workforce
• Identify three or more issues that will impact the future public health workforce in terms of its size, composition, and
distribution
Public health is important work, and the people who carry out that work contribute substantially to the health status
and quality of life of the individuals, families, and communities they serve. Yet public health is not among the best
known or most highly respected careers, in part because when public health efforts are successful, nothing happens.
Events that don’t occur don’t attract attention. For example, the remarkable record of declining mortality rates and
ever increasing spans of healthy life, due in large part to public health efforts, draws little public attention. Indeed, the
vast majority of those who will ultimately benefit from the efforts of past and present public health workers are yet to
be born. With the work of public health not widely recognized and valued for its accomplishments and contributions, it
is not surprising that careers in public health are among the least understood and appreciated in the health sector.
Nonetheless, even if the public views public health as poorly defined and abstract, public health workers are real
and tangible. These workers make up a public health workforce that can be defined and described in several important
dimensions, including its size, distribution, composition, skills, and career pathways. Unfortunately, there is less
information on these vital statistics of the public health workforce than for many other professional and occupational
categories working in the health sector today.
For too long, too little attention has been directed to the public health workforce and its needs. Despite ample
warnings in the 1988 Institute of Medicine (IOM) report, there were few efforts between 1980, when the Health
Resources and Services Administration (HRSA) produced crude estimates of the size and composition for the United
States Congress and 2000, when Kristine Gebbie and colleagues completed their landmark enumeration report on the
public health workforce at the turn of the century.1-3 Two decades of inattention provide eloquent testimony to the low
priority given to the public health system’s most important asset—its workforce.
Beginning in the year 2002, funding for public health workforce preparedness and training increased dramatically.
This influx of funding also brought increased expectations for positive change and greater accountability for results.
As a result, the public health system is now under the microscope, with federal, state, and local governments needing
to show that the vital signs of the public health infrastructure, including its workforce, are improving. Unfortunately,
decades of inattention left little information to serve as a basis for comparison.
A central challenge for public health workforce development efforts today is to provide more and better information
about key dimensions of the public health workforce in terms of its size, distribution, composition, and competency, as
well as its impact on public health goals and community health. This chapter, like the Public Health Workforce
Enumeration 2000 report, seeks to advance this important agenda.
Subsequent chapters focus on various public health occupations and careers in order to assist individuals seeking to
make career decisions. This chapter sets the stage for an appreciation of what specific categories of public health
workers do and how they contribute to societal well-being in the 21st century by examining the following questions:
• What is the public health workforce?
• How large is this workforce and how is it distributed?
• What professions and occupations are included?
• How does the public health workforce impact the health of populations?
• Will the public health workforce continue to grow? What trends in the overall economy, the health sector, or the
public sector will impact public health jobs and career opportunities in the future?
PUBLIC HEALTH WORK AND PUBLIC HEALTH WORKERS
From a functional perspective, it is the individuals involved in carrying out the core functions and essential services of
public health who constitute the public health workforce. Critical to an understanding of this characterization of the
public health workforce are the terms core functions and essential public health services. These terms are examined in
depth in other chapters with a useful summary of these concepts provided in the “Public Health in America”
statement.4 In it, the practice of public health is described in terms of both its ends (vision, mission, and six broad
responsibilities) and how it accomplishes those ends (essential public health services). These essential public health
services constitute an aggregate job description for the entire public health workforce, with the workload divided
among the many different professional and occupational categories comprising the total public health workforce.
This functional perspective clearly links public health workers to public health practice. Unfortunately, this does not
simplify the practical task of determining who is, and who is not, part of the public health workforce. There has never
been any specific academic degree, even the master’s of public health (MPH) degree, or unique set of experiences that
distinguish public health’s workers from those in other fields. Many public health workers have a primary professional
discipline in addition to their attachment to public health. Physicians, nurses, dentists, social workers, nutritionists,
health educators, anthropologists, psychologists, architects, sanitarians, economists, political scientists, engineers,
epidemiologists, biostatisticians, managers, lawyers, and dozens of other professions and disciplines carry out the
work of public health. This multidisciplinary workforce, with somewhat divided loyalties to multiple professions, blurs
the distinctiveness of public health as a unified profession. At the same time, however, it facilitates the
interdisciplinary approaches to community problem identification and problem solving, which are hallmarks of modern
public health practice.
OUTSIDE-THE-BOOK THINKING 7-1
What distinguishes a public health professional from a clinical professional working for a public health organization?
SIZE AND DISTRIBUTION OF THE PUBLIC HEALTH WORKFORCE
There is little agreement as to the size of the public health workforce in the United States except that it is only a small
subset of the more than 15 million persons employed in the health sector of the American economy. Enumerations and
estimates of public health workers suffer from one central limitation—the definition of a public health worker is
unclear. An influential 2003 IOM report on public health education offered a seemingly straightforward definition of a
public health professional as “a person educated in public health or a related discipline who is employed to improve
health through a population focus”.5 Yet even this definition lacks precision and impedes enumeration; many public
health professionals were not educated in public health or related disciplines; many others are not employed in
organizations seeking to improve health through a population focus. Public health workers employed outside
governmental public health agencies are especially difficult to identify; and not all employees of public health
organizations and agencies have population health responsibilities associated with their jobs. Identifying specific types
of public health workers is also difficult, since many have other professional affiliations.
Because of these limitations, a precise picture of the public health workforce is not available. But it is clear that
efforts to identify and categorize public health workers must take into account three important aspects of public health
practice:6
• Work setting: Public health workers work for organizations actively engaged in promoting, protecting, and
preserving the health of a defined population group. The organization may be public or private, and its public
health objectives may be secondary or subsidiary to its principal objectives. In addition to governmental public
health agencies, other public and private organizations employ public health workers. For example, school health
nurses working for the local school district and health educators employed by the local Red Cross chapter are
part of the public health workforce.
• Work content: Public health workers perform work addressing one or more of the essential public health
services. Relatively few job descriptions for public health workers are tailored from the essential public health
services, and even when they are, the scope of tasks can be very broad. A focus on populations, as opposed to
individuals, is often a distinguishing characteristic of these job descriptions. For example, an individual trained as
a health educator who works for a community-based teen pregnancy prevention program is clearly a public health
worker. But the same can’t be said of a health educator working for a commercial advertising firm promoting
cosmetics.
• Worker: The individual must occupy a position that conventionally requires at least 1 year of postsecondary
specialized public health training and that is (or can be) assigned a professional, administrative, or technical
occupational title (to be defined later in this chapter). This distinction may seem artificial but rests on the notion
that public health practice relies on a foundation of knowledge, skills, and attitudes that, in most circumstances,
cannot be completely acquired through work experiences alone.6
The relationships among these three aspects are illustrated in Figure 7-1, although there is no attempt to draw this
modified Venn diagram to scale. Nonetheless, the total area captured with this composite represents all workers who
would meet one or more of the definitions established for the individual workers, work content, and work settings
using these three dimensions. For example, workers could be defined at some level of educational attainment and/or
work experience. Perhaps an undergraduate or graduate level degree in public health and/or 5 years of experience
could be elements of this definition.
FIGURE 7-1 Relationships of Key Aspects of the Public Health Workforce Based on Worker Skills, Work Setting,
and Content of Work
Similarly, the definition of the work setting could call for working in an organization or entity whose mission
focused on achieving public health goals. A more restrictive definition might focus on public or voluntary sector
organizations or perhaps only on governmental health agencies. A definition for the content of the work could require
consistency with the public health core functions/essential public health services framework. For example, if more
than 50% of the work effort encompassed core functions or essential public health services, this could meet the
definition.
Once definitions for the worker, work setting, and work content are established, the universe of public health
workers would be established and seven different sectors within that universe could be identified. Whether everyone
meeting any of the three definitions would be considered a public health worker, or whether some combination of
categories (e.g., trained, doing public health work, within a governmental health agency) would be used to establish a
conceptual definition of the public health workforce requires discussion and eventual consensus. With a rational
definition of who is and who is not a public health worker, strategies to enumerate and capture key information on
public health workers can be devised and implemented. Without a common frame of reference, widely varying
estimates of the current and past public health workforce will proliferate. This has in fact occurred as will be discussed
later in this chapter.
Despite these uncertainties as to the size of the public health workforce, there is information documenting general
trends over recent decades. For example, the number of workers in the health sector of the U.S. economy has been
steadily increasing while the proportion of total national health expenditures attributed to public health activity has
remained fairly constant.1 This evidence suggests the number of public health workers has grown at a rate generally
consistent with that of all health workers and that the public health workforce likely includes 500,000–750,000
workers (and perhaps even more if public health workers in industries outside the governmental and health industry
sectors are included).
This range is consistent with the crude enumeration of the public health workforce conducted for the year 2000,
which identified 450,000 public health workers.3 The year 2000 enumeration did not include most public health
workers employed by nongovernmental agencies as well as many public health workers employed by government
agencies other than official public health agencies. As a result the actual total exceeded the 450,000 number reported
in the enumeration.
Another indication that the public health workforce has been increasing over recent decades comes from data
collected in the ongoing employment and payroll census of federal, state, and local governments by the U.S. Bureau of
the Census.7 Data from this source indicated that there were 103,000 more full-time equivalent (FTE) workers of
federal, state, and local health agencies in 2012 than in 1995 (see Table 7-1).
TABLE 7-1 Full-Time Equivalent (FTE) Workers of Federal, State, and Local Governmental Health* Agencies,
Selected Years, 1995–2012, U.S.
*Health: public health services, emergency medical services, mental health, alcohol and drug abuse, outpatient clinics, visiting nurses, food and
sanitary inspections, animal control, other environmental health activities (e.g., pollution control), etc.
Data from U.S. Bureau of the Census. Federal, State, and Local Governments, Public Employment and Payroll Data. Available at
www.census.gov/govs/apes. Accessed June 10, 2014.
Between 1995 and 2008 the number of workers employed in federal, state, and local government health agencies
increased steadily, with the greatest gains at the local government level. The economic recession of 2008/2009
temporarily slowed the increase for workers in federal and state health agencies, but the pattern of steady increases
reappeared when the recession ended. The number of workers in health agencies of local government fell both during
and after the recession through 2012. It is likely that the influx of financial support for state and local governments
associated with the American Recovery and Reinvestment Act of 2009 minimized the loss of local government
employees through 2010, when this funding was discontinued. Fiscal and political pressures on local governments
persisted after 2010 accounting for continuing losses of local government workers. This downward trend persisted
through 2012, after which stabilization and small increases reappeared. Figure 7-2 traces the ratio of state and local
government health agency workers to population between 1995 and 2012 further illustrating these trends. By 2012
the ratio of state and local government health agency workers to population had reverted to levels not seen since the
late 1990s.
Similar to other health sector workers, public health workers are more likely to be found in urban and suburban
settings rather than rural communities. The public health worker to population ratio, however, is often higher in rural
areas than in urban areas. States show significant variation as well, with higher ratios in many of the smaller and less
urban states in the East and West and lower ratios in the Central states.
OUTSIDE-THE-BOOK THINKING 7-2
Choose a recent (within the last 3 years) outbreak or other public health emergency situation that has drawn significant
media attention. Describe how specific occupational categories in the public health infrastructure contributed to either
the emergency situation or its solution. The Morbidity and Mortality Weekly Report contents for recent weeks would be a
good place to look for recent outbreaks; various print and electronic media may also be useful sources of information.
The national public health workforce enumeration study completed in 2000 found that one-third of the public health
workforce were employed by state agencies and another one-third by local governmental agencies.3 This enumeration
also reported that 20% worked for federal agencies and 14% worked for nongovernmental organizations in the
voluntary and private sectors. Government employment census data, which excludes nongovernmental workers, also
classify one-third as state workers but 44% as employees of local government and 24% as working for federal
agencies. Some of these differences can be attributed to state public health systems in which state employees work at
the local level but are counted as state employees in the employment census data and as local health department
(LHD) employees in the public health enumeration study. These differences may also be partly attributed to the
inclusion of workers in state and local governmental agencies other than the local public health agency in the
government employment census data; these were not captured in the year 2000 public health enumeration study. For
example, substance abuse and mental health prevention services, school health services, or restaurant inspections
may operate from local mental health agencies, school districts, or consumer affairs agencies rather than from the
LHD. The National Association of County and City Health Officials (NACCHO) estimated that LHDs employed 162,000
workers (146,000 FTEs) in 2013.8
FIGURE 7-2 Full-Time Equivalent (FTE) Workers for State and Local Health* Agencies per 10,000 Population,
Selected Years 1995–2012, United States
Data from U.S. Bureau of the Census. Federal, State, and Local Governments, and Public Employment and Payroll Data. Available at
www.census.gov/govs/www/apes. Accessed June 15, 2014.
Although recent decades have witnessed an increase in the number of public health workers employed by
nongovernmental agencies because of expanded partnerships for public health priorities, governmental public health
workers are often considered the primary public health workforce. Their number, composition, distribution, and
competence are issues of public concern.
Government employment census data provide useful insights into overall trends at the national level and among the
various levels of government. The year 2000 public health enumeration study, together with periodic surveys of state
and local public health agencies, provide richer information on the composition of the public health workforce, such as
the proportion and types of professional occupational categories within that workforce. Together these sources enrich
our understanding of the size and composition of the public health workforce today.
COMPOSITION OF THE PUBLIC HEALTH WORKFORCE
Public health is multidisciplinary, with many different professions and occupations involved in its work. The Bureau of
Labor Statistics (BLS) tracks workers in hundreds of standard occupational classifications (SOCs) regardless of the
industry (such as government, health care, etc.) in which they are employed. In recent years, there has been an effort
to link standard occupational classifications for public health worker titles and positions, although this effort has been
challenging. Because the overall universe of public health workers is poorly defined, the precise proportion of the
various occupational categories within it cannot be determined. It is clear that nurses and environmental health
practitioners constitute the largest subgroups of public health workers. Managers, epidemiologists, health educators,
nutritionists, and laboratory workers are also significant subgroups. Figure 7-3 provides general information on
occupational categories and titles from the public health workforce enumeration completed in 2000. Specific
categories and titles were not reported for one-fourth of the workers in this study.
Despite the lack of precise information, it appears that professional occupational categories comprise more than
one-half of the estimated 500,000–800,000 workers in the public health workforce. For comparison purposes, there
were 2.7 million nurses, 900,000 physicians, 200,000 pharmacists, 170,000 dentists, and 90,000 dietitians/nutritionists
employed in the United States in 2012.9
Ongoing surveys of local health departments (LHDs) document that three positions are found in more than 80% of
all LHDs—public health nurse, administrator, and sanitarian/environmental health specialist.8,10 These positions are
present in large and small agencies alike. The next most frequent positions (emergency preparedness coordinator,
health educator, dietitian/nutritionist, and physician) are found in only 40–60% of LHDs. There is considerable
variation in the median FTEs in these positions, largely associated with agency size (Figure 7-4).
Two general patterns of LHD staffing exist around a core set of employees. One pattern focuses on clinical services,
the other on more population-based programs.11 The core employees consist of dietitian/nutritionists,
sanitarians/environmental specialists, administrators, lab specialists, and health educators. The clinical pattern adds
physicians, nurses, and dental health workers. The population-based pattern includes epidemiologists, public health
nurses, social workers, and program specialists.
The availability of information on public health workers at the state and local level varies from state to state and is
often inconsistent and incomplete. Detailed information from the official state health departments has only recently
become available, although this does not include public health workers employed by state agencies other than the
official state health department. The periodic profiles of LHDs completed by NACCHO before 2005 provide only
general data on the proportion of responding agencies that employ specific public health job titles, either directly or
through contracted services. The national profiles of LHDs completed after 2005 provide national estimates on the
total number of full time equivalent (FTE) workers as well as FTEs for 10–15 specific titles.
FIGURE 7-3 Percentage of Public Health Workers in Selected Occupational Categories and Titles, United States,
2000
Data from Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Information and
Analysis and Center for Health Policy, Columbia School of Nursing. The Public Health Workforce Enumeration 2000. Washington, DC: HRSA; 2000.
FIGURE 7-4 Percentage of Local Health Department (LHD) Workforce for Selected Occupations, United States,
2013 Estimated Total Employees = 162,000 Estimated Total FTEs = 146,000
Data from National Association of County and City Health Officials. 2013 National Profile of Local Health Departments. Washington, DC: NACCHO;
2014.
Gaps in information on the public health workforce extend to some of the most basic and important characteristics
of that workforce. For example, there is very little information available on the racial and ethnic characteristics of the
overall public health workforce. Although important, information on cultural competency is virtually nonexistent.
PUBLIC HEALTH WORKER ETHICS AND EDUCATION
Public health workers may come from different academic, professional, and experiential backgrounds, but they share a
common bond. All are committed to a common mission and share common ethical principles, as exemplified by the
following list advanced by the American Public Health Association:
• Public health should address principally the fundamental causes of disease and requirements for health, aiming
to prevent adverse health outcomes.
• Public health should achieve community health in a way that respects the rights of individuals in the community.
• Public health policies, programs, and priorities should be developed and evaluated through processes that
ensure an opportunity for input from community members.
• Public health should advocate and work for the empowerment of disenfranchised community members, aiming to
ensure that the basic resources and conditions necessary for health are accessible to all.
• Public health should seek the information needed to implement effective policies and programs that protect and
promote health.
• Public health institutions should provide communities with the information they have that is needed for decisions
on policies or programs and should obtain the community’s consent for their implementation.
• Public health institutions should act in a timely manner on the information they have within the resources and
the mandate given to them by the public.
• Public health programs and policies should incorporate a variety of approaches that anticipate and respect
diverse values, beliefs, and cultures in the community.
• Public health programs and policies should be implemented in a manner that most enhances the physical and
social environment.
• Public health institutions should protect the confidentiality of information that can bring harm to an individual or
community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to
the individual or others.
• Public health institutions should ensure the professional competence of their employees.
• Public health institutions and their employees should engage in collaborations and affiliations in ways that build
the public’s trust and the institution’s effectiveness.12
Information from national and state surveys indicates that the majority of public health workers lack formal
education and training in public health. In 1980, HRSA determined that only 20% of the 250,000 professionals in the
primary public health workforce had formal training in public health.2
More than three decades later, there is little evidence that this situation has improved. While the proportion of
those who have formal training varies by category of worker, the lack of formal training is striking in even some of the
most critical categories. For example, NACCHO surveys from the early 1990s through 2013 found that only 20–25% of
local health department leaders had formal public health education or training.13
This is not surprising in view of the small number of undergraduate, graduate, and doctoral degrees in public health
that are awarded each year. Public health degrees at the undergraduate level represent only 0.2% of all undergraduate
degrees, and public health doctoral degrees comprise the same percentage of all doctoral degrees. Master’s degrees
in public health, however, comprise about 1.3% of all master’s-level degrees.14
Formal training for many public health workers focuses only on a specific aspect of public health practice, such as
environmental health or community or school health nursing. Environmental health practitioners, nurses,
administrators, and health educators account for the majority of public health workers with formal training in public
health. Even among those with formal training in public health, public health workers with graduate degrees from
schools of public health or other graduate public health programs represent only a small fraction of the total. The total
number of master’s-level graduates of schools of public health and other graduate-level public health degree programs
was about 12,000 in 2010.
OUTSIDE-THE-BOOK THINKING 7-3
Are public health professionals viewed as change agents in their communities today? Why or why not? Do you hold the
same opinion for public health organizations? Why or why not?
Evidence of the lack of formal training within this workforce, however, does not necessarily lead to the conclusion
that public health workers are unprepared.15 Instead, public health workers enter the field having earned a wide
variety of degrees and professional training credentials from academic programs and institutions unrelated to public
health. Often overlooked, these institutions produce the bulk of the public health workforce and represent major assets
for addressing unmet needs.
On-the-job training and work experience contribute substantially to the overall competency and preparedness of the
public health workforce. For example, public health workers are frequently involved in responses to earthquakes,
floods, and other disasters and have increasingly acquired and demonstrated skills in assessing community health
needs and devising community health improvement plans. These are skills that most public health workers acquired
through real-world work experience rather than through their formal training.
Continuing education and career development for public health workers has long been a cottage industry involving
many different parties. Academic institutions certainly are contributors, but public health agencies at the state and
local level, public health associations and institutes (national, state, and local), and other voluntary-sector health
organizations participate as well. Many different entities offer credits for continuing education, including professional
organizations, academic institutions, and hospitals, among others. Public health workers value continuing education
credits as a means to satisfy requirements of their core disciplines in order to maintain some level of credentialing
status (such as licensed physicians and nurses, certified health education specialists, and so on). Very few states
enforce continuing education requirements for the public health disciplines licensed by that state. There is no formal
system of public health-specific continuing education units (CEUs) and only fledgling efforts toward credentialing
public health workers. The notable development in this area is the Certified in Public Health (CPH) credential offered
since 2008 by the National Board of Public Health Examiners for graduates of master’s degree programs accredited by
the Council on Education in Public Health. As of 2014, more than 3,000 public health workers had earned the CPH
credential.16
CHARACTERISTICS OF PUBLIC HEALTH OCCUPATIONS
The remaining sections of this chapter define and describe several key dimensions of public health occupations and
organizations that provide the framework for examining specific positions and careers for public health workers in
later chapters. Information on the full spectrum of occupations in the public health workforce is available from a
variety of sources, including federal health and labor agencies and national public health organizations. Table 7-2
previews the public health titles, occupational categories, and careers examined in the occupation-focused chapters
that follow. The first column identifies the public health job titles and careers addressed in each chapter. The second
column lists specific BLS standard occupational categories (SOCs) included in each chapter. SOCs are explained more
fully later in this chapter.
TABLE 7-2 Public Health Occupations and Careers Addressed in Subsequent Chapters
Chapter
Number
Career Category with Examples of Titles Used in
Public Health Organizations
Bureau of Labor Statistics Standard Occupational
Categories Related to Public Health
8 Public Health Administration
• Health Services Manager
• Public Health Agency Director
• Health Officer
• Emergency Preparedness and Response Director
Professional Occupations
• Emergency Management Directors
• Medical and Health Services Managers
• Social and Community Services Managers
9 Environmental and Occupational Health
• Environmental Engineer
• Environmental Health Specialist (entry level)
• Environmental Health Specialist (midlevel)
• Environmental Health Specialist (senior level)
• Occupational Health and Safety Specialist
Professional Occupations
• Environmental Engineers
• Environmental Scientists and Specialists (including
Health)
• Health and Safety Engineers (except Mining Safety
Engineers and Inspectors)
• Occupational Health and Safety Specialists
Technical Occupations
• Environmental Engineering Technicians
• Environmental Science and Protection Technicians
(including Health)
• Occupational Health and Safety Technicians
10 Public Health Nursing
• Public Health Nurse (entry level)
• Public Health Nurse (senior level)
• Licensed Practical/Vocational Nurse
Professional Occupations
• Nurse Practitioners
• Registered Nurses
Technical Occupations
• Home Health Aides
• Licensed Practical and Licensed Vocational Nurses
• Nursing Assistants
11 Epidemiology and Disease Control
• Disease Investigator
• Epidemiologist (entry level)
• Epidemiologist (senior level)
Professional Occupations
• Epidemiologists
• Statisticians
12 Public Health Education and Information
• Public Health Educator (entry level)
• Public Health Educator (senior level)
• Public Information Officer
• Community Health Workers (and other Outreach
Occupations)
Professional Occupations
• Health Educators
• Public Relations Specialists
Technical Occupations
• Community Health Workers
13 Other Public Health Professional and Technical
Personnel
• Public Health Nutritionist/Dietician
• Public Health Social, Behavioral and Mental Health
Worker
• Public Health Laboratory Worker
• Public Health Physician
• Public Health Veterinarian
• Public Health Pharmacist
• Public Health Oral Health Professional
• Administrative Law Judge/Hearing Officer
• Public Health Program Specialist/Coordinator
• Public Health Policy Analyst
• Public Health Information Specialist
Professional Occupations
• Audiologists
• Administrative Law Judges, Adjudicators, and
Hearing Officers
• Dental Hygienists
• Dentists (General Dentist)
• Dieticians and Nutritionists
• Healthcare Social Workers
• Medical and Clinical Laboratory Technologists
• Mental Health Counselors
• Mental Health and Substance Abuse Social Workers
• Microbiologists
• Optometrists
• Pharmacists
• Physician Assistants
• Physicians (Family or General Practitioners)
• Substance Abuse and Behavioral Disorder Counselors
• Veterinarians
Technical Occupations
• Animal Control Workers
• Emergency Medical Technicians and Paramedics
• Medical and Clinical Laboratory Technicians
There are many aspects of an occupation or career that are important to current and prospective public health
workers. The framework used in this book includes
• Occupational classification: these are based on job titles and whether the duties of the job are primarily
administrative, professional, technical, or supportive in nature. Many positions in public health practice have a
variety of job titles associated with them. Similarly, the same job title can have a variety of regular duties and day-
to-day responsibilities.
• Public health practice profile: The public health functions and essential public health services addressed by each
occupational grouping are presented in a public health practice profile.
• Important and essential duties: These are the defining characteristics of any position describing what the worker
does on a daily basis. Examples are derived from a sampling of job and position descriptions from a variety of
sources.
• Minimum qualifications: Some positions require a specific academic degree or credential; many do not. Some
require previous experience, while others do not. All require some particular minimum level of knowledge, skills,
and abilities. Many also require specific physical capabilities. These characteristics will be identified for each
public health occupation.
• Workplace considerations: This description will identify levels of government that employ significant numbers of
workers in each occupational category as well as important nongovernmental work settings for public health
workers. This section will also highlight considerations related to physical demands, work schedules, travel, and
general working conditions.
• Salary estimates: Salary levels for public health workers are estimated based on information from current job
postings and the May 2013 survey of employment and wages coordinated by the Labor Department’s BLS.
• Career prospects: Estimates as to current need and future demand for specific public health occupations and
career paths are provided, based on the analyses performed by public health organizations and the BLS’
projections for various occupations.
• Additional information: Sources of additional information for each occupation or career are identified, including
education and training opportunities.
The following sections briefly describe the type and source of information included for each of these characteristics.
Occupational Classifications
Throughout the economy, including the health sector, occupations are broadly classified as either white collar or blue
collar, depending on the degree of education and experience normally required. White collar occupations include five
major occupational categories (professional, administrative, technical, clerical, and other), based on the subject matter
of work, the level of difficulty or responsibility involved, and the educational requirements established for each
occupation. Blue collar occupations are composed of the trades, crafts, and manual labor (unskilled, semiskilled,
skilled), including foreman and supervisory positions entailing trade, craft, or laboring experience and knowledge as
the paramount requirement.
The U.S. Office of Personnel Management tracks occupations in various industries using four general categories—
professional, administrative, technical, and support.
• Professional occupations are those that require knowledge in a field of science or learning characteristically
acquired through education or training equivalent to a bachelor’s or higher degree with major study in or
pertinent to the specialized field, as distinguished from general education. The work of a professional occupation
requires the exercise of discretion, judgment, and personal responsibility for the application of an organized body
of knowledge that is continuously studied to make new discoveries and interpretations, and to improve the data,
materials, and methods. Professionals require specialized and theoretical knowledge. Well-known examples of
professional job titles include physicians, registered nurses (RNs), dietitians, health educators, social workers,
psychologists, lawyers, accountants, economists, system analysts, and personnel and labor relations workers.
Professionals comprise the majority (56%) of public health workers (see Figure 7-5).
• Administrative occupations are those that involve the exercise of analytical ability, judgment, discretion, personal
responsibility, and the application of a substantial body of knowledge of principles, concepts, and practices
applicable to one or more fields of administration or management. Although these positions do not require
specialized educational majors, they do involve the type of skills (analytical, research, writing, judgment) typically
gained through a college-level general education, or through progressively responsible experience.
Administrators set broad policies, oversee overall responsibility for the execution of these policies, direct
individual departments or special phases of the agency’s operations, or provide specialized consultation on a
regional, district, or area basis. Common job titles for administrators include department heads, bureau chiefs,
division chiefs, directors, deputy directors, and similar titles. Administrators and managers comprise 5% of all
public health workers.
• Technical occupations are those that involve work that is not routine in nature and is typically associated with,
and supportive of, a professional or administrative field. Such occupations involve extensive practical knowledge
gained through on-the-job experience, or specific training less than that represented by college graduation. Work
in these occupations may involve substantial elements of the work of the professional or administrative field but
requires less than full competence in the field involved. Technical occupations require a combination of basic
scientific or technical knowledge and manual skills. Titles include computer specialists, licensed practical nurses
(LPNs), inspectors, programmers, and a variety of technicians (environmental, laboratory, medical, nursing,
dental, and so on). The technical occupations category also includes paraprofessionals who perform some of the
duties of a professional or technician in a supportive role usually requiring less formal training and experience
than that normally required for professional status. Included are community health workers, outreach workers,
research assistants, medical aides, child support workers, home health aides, emergency medical technicians,
among others. Workers in technical occupations account for 20% of all public health workers.
FIGURE 7-5 Mean Salary for Full-Time Equivalent Workers of State and Local Health* Agencies, Selected Years,
1998–2012, United States
Data from U.S. Bureau of the Census. Federal, State, and Local Governments, and Public Employment and Payroll Data. Available at
www.census.gov/govs/apes. Accessed June 15, 2014.
• Administrative support occupations are those that involve structured work in support of office, business, or fiscal
operations; duties are performed according to established policies or techniques and require training, experience,
or working knowledge related to the tasks to be performed. Clerical titles are often responsible for internal and
external communication as well as recording and retrieval of data, information, and other paperwork required in
an office. This category includes bookkeepers, messengers, clerk typists, stenographers, court transcribers,
hearing reporters, statistical clerks, dispatchers, license distributors, payroll clerks, office machine and computer
operators, telephone operators, legal assistants, and so on. In addition, workers in any of the blue-collar
occupational categories are considered support workers within the public health workforce. About 19% of public
health workers are in the administrative support category.
As documented in Figure 7-6, 81% of public health workers fall into the professional, administrative, and technical
categories. More than one half (56%) are classified as professionals, similar to the proportion of professionals among
all 15 million health workers. Nursing and environmental health activities account for the largest number of public
health workers when both professional and technical occupations are considered. RNs represent the largest
professional category within the public health workforce.
The U.S. Department of Labor collects information on occupations throughout the economy, including the public
sector. An official taxonomy for occupations allows the Department of Labor’s BLS to track information on hundreds of
SOCs in terms of the number and location of jobs, salaries, and duties performed. BLS also develops projections for
the number of future positions for these occupational categories based on economic and employment trends.
Occupations generally can be found in a variety of industries, making it difficult to pinpoint trends and needs specific
to the public health system. For example, RNs are the largest occupational category in the overall health workforce,
with 2.7 million workers, but only a small percentage of all RNs (about 75,000) work in public health agencies. Many
more work in hospitals and other healthcare organizations. This is also true for physicians, health services
administrators, health educators, nutritionists, and many other occupations. Public health agencies, however, are the
largest employers of several SOCs, such as environmental health specialists and epidemiologists. For those
occupational categories, BLS information is especially useful.
FIGURE 7-6 Percentage of Public Health Workers in Selected Occupational Categories, United States, 2000
Data from Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Information and
Analysis and Center for Health Policy, Columbia School of Nursing. The Public Health Workforce Enumeration 2000. Washington, DC: HRSA; 2000.
SOCs relevant for public health are identified in the second column of Table 7-2, with nearly 40 specific categories
listed.17 Each of these categories is addressed in subsequent chapters, with the greatest attention on those with the
largest numbers of workers in the public health workforce. These 39 occupational categories clearly do not cover all
titles found in public health organizations. Nor do they capture the entire scope of work undertaken by public health
workers. For these reasons, each chapter will focus specifically on job titles and job descriptions commonly found in
public health organizations (see the first column of Table 7-2), with information on titles, duties, public health roles,
and qualifications. Related job titles are addressed in the same chapter in order to illustrate links and possible career
pathways.
Estimates of the number of current workers in each occupational category are synthesized from two sources. The
BLS conducts surveys of all standard occupational categories twice yearly, including information on the industries and
levels of government that employ workers in each SOC.17 This source allows for estimates of the total number of
workers in a particular SOC who work for federal, state, and local agencies.
Projections for the number of positions for each occupational title in the year 2022 are also provided by the BLS,
allowing for estimates of total job openings expected to occur between the years 2012 and 2022.
A second important source of estimates for public health workers in relevant SOCs is the Public Health Workforce
Enumeration 2000 study commissioned by HRSA.3 This enumeration collected information on workers of federal, state,
and local public health agencies in the year 2000 based on existing data, reports, and surveys. As such, it was as much
a qualitative and descriptive enumeration as a quantitative one. The year 2000 public health workforce enumeration
identified a total of 450,000 public health workers, including 15,000 workers in voluntary sector organizations and
15,000 public health students. Occupational categories could not be established for 112,000 public health workers,
making it difficult to project the actual number of workers in specific categories, such as public health nurses or
epidemiologists. Both sources provide insights useful for estimating the number of existing positions for each
occupational category and title.
Public Health Practice Profile
Individual workers, as well as occupational categories, produce work important to achieving public health goals and
objectives. As described in previous chapters, key public health goals and objectives address preventing disease and
injury, promoting healthy behaviors, protecting against health risks and threats, responding to emergencies, and
ensuring the quality of health services.4 This overall public health practice framework provides the basis for
channeling contributions both by individuals and organizations toward common goals. The specific public health
practice tasks of different occupations and individuals generally fall into one or more of the 10 essential public health
services. Earlier chapters characterized the essential public health services as how the work of public health is
accomplished and its ends are achieved. It is useful to view these functions and essential public health services as an
aggregate job description for the entire public health workforce, with the workload then shared among the many
different professional and occupational categories composing the total public health workforce.
The chapters that follow will each identify several purposes and essential public health services that form the core
of the duties and job descriptions for each occupational category and public health career. An example of this format is
provided in Table 7-3. A similar summary, in checklist format, appears in each occupation-focused chapter.
TABLE 7-3 Public Health Profile Example
(Example)
Public Health Practitioners
Make a Difference by:
Public Health Purposes
Preventing epidemics and the spread of disease
Protecting against environmental hazards
Preventing injuries
Promoting and encouraging healthy behaviors
Responding to disasters and assisting communities in recovery
Ensuring the quality and accessibility of health services
Essential Public Health Services
Monitoring health status to identify community health problems
Diagnosing and investigating health problems and health hazards in the community
Informing, educating, and empowering people about health issues
Mobilizing community partnerships to identify and solve health problems
Developing policies and plans that support individual and community health efforts
Enforcing laws and regulations that protect health and ensure safety
Linking people with needed personal health services and ensuring the provision of health care when otherwise
unavailable
Ensuring a competent public health and personal healthcare workforce
Evaluating effectiveness, accessibility, and quality of personal and population-based health services
Researching new insights and innovative solutions to health problems
In this example, the public health occupational category is primarily involved in addressing three public health
goals: preventing epidemics, preventing injuries, and promoting healthy behaviors. This public health occupational
category works to address these goals largely through performing five essential public health services—monitoring
health status, investigating health problems, educating people about health, evaluating effectiveness, and researching
new solutions to health problems.
For this example, and those in later chapters, the assignment of specific public health purposes and essential public
health services may appear somewhat arbitrary. In each case, however, judgments are made as to which purposes and
essential services are most closely associated with each occupational category. Some occupational categories may
appear to have a relatively limited focus (e.g., public health laboratory workers) in comparison with others (e.g., public
health nurses) that may have very broad roles that could conceivably cover all purposes and services. For each
occupational category and title, however, the number of purposes and essential services identified for each
occupational category is limited to no more than one half the number possible (3 of 6 purposes, 5 of 10 essential public
health services). Table 7-4 provides a composite profile that aggregates information from selected public health
occupations examined in subsequent chapters.
Characterizing the work of an occupational category in this manner provides a functional view of the work
performed. It also facilitates an understanding of how the work of one occupational category relates to the work of
other categories and how the overall workload is distributed across the various public health occupational categories.
Important and Essential Duties
The most important aspect of any job or career is what workers do day in and day out. It is those basic and routine
duties that best define positions in public health or any other field of endeavor. This list varies considerably from one
position to another and often from one level of the same position to a higher level (e.g., from an entry-level
environmental health specialist to a midlevel environmental health specialist). Important and essential duties for
various titles within subsequent chapters are based on information from a sampling of job and position descriptions
from a variety of public health organizations. In order to illustrate these routine duties, each of these chapters also
provides an example of a daily schedule for the occupational category addressed in that chapter.
TABLE 7-4 Composite Public Health Practice Profile for Public Health Occupations and Titles Addressed in
Subsequent Chapters
Notes: Adm: public health managers; EH: environmental health workers; PHN: public health nurses; Epi: epidemiologists; HE: health educators;
Nutr: nutritionists and dieticians; BH: behavioral health professionals; Lab: public health laboratory workers; Docs: physicians, veterinarians,
optometrists, pharmacists; Oral: oral health professionals; Law: administrative judges and hearing officers: Spec; public health program
specialists/coordinators; Pol: policy analysts.
Minimum Qualifications
Another key dimension of a position is a statement of the minimum qualifications necessary for that job. Often these
minimum qualifications must be met in order for a worker to apply for a particular position. Minimum qualifications
may emphasize experience or education or both. In any event, there is a battery of skills or competencies that are
expected of those applying for and those working in public health positions. Minimum levels of knowledge, skills, and
abilities are presented for public health job titles addressed in the subsequent occupation-specific chapters. Additional
qualifications, such as physical capabilities appropriate for specific jobs or job locations, are also presented. These
qualifications are synthesized from a sampling of current position descriptions.
The range of public health occupations and careers extends from those requiring considerable education and
training to those that require relatively little. For example, some state and local health officials may hold several
degrees, such as a bachelor’s degree in science, an MPH, and a doctoral degree in medicine. At the same time, key
staff performing investigations of communicable disease or environmental threats may have only an associate or
bachelor’s degree at the undergraduate level. It is not uncommon for some technical and clerical staff to have attained
no more than a high school diploma with on-the-job training. Because this book largely targets undergraduate and
graduate-degree students, particular emphasis is on occupations and careers requiring at least an undergraduate
degree.
Workplace Considerations
Public health work takes place in many organizations and settings other than governmental public health agencies
such as state health agencies or local public health departments. Many community and voluntary organizations
collaborate with governmental public health agencies and employ staff whose work parallels that of workers in
governmental public health agencies. This is true both for nongovernmental public health efforts here in the United
States and those on the international level.
Another important workplace consideration relates to special physical capabilities, travel requirements, and other
unique aspects of specific jobs. For example, some positions may require the ability to lift and move items weighing up
to 50 pounds. Other jobs may require the ability to walk great distances or to have normal vision or hearing. Others
may require the ability to work outside in cold and inclement weather, or to work unusual hours.
Salary Estimates
Detailed and specific salary information is not widely available. Information will be provided based on limited sources,
including BLS data and current job postings. This information should not be considered to be definitive, timely, or
completely accurate. Salary scales vary widely from agency to agency depending on a variety of circumstances and
conditions. Figure 7-5 indicates that the overall average salary of a full-time workers employed by a state or local
health agency increased by 50% to more than $50,000 between 1998 and 2012.
Career Prospects
Current and future opportunities for public health careers, as do careers in all fields, are a function of relationships
among the population, the labor force, the overall economy, and the demand for public health programs and services.17
The size and composition of the population strongly influence both the size of the workforce and the types of services
needed by the population.
The U.S. population continues to increase, although at a slower rate than in recent decades. The average age of the
population continues to increase as well, and the proportion of the population in the older age categories will continue
to increase. As older workers near retirement, replacement of workers will create job opportunities and career
advancement possibilities in addition to those created by the continued growth of the overall population.
Among the various sectors of the U.S. economy, the health sector is projected to grow faster and add more jobs than
other sectors. About one in every four new jobs will be in the health sector, with professional and technical
occupational categories exhibiting the greatest growth and offering the greatest opportunities for new jobs and career
advancement. In sum, the overall outlook for professional and technical occupations in public health is very bright for
those now in or about to enter the job market.
The optimal number of public health workers is controversial and uncertain. There is widespread concern within
the public health community that there will soon be a shortage of public health workers. Several key public health
occupational categories are currently in short supply, such as public health nurses and epidemiologists. The
information provided in the career prospect section will identify specific occupational categories that are projected to
be in greatest need. Despite the uncertainties, the BLS provides projections for the number of positions likely to be
needed in 2022 and the number of job openings that will occur through new positions and retirements.
Subsequent chapters focus on specific public health occupations and careers. But careers in public health, like
those in many fields, are not always straightforward. Individual workers can begin in one career pathway and then
shift into another. For example, administrators of public health agencies could come up through the ranks of program
and agency management or from one of the public health professional categories, such as environmental health,
nursing, or health education. This section will identify some of these paths and career ladders for public health
workers.
Additional Information
Only basic information is offered in the chapters that follow. Most public health occupational categories and careers,
however, have excellent sources for more detailed information. Several sources, often professional associations or
organizations, will be identified whenever possible. Career development opportunities through education, training,
and credentialing are also identified for each public health workforce category.
OUTSIDE-THE-BOOK THINKING 7-4
How have the needs for different public health occupations changed over the past century? How will the need for various
public health occupations change over the next two decades?
PUBLIC HEALTH WORKFORCE GROWTH PROSPECTS
Will the public health workforce increase or decrease in size over the next several decades? There should be little
debate over this question, but there is. One reason for controversy derives from the general lack of information on the
public health workforce between 1980 and 2000. Another relates to the many complex forces within public health and
the broader economy that influence the number of public health workers needed.
In hindsight, it is clear that HRSA’s estimate as to the size of the public health workforce in 1980 lacked precision.
This is unfortunate, because the 500,000 figure from 1980 is frequently cited as documentation that the public health
workforce must be shrinking because only 450,000 public health workers were enumerated in 2000. On closer
examination, however, the HRSA 1980 estimate actually indicated that only 250,000 of the 500,000 public health
workers were in the primary public health workforce consisting of federal, state, and local public health agency
workers and selected others who devoted most of their work efforts to public health activities.2 Even within this
250,000 figure were faculty and researchers at academic institutions; occupational health physicians and nurses
working for various private companies; health educators teaching in schools; and administrators working in hospitals,
nursing homes, and other medical care settings. The actual number of public health professionals working for federal,
state, and local public health agencies in 1980, after adjusting for these inclusions, was closer to 140,000. The total for
the comparable categories from the Public Health Workforce Enumeration 2000 was 260,000, a figure that indicates
the public health workforce grew rather than shrank between 1980 and 2000. Data from the employment census of
governmental agencies support this conclusion, showing there has been a steady increase in FTE workers of
governmental health agencies over the past several decades.
Together this evidence suggests that the public health workforce has been increasing throughout the 1990s, and
into the first and second decades of the new century. This is consistent with the documented expansion of the health
sector within the overall economy, which continues to grow at a more rapid rate than the rest of the economy. If public
health activities continue to maintain even their current small share of total health spending, funding for public health
activities and public health workers will grow commensurately. It is conceivable that public health activities could even
increase their share of overall health spending, fostering even more rapid growth of employment opportunities.
Several prevention and public health provisions of the Affordable Care Act suggest that this is possible.
There are mounting concerns, however, that the growth of the public health workforce may be slowing, at least in
the public sector. It was somewhat surprising that the infusion of bioterrorism preparedness funding after 2001 didn’t
result in even greater numbers of state and local public health workers than are reflected in Table 7-1. It appears that
state and local governments initially shifted some workers onto federal bioterrorism grant payrolls, thereby saving
state and local resources or possibly shifting resources from public health to other priorities such as education. The
severe national economic downturn in 2008/2009 forced many states and localities to suspend hiring and subject
workers to furloughs and layoffs. The massive infusion of funding to state and local governments through the American
Recovery and Reinvestment Act of 2009 also served to temporarily support positions in public health agencies until
this funding ended in 2010. The long-term impact of the recession on the national public health workforce remains
uncertain, although surveys conducted by the Association of State and Territorial Health Officials and NACCHO
suggest that state and local health departments suffered significant staff reductions between 2008 and 2012.18
Recent history indicates that federal funding to states and localities for bioterrorism preparedness served as a
temptation to replace or supplant state and local support for public health with federal money. The funding of
epidemiologists further illustrates this phenomenon. In 2004, federal bioterrorism funds paid the salaries of 460
epidemiologists; among 390 epidemiologists working on bioterrorism and emergency response activities, 62% were
funded by the federal government. Infectious disease epidemiologists did not increase between 2001 and 2004, but in
2004 nearly 20% were paid through federal bioterrorism funds.19 This scenario likely affected several other public
health occupational categories, such as laboratory workers and emergency response coordinators. It underscores the
important role of the underlying fiscal environment of state and local governments in determining the size of the
public health workforce.
OUTSIDE-THE-BOOK THINKING 7-5
What factors determine the optimum size of the public health workforce in a community? Are these the same factors that
would determine the optimum size of the public health workforce at the state or national level?
Two additional modern forces affect public health workforce size. These are the expansion of information
technology and the resulting increase in worker productivity. Public health practice, by its very nature, is information
dependent and information driven. Enhanced information technology tools and increased individual worker
productivity mean fewer workers are needed to support the work of administrators, professionals, and technical staff.
This trend would tend to increase the proportion of professionals within the public health workforce; however, these
trends also mean fewer professionals are needed to perform the same volume of work. The net effect is therefore
difficult to forecast in terms of the number and type of workers needed.
Trends within the health sector will also continue to affect public health workers. Health is highly valued both as a
personal and societal goal. The economic value placed on health exceeds $3 trillion annually, or nearly $10,000 per
person in the United States.9 There is no indication that health will assume a lower priority within the American social
value system. In recent years, for example, expenditures for health purposes have grown faster than the rate for the
overall economy. In effect, health is becoming an even greater priority. Between the two general strategies to achieve
health—preventive and therapeutic approaches—the balance may be slowly shifting toward more prevention. There is
still a notable imbalance, with a 20 to 1 ratio; however, this shift is likely to continue. Taken together with an increased
priority on health itself, public health activities, including those carried out by public health agencies and workers,
should continue to increase in size, importance, and value to society.
The value placed on public health activities can be measured in economic terms, such as funding levels for
programs, services, and the workers who implement public health programs and services. To sustain or even enhance
public health funding, national leadership is necessary. Federal health agencies such as CDC and HRSA are especially
important in the area of public health workforce development. Complementing sustained national leadership, state and
local governments must remain committed to and invested in public health objectives. However, states and local
governments across the United States face difficult economic circumstances and tough choices as they look to cut
back services that are either low priority or that have other funding sources.
Beyond funding, administrative and bureaucratic obstacles challenge public health workforce development efforts
in the public sector. State and local agencies are often the locus of some of the most significant recruitment and
retention problems facing the public health workforce. These include slow hiring by governmental agencies, civil
service systems, hiring freezes, budget crises affecting state and local government, and the lack of career ladders,
competitive salary structures, and other forms of recognition that value workers for their skill and performance.
Despite the uncertainties inherent in these influences, past trends and current forces suggest that professional and
administrative jobs and careers in public health are likely to grow over the next decade. Unfortunately, it will be
difficult to measure progress without deployment of a standard taxonomy for public health occupations and more
comprehensive enumeration strategies and tools that provide better information on the key dimensions of the public
health workforce.20,21
Job opportunities generally track with population density and demographic shifts. Within the health sector, job
opportunities cluster around metropolitan areas. Public health positions also follow this pattern. There are more
positions, and therefore more opportunities, in metropolitan areas than there are in rural areas. General demographic
trends indicate a continuing shift of population from the Northeast and Midwest regions of the United States to the
South, Southwest, and West Coast. It is likely that health sector jobs and public health positions will also follow this
pattern.
The ratio of positions to population, however, is higher in rural areas (and states that have higher proportions of
their population living in nonmetropolitan areas). This occurs because there is a basic core staffing that must be
present regardless of the size of the population and because rural and remote communities often lack other public
health resources and assets. Higher public health worker to population ratios in rural areas raise questions as to
whether scarce resources, in the form of public health professionals, are used efficiently in state-local public health
systems. Given limited resources, this finding argues in favor of further consolidation of small local public health
agencies into larger ones.
The demand for many public health professional occupations is growing steadily. In recent decades, an increasing
number of LHDs employed epidemiologists, health educators, health information specialists, emergency response
coordinators, and public health information officers. The aftermath of terrorist events of 2001, including the series of
anthrax spore attacks through the postal system, spotlighted the need for two professional positions in particular. The
first, emergency response coordinators, is new to the list of public health occupations; the second, epidemiologists, is
one of the oldest public health professional occupations. State and local public health agencies are rapidly hiring
emergency response coordinators. These people come to these new positions with a wide range of academic and
experiential qualifications. Epidemiologists, on the other hand, have more restrictive qualifications in terms of
academic preparation such as master’s and doctoral degrees. Concerns over the past few decades that epidemiologists
were in short supply and great demand are now heightened as agencies seek to hire more of these specialists. The
number of epidemiologists coming out of graduate programs does not appear to be keeping pace with the need,
despite an increase in interest as measured by the number of applications for epidemiology training programs.
Prior to 2001, health educators and community health planners were steadily growing professional categories in the
public health workforce. Expansion of health education and promotion programs, and an increase in community health
planning and community health improvement activities account for this trend. More recently, the Affordable Care Act
has focused increased attention on the potential roles for community health workers. If the U.S. health system shifts
even slightly toward a greater emphasis on public health and prevention activities, other public health occupations
may benefit as well.
PUBLIC HEALTH PRACTITIONER COMPETENCIES
Beyond workforce size, distribution, and composition are issues related to the essential competencies and skills that
will be most important in public health practice and how these skills are best acquired. Establishing and promoting
competencies for public health workers is tricky business. For one thing, public health workers come from a variety of
professional backgrounds, many of which have their own core competencies. For example, public health nursing has a
set of core competencies and health educators use a sophisticated competency framework for purposes of
certification. The same is true for public health physicians, administrators, epidemiologists, and several other public
health professional occupations. Identifying a common core for these various professional categories generally leads to
a framework with very general and nonspecific competencies that are difficult to relate to a specific situation or
problem. The Council on Linkages between Academia and Public Health Practice spent two decades grappling with
this problem before arriving at the set of core competencies for public health professionals summarized in Table 7-5
for entry-level workers.
TABLE 7-5 Core Competencies for Tier 1 (Entry-Level) Public Health Workers
Analytical/Assessment Skills
1. Describes factors affecting the health of a community (e.g., equity, income, education, environment)
2. Identifies quantitative and qualitative data and information (e.g., vital statistics, electronic health records,
transportation patterns, unemployment rates, community input, health equity impact assessments) that can be used for
assessing the health of a community
3. Applies ethical principles in accessing, collecting, analyzing, using, maintaining, and disseminating data and
information
4. Uses information technology in accessing, collecting, analyzing, using, maintaining, and disseminating data and
information
5. Selects valid and reliable data
6. Selects comparable data (e.g., data being age-adjusted to the same year, data variables across datasets having similar
definitions)
7. Identifies gaps in data
8. Collects valid and reliable quantitative and qualitative data
9. Describes public health applications of quantitative and qualitative data
10. Uses quantitative and qualitative data
11. Describes assets and resources that can be used for improving the health of a community (e.g., Boys & Girls Clubs,
public libraries, hospitals, faith-based organizations, academic institutions, federal grants, fellowship programs)
12. Contributes to assessments of community health status and factors influencing health in a community (e.g., quality,
availability, accessibility, and use of health services; access to affordable housing)
13. Explains how community health assessments use information about health status, factors influencing health, and
assets and resources
14. Describes how evidence (e.g., data, findings reported in peer-reviewed literature) is used in decision making
Policy Development/Program Planning Skills
1. Contributes to state/Tribal/community health improvement planning (e.g., providing data to supplement community
health assessments, communicating observations from work in the field)
2. Contributes to development of program goals and objectives
3. Describes organizational strategic plan (e.g., includes measurable objectives and targets; relationship to community
health improvement plan, workforce development plan, quality improvement plan, and other plans)
4. Contributes to implementation of organizational strategic plan
5. Identifies current trends (e.g., health, fiscal, social, political, environmental) affecting the health of a community
6. Gathers information that can inform options for policies, programs, and services (e.g., secondhand smoking policies,
data use policies, HR policies, immunization programs, food safety programs)
7. Describes implications of policies, programs, and services
8. Implements policies, programs, and services
9. Explains the importance of evaluations for improving policies, programs, and services
10. Gathers information for evaluating policies, programs, and services (e.g., outputs, outcomes, processes, procedures,
return on investment)
11. Applies strategies for continuous quality improvement
12. Describes how public health informatics is used in developing, implementing, evaluating, and improving policies,
programs, and services (e.g., integrated data systems, electronic reporting, knowledge management systems,
geographic information systems)
Communication Skills
1. Identifies the literacy of populations served (e.g., ability to obtain, interpret, and use health and other information;
social media literacy)
2. Communicates in writing and orally with linguistic and cultural proficiency (e.g., using age-appropriate materials,
incorporating images)
3. Solicits input from individuals and organizations (e.g., chambers of commerce, religious organizations, schools, social
service organizations, hospitals, government, community-based organizations, various populations served) for
improving the health of a community
4. Suggests approaches for disseminating public health data and information (e.g., social media, newspapers,
newsletters, journals, town hall meetings, libraries, neighborhood gatherings)
5. Conveys data and information to professionals and the public using a variety of approaches (e.g., reports,
presentations, email, letters)
6. Communicates information to influence behavior and improve health (e.g., uses social marketing methods, considers
behavioral theories such as the Health Belief Model or Stages of Change Model)
7. Facilitates communication among individuals, groups, and organizations
8. Describes the roles of governmental public health, health care, and other partners in improving the health of a
community
Cultural Competency Skills
1. Describes the concept of diversity as it applies to individuals and populations (e.g., language, culture, values,
socioeconomic status, geography, education, race, gender, age, ethnicity, sexual orientation, profession, religious
affiliation, mental and physical abilities, historical experiences)
2. Describes the diversity of individuals and populations in a community
3. Describes the ways diversity may influence policies, programs, services, and the health of a community
4. Recognizes the contribution of diverse perspectives in developing, implementing, and evaluating policies, programs,
and services that affect the health of a community
5. Recognizes the contribution of diverse perspectives in developing, implementing, and evaluating policies, programs,
and services that affect the health of a community
6. Describes the effects of policies, programs, and services on different populations in a community
7. Describes the value of a diverse public health workforce
Community Dimensions of Practice Skills
1. Describes the programs and services provided by governmental and nongovernmental organizations to improve the
health of a community
2. Recognizes relationships that are affecting health in a community (e.g., relationships among health departments,
hospitals, community health centers, primary care providers, schools, community-based organizations, and other types
of organizations)
3. Suggests relationships that may be needed to improve health in a community
4. Supports relationships that improve health in a community
5. Collaborates with community partners to improve health in a community (e.g., participates in committees, shares data
and information, connects people to resources)
6. Engages community members (e.g., focus groups, talking circles, formal meetings, key informant interviews) to
improve health in a community
7. Provides input for developing, implementing, evaluating, and improving policies, programs, and services
8. Uses assets and resources (e.g., Boys & Girls Clubs, public libraries, hospitals, faith-based organizations, academic
institutions, federal grants, fellowship programs) to improve health in a community
9. Informs the public about policies, programs, and resources that improve health in a community
10. Describes the importance of community-based participatory research
Public Health Sciences Skills
1. Describes the scientific foundation of the field of public health
2. Identifies prominent events in the history of public health (e.g., smallpox eradication, development of vaccinations,
infectious disease control, safe drinking water, emphasis on hygiene and hand washing, access to health care for
people with disabilities)
3. Describes how public health sciences (e.g., biostatistics, epidemiology, environmental health sciences, health services
administration, social and behavioral sciences, and public health informatics) are used in the delivery of the 10
Essential Public Health Services
4. Retrieves evidence (e.g., research findings, case reports, community surveys) from print and electronic sources (e.g.,
PubMed, Journal of Public Health Management and Practice, Morbidity and Mortality Weekly Report, The World
Health Report) to support decision making
5. Recognizes limitations of evidence (e.g., validity, reliability, sample size, bias, generalizability)
6. Describes evidence used in developing, implementing, evaluating, and improving policies, programs, and services
7. Describes the laws, regulations, policies, and procedures for the ethical conduct of research (e.g., patient
confidentiality, protection of human subjects, Americans with Disabilities Act)
8. Contributes to the public health evidence base (e.g., participating in Public Health Practice-Based Research
Networks, community-based participatory research, and academic health departments; authoring articles; making data
available to researchers)
9. Suggests partnerships that may increase use of evidence in public health practice (e.g., between practice and
academic organizations, with health sciences libraries)
Financial Planning and Management Skills
1. Describes the structures, functions, and authorizations of governmental public health programs and organizations
2. Describes government agencies with authority to impact the health of a community
3. Adheres to organizational policies and procedures
4. Describes public health funding mechanisms (e.g., categorical grants, fees, third-party reimbursement, tobacco taxes)
5. Contributes to development of program budgets
6. Provides information for proposals for funding (e.g., foundations, government agencies, corporations)
7. Provides information for development of contracts and other agreements for programs and services
8. Describes financial analysis methods used in making decisions about policies, programs, and services (e.g., cost-
effectiveness, cost-benefit, cost-utility analysis, return on investment)
9. Operates programs within budget
10. Describes how teams help achieve program and organizational goals (e.g., the value of different disciplines, sectors,
skills, experiences, and perspectives; scope of work and timeline)
11. Motivates colleagues for the purpose of achieving program and organizational goals (e.g., participating in teams,
encouraging sharing of ideas, respecting different points of view)
12. Uses evaluation results to improve program and organizational performance
13. Describes program performance standards and measures
14. Uses performance management systems for program and organizational improvement (e.g., achieving performance
objectives and targets, increasing efficiency, refining processes, meeting Healthy People objectives, sustaining
accreditation)
Leadership and Systems Thinking Skills
1. Incorporates ethical standards of practice (e.g., Public Health Code of Ethics) into all interactions with individuals,
organizations, and communities
2. Describes public health as part of a larger interrelated system of organizations that influence the health of
populations at local, national, and global levels
3. Describes the ways public health, health care, and other organizations can work together or individually to impact the
health of a community
4. Contributes to development of a vision for a healthy community (e.g., emphasis on prevention, health equity for all,
excellence and innovation)
5. Identifies internal and external facilitators and barriers that may affect the delivery of the 10 Essential Public Health
Services (e.g., using root cause analysis and other quality improvement methods and tools, problem solving)
6. Describes needs for professional development (e.g., training, mentoring, peer advising, coaching)
7. Participates in professional development opportunities
8. Describes the impact of changes (e.g., social, political, economic, scientific) on organizational practices
9. Describes ways to improve individual and program performance
Note: Tier 1 competencies apply to public health professionals who carry out the day-to-day tasks of public health organizations and are not in
management positions. Responsibilities of these professionals may include data collection and analysis, fieldwork, program planning, outreach,
communications, customer service, and program support.
Reproduced from Council on Linkages between Academia and Public Health Practice; 2014. Available at
http://www.phf.org/resourcestools/Pages/Core_Public_Health_Competencies.aspx. Accessed July 11, 2014.
CONCLUSION
Recent decades witnessed an increase in the number of public health workers employed by both governmental and
nongovernmental agencies. This expansion of the workforce, however, leaves many questions unanswered as to the
appropriate number, distribution, training, and preparedness of the public health workforce, making these issues of
public concern. Some of these concerns have persisted since the late 1800s, as suggested by an editorial appearing in
the Journal of the American Medical Association more than a century ago:
It is unfortunate that in the absence of epidemics or pestilence, too little attention is paid to the protection of
the public health, and as a necessary consequence, to the selection of those whose duties require them to
guard the public health.22(p189)
Other concerns are of more recent vintage. The economic recession of 2008/2009 displaced millions of workers in
both the public and private sectors of the economy. State and local governments were especially hard hit, and are
recovering slowly. Sources point to the aging of the public health workforce, current shortages of public health nurses
and epidemiologists, and the imminent retirement of many public health professionals. On the other hand, national
health reform legislation enacted in 2010 included several provisions for stabilizing and strengthening the public
health workforce and an increased emphasis on population-focused prevention.
The public health workforce is growing and will continue to grow for years to come. Many public health
occupational categories will see a steady increase; others will grow even more rapidly. Core public health practice
competencies will increasingly influence education and training programs and hopefully find their way into the human
resource activities and personnel systems of governmental public health agencies. Worker recognition initiatives based
on relevant competencies, such as credentialing and certification programs, will also grow in order to address the
need for both heightened accountability and expanded career pathways.
Although strategies that focus on the pipeline are necessary and useful, they will never be sufficient to ensure an
effective public health workforce over the long term. Comprehensive workforce development strategies must focus not
only on current and future workers, but also on the organizations in which the work of public health is performed. In
the decades that lie ahead, the most important resource and asset of the public health system—its workforce—faces as
many challenges as opportunities.
REFERENCES
1. Institute of Medicine, National Academy of Sciences. The Future of Public Health. Washington, DC: National Academy Press; 1988.
2. Health Resources and Services Administration, U.S. Department of Health and Human Services. Public Health Personnel in the United States,
1980: Second Report to Congress. Washington, DC: U.S. Public Health Service; 1982.
3. Health Resources and Services Administration, U.S. Department of Health and Human Services. Public Health Workforce Enumeration 2000.
Washington, DC: Government Printing Office; December 2000.
4. Public Health Functions Steering Committee. Public Health America. I. Washington, DC: U.S. Public Health Service; 1995.
5. Institute of Medicine, National Academy of Sciences. Who Will Keep the Public Healthy? Education Public Health Professionals for the 21st
Century. Washington, DC: National Academy Press; 2003.
6. Kennedy VC, Moore FI. A systems approach to public health workforce development. J Public Health Manage Pract. 2001; 7: 17–22.
7. U.S. Bureau of the Census. Federal, State, and Local Governments, Public Employment and Payroll Data. www.census.gov/govs/apes/. Accessed
June 16, 2014.
8. National Association of County and City Health Officials. 2013 National Profile of Local Health Departments. Washington, DC: National
Association of County and City Health Officials; 2014.
9. Centers for Disease Control and Prevention, National Center for Health Statistics. Health United States, 2013. Hyattsville, MD: National Center
for Health Statistics; 2014.
10. National Association of County and City Health Officials. 2008 National Profile of Local Health Departments. Washington, DC: National
Association of County and City Health Officials; 2009.
11. Gerzoff RB, Baker EL. The use of scaling techniques to analyze U.S. local health department staffing structures, 1992–1993. Proceedings of the
Section on Government Statistics and Section on Social Statistics of the American Statistical Association. 1998: 209–213.
12. Thomas JC, Sage M, Dillenberg J, Guillory VJ. A code of ethics for public health. Am J Public Health. 2002; 92: 1057–1059.
13. Gerzoff RB, Richards TB. The education of local health department top executives. J Public Health Manage Pract. 1997; 3: 50–56.
14. U.S. Department of Education, National Center for Education Statistics, Integrated Postsecondary Education Data System (IPEDS), Fall 2010,
Completions component. 2011.
15. Turnock BJ. Roadmap for public health workforce preparedness. J Public Health Manage Pract. 2003; 9: 471–480.
16. National Board of Public Health Examiners. http://www.nbphe.org. Accessed June 9, 2014.
17. Bureau of Labor Statistics, U.S. Department of Labor. www.bls.gov. Accessed June 15, 2014.
18. National Association of County and City Health Officials. Local health department job looses and program cuts: Findings from the 2013 Profile
study. Washington, DC: NACCHO; 2013.
19. Council of State and Territorial Epidemiologists. 2004 National Assessment of Epidemiologic Capacity: Findings and Recommendations.
Washington, DC: Council of State and Territorial Epidemiologists; 2004. http://www.cste.org/Assessment/ECA/pdffiles/ECAfinal05 . Accessed
October 8, 2014.
20. Tilson H, Gebbie KM. The public health workforce. Ann Rev Public Health. 2004; 25: 341–356.
21. Gebbie KM, Turnock BJ. The public health workforce, 2006: new challenges. Health Aff (Millwood). 2006; 25: 923–933.
22. American Medical Association. Editorial. JAMA. 1893; 20: 189.
CHAPTER 8
Public Health Administration
LEARNING OBJECTIVES
Given the need for managers and administrators in the public health system, describe key features of
occupations and careers in public health administration and how these contribute to carrying out public
health’s core functions and essential services. Key aspects of this competency expectation include being able
to
• Describe several different occupational titles in this category
• Identify the essential public health services that are most critical for positions in this category
• Describe important and essential duties for several job titles in this category
• Identify minimum qualifications and describe general workplace considerations, salary expectations, and career
prospects for positions in this category
Public health organizations require leaders, managers, and administrators at various levels throughout the
organization to plan, organize, direct, control, and coordinate health services, education, or policy. The people serving
in these positions come from a wide variety of educational, professional, and work experience backgrounds. Many lack
formal training and previous experience in public health. Nonetheless, they constitute the third largest occupational
category within the public health workforce, behind only nurses and environmental health workers, and they represent
a force even larger than their numbers. Table 8-1 offers a snapshot of an average day in the life of a public health
administrator.
OCCUPATIONAL CLASSIFICATION
There is no standard occupational category (SOC) specific to public health administrators and managers. There is a
generic standard occupational category for medical and health services managers that encompasses administrative
positions in any healthcare or health services organization. This SOC is one of the administrative occupations within
the white collar grouping of occupations.
Public health administrators are health services managers leading a public health agency, program, or major
subunit. Public health administrators plan, analyze, organize, direct, coordinate, and evaluate the use of resources to
deliver health services, education, or policy; they often manage or regulate health agencies and facilities. The category
includes such job titles as director, administrator, chief, manager, or one of the many titles indicating chief public
health official of a jurisdiction (e.g., secretary of health, health officer, health commissioner, administrator, or health
official). Titles that include the term coordinating or senior are generally not classified as public health administrators
but are included with the profession referenced (e.g., coordinating nutritionist with public health nutritionist, senior
public health nurse with public health nurse).
Data from the Bureau of Labor Statistics (BLS) indicate there were 300,000 health services administrators in the
United States in 2013, with 25,000 working for federal, state, and local health agencies,1 The Public Health Workforce
Enumeration 2000 study suggests there were about 21,000 working in governmental public health agencies in the
year 2000.2 Recent surveys of local and state public health agencies indicate that more than 16,000 of these positions
are in local health departments (LHDs) and official state health agencies.3,4 Data and information from these various
sources are used throughout this chapter.
TABLE 8-1 A Typical Day for a Public Health Administrator
7:30 a.m. Breakfast with local hospital administrator and staff regarding diabetes screening
8:30 a.m. In office, follow-up call with state epidemiologist regarding recent outbreak of foodborne illness
9:00 a.m. Weekly meeting with senior staff
10:15 a.m. Meet with epidemiology, health education, and planning staff regarding completion of community needs
assessment
10:45 a.m. Meet with county commissioner regarding West Nile Virus concerns in her area
11:15 a.m. Review and update electronic slide presentation for today’s lunch meeting
11:45 a.m. Meet with local Chamber of Commerce leadership before lunch, which includes public health presentation to
business community
1:00 p.m. Discuss budget amendment proposal with fiscal and program staff
1:30 p.m. Media interview regarding West Nile Virus concerns
2:00 p.m. Give welcoming remarks and overview for new employee orientation
3:00 p.m. Conference call for committee of National Association of County and City Health Officials task force on
workforce and leadership development
4:00 p.m. Review information suggested by senior staff for presentation to board of health
4:30 p.m. Drop by the clinic to see how things went today
5:15 p.m. Prepare remarks for board of health meeting
7:00 p.m. Attend monthly meeting of board of health
In addition to medical and health services managers, there are several other standard occupational classifications
that may be involved with public health administration. These include the SOCs for social and community services
managers and emergency management directors, as well as administrative business professionals and support staff.
Social and community services managers plan, direct, or coordinate the activities of a social service program or
community outreach organization. These positions generally oversee a program or organization’s budget and policies
regarding participant involvement, program requirements, and benefits. This work may involve directing health and
social workers, counselors, or probation officers. In 2013 there were 115,000 workers in this occupational category
with nearly 25,000 employed in the public sector.
As with medical and health services managers, titles for social and community services managers vary considerably.
Common titles include Program Director, Social Services Director, Program Manager, Vocational Rehabilitation
Administrator, Adoption Services Manager, Children’s Service Supervisor, Clinical Services Director, Community
Services Block Grant/Outreach Social Worker, Director of Child Welfare Services, and Director of Social Services.
Social and community services organizations frequently collaborate with a variety of public and voluntary sector
organization to achieve public health objectives for a community, often through participating in community health
improvement initiatives and activities.
Emergency management directors provide oversight to organizations or units involved with preparing for and
responding to a spectrum of emergency situations and threats. Within public health agencies, such managers may
supervise the public health emergency preparedness and response activities of the organization. Since the turn of the
century, positions such as emergency response coordinator or manager have experienced steady growth in state and
local public health agencies.
Administrative business professionals are trained at a professional level in their field of expertise prior to entry in
public health and perform work in business, finance, auditing, management, and accounting. Data extrapolated from
the Public Health Workforce Enumeration 2000 study identified 7,500 administrative business professionals working in
governmental public health agencies in the year 2000. Administrative business support staff, including bookkeepers,
accounting clerks, and auditing clerks, work with administrative business professionals in areas of business and
financial operations. In addition, there were another 80,000 administrative support workers (such as receptionists,
typists, and stenographers) who perform nontechnical support work in all areas of agency management and program
administration. Administrative business professionals and administrative support staff titles fall within the
administrative chain of command of an agency but are not classified within the administrator and manager category.
Nonetheless, these titles can serve as steps along a career development path leading to a public health administrator
position.
OUTSIDE-THE-BOOK THINKING 8-1
What will be the most important new or expanded roles for public health administrators in the 21st century?
PUBLIC HEALTH PRACTICE PROFILE
Public health managers and administrators work at a level within an organization that often bears responsibility for
achieving organizational goals and objectives. This means they may be involved with addressing any or all six public
health responsibilities, although their background and experience may provide greater expertise in some of these roles
than others. For example, administrators of local public health agencies who worked their way to the top of the
organization through the ranks of environmental health may continue to be directly involved in protecting against
environmental hazards or responding to disasters. An administrator from the ranks of the nursing staff may remain
more directly involved in disease prevention and quality assurance of health services. For most public health
administrators, managing responses to public health emergencies and ensuring the quality of health services require
their personal attention. If these administrators also have professional training in epidemiology, disease and injury
prevention, environmental health, or health education, they may be directly involved in these duties as well.
Otherwise, the professional and program staff of the organization guide activities for these roles.
OUTSIDE-THE-BOOK THINKING 8-2
What are the most important contributions to improving the health of the public that public health managers and
administrators make today?
Similarly, among the 10 essential public health services, administrators may have more personal expertise in some
services than others. There are several essential public health services, however, that all administrators must address.
These include developing and mobilizing collaborative relationships and partnerships within the community,
developing policies and plans, enforcing laws and regulations, ensuring a competent workforce, and evaluating the
effectiveness, accessibility, and quality of health services. Table 8-2 summarizes public health purposes and essential
public health services at the core of positions for public health administrators.
TABLE 8-2 Public Health Practice Profile for Public Health Administration
Public Health Administrators Make a Difference by:
Public Health Purposes
Preventing epidemics and the spread of disease
Protecting against environmental hazards
Preventing injuries
Promoting and encouraging healthy behaviors
Responding to disasters and assisting communities in recovery
Ensuring the quality and accessibility of health services
Essential Public Health Services
Monitoring health status to identify community health problems
Diagnosing and investigating health problems and health hazards in the community
Informing, educating, and empowering people about health issues
Mobilizing community partnerships to identify and solve health problems
Developing policies and plans that support individual and community health efforts
Enforcing laws and regulations that protect health and ensure safety
Linking people with needed personal health services and ensuring the provision of health care when otherwise
unavailable
Ensuring a competent public health and personal healthcare workforce
Evaluating effectiveness, accessibility, and quality of personal and population-based health services
Researching new insights and innovative solutions to health problems
IMPORTANT AND ESSENTIAL DUTIES
There are many possible job titles and positions for public health administrators. The focus in this chapter will be on
four positions: (1) health services manager; (2) local health department (LHD) director; (3) health officer; and (4)
public health emergency preparedness and response coordinator. Each of these positions and a representative panel of
their important and essential duties are described in this section.
Health Services Manager
This is an administrative and management position that directs, plans, analyzes, and coordinates health, public health,
and regulatory programs and services. A worker in this or a similar title (such as health administrator) is often
responsible for directing or assisting in the overall planning, directing, and coordinating of assigned health, public
health, and regulatory programs and services, including the identification of program priorities and the development
and implementation of new programs and services. This position could be located at a variety of managerial levels.
Responsibilities may be in areas such as chronic disease prevention; environmental health and communicable disease
prevention; health standards and licensure; maternal, child, and family health; nutritional health and services; health
information; regulation; senior services; health improvement; emergency response; or closely related areas. Positions
have program management and decision-making authority and usually have policy, assessment, planning, budget, and
supervisory responsibilities. Direction is received from a designated administrative superior who reviews work through
conferences, reports, and evaluation of operational results. The health services manager, however, is expected to
exercise considerable initiative and judgment in planning and carrying out assignments.
Important and essential duties for health services managers may include
• Directs or assists in the overall planning, development, and administration of assigned health, public health, and
regulatory programs and services in such areas as chronic disease prevention; maternal, child, and family health;
environmental health and communicable disease prevention; nutritional health and services; health standards and
licensure; health information; regulations; health improvement; or emergency response
• Develops and coordinates comprehensive public health systems for a specific geographic area, such as a county,
city, or district
• Provides consultation to physicians, healthcare providers, hospitals, LHDs, and other agencies linked with health
care in the effective delivery of health, public health, and regulatory programs and services
• Ensures individuals receive program services appropriate to their needs and program eligibility
• Oversees or assists in the development of community-based coalitions and works with coalitions, advocacy
groups, and others interested in program issues to develop plans and outcomes on how to address specific health,
public health regulatory, and senior programs and services concerns
• Prepares new or revises existing legislation and develops standards, regulations, and policies to implement the
legislation
• Directs or assists administrative personnel in general management aspects of policy development and program
planning and coordination as related to assigned responsibilities; assists in the evaluation of the effect of policy
and organizational changes and new programs
• Reviews and revises programs in area of responsibility to ensure compliance of operations with laws,
regulations, policies, plans, and procedures
• Supervises staff to carry out the strategies of the organization or program
• Participates in meetings with agency administrators to develop, coordinate, implement, and interpret new or
revised initiatives
• Participates in conferences and meetings relating to areas of assigned responsibility
• Participates in the development of budget requests and the monitoring of expenditures according to budget
allocations and appropriations
• Conducts research, institutes special studies, and prepares or reviews reports and related information to
evaluate existing organizations, policies, procedures, and practices as related to the assigned program
• Maintains contact, cooperates with, and addresses local and community organizations and other interested
groups pertaining to the assigned programs
Local Health Department Director
Under administrative direction, LHD directors plan, organize, direct, manage, and supervise public health programs
for their jurisdiction; direct the enforcement of federal, state, and local health laws and regulations; direct staff
providing public health and education programs; represent agency activities, programs, and services with community
organizations and other governmental agencies; perform special assignments as directed; and provide administrative
support for its governing bodies (such as a board of health or a city or county board of supervisors). LHD directors
often serve as agency head with general responsibility for the administration of the jurisdiction’s public health
programs and functions and may serve as the health officer for the jurisdiction. Many of the nonmedical duties of
health officers are also performed by LHD directors. This position may report to a municipal or county board of health
or board of supervisors (or perhaps a city council) through the municipal or county administrative officer or chief
elected official. As agency head, this position often directly supervises positions such as director of nursing, fiscal
officer, director of environmental health, director of health education, and sometimes a medical health officer.
Important and essential duties for a LHD director may include
• Plans, organizes, directs, coordinates, and administers public health programs for the jurisdiction, such as
communicable disease control, immunization, environmental health, health education, maternal and child health,
vital statistics, and health programs for adults, children, handicapped children, and schools
• Enforces public health laws and regulations within the jurisdiction
• Develops and recommends agency goals, objectives, and policies
• Provides strategic direction and leadership in identifying community health needs and developing and
implementing community health improvement plans that meet identified needs
• Prepares and administers agency budgets recommended by the jurisdiction’s executive officer and approved by
the governing board or entity
• Controls fiscal expenditures and revenues
• Monitors and evaluates overall agency and program performance and directs change to improve quality and
effectiveness
• Hires, supervises, evaluates, and ensures proper training of agency staff in accordance with personnel rules
• Administers a variety of categorical programs
• Provides direction and develops policies for clinical services through protocol development
• Develops policies and protocols for the control and prevention of communicable diseases
• Plans and develops new program efforts
• Develops and administers grants
• Initiates appropriate epidemiologic investigations of communicable disease outbreaks
• Provides health information to the public, community organizations, and other county staff
• Maintains contact with the press and community organizations
• Interprets policies and regulations for the public
• Supervises administration, program development, fiscal management, and provision of direct client services at
agency clinic sites
• Represents the agency with other government agencies
Health Officer
Health officers, often physicians, plan, organize, direct, and provide medical oversight over public health programs for
their local public health jurisdictions; provide technical consultation to citizens, public officials, staff, and community
organizations and agencies on public health and preventive medicine issues; and serve as the designated health
officers. A health officer provides medical supervision for the LHD by coordinating public healthcare services with
external agencies and healthcare providers and providing ongoing communication with the local medical community.
This position is also responsible for providing medical oversight and enforcement of public health regulations for a
variety of public health programs and services including environmental health, vital records, communicable disease
control, public health nursing, emergency and disaster medical planning, public health education, and state maternal
and child health services. This title is distinguished from the LHD director in that the latter has overall management
responsibility for the LHD’s programs and services, whereas the health officer directs the medical oversight for all
public health programs. In some instances, the health officer also serves as LHD director; in others, this position
reports to the public health director or to the director of a higher-level health and human services agency. Some states
(about one half) require the health officer to be a licensed physician; the other one half allows non-physicians to serve
as health officers or sets no requirements. Health officers often supervise titles such as the director of public health
nursing, the director of environmental health, director of health education, and other professional and program
directors.
Important and essential duties for health officers may include
• Plans, organizes, directs, and evaluates the medical oversight of public health programs
• Ensures enforcement of applicable public health, environmental health, and sanitation orders, ordinances, and
statutes
• Analyzes legislative changes; evaluates and develops medical and public health policies, programs, and
procedures; and formulates improvements
• Serves as an advocate to promote statewide public health policies, which also benefit the local jurisdiction
• Disseminates and interprets policies, laws, regulations, and state and federal directives regarding medical and
public health issues to physicians, department staff, and representatives of hospitals, nursing homes, medical
clinics, and schools by written means and personal contacts; acts as medical epidemiologist for public health
diseases
• Consults and coordinates with federal and state officials and representatives of local public and private health
agencies in the enforcement of health laws and the development of programs to meet public health needs
• Plans, organizes, directs, coordinates, and administers public health programs for the jurisdiction, such as
communicable disease control, immunization, environmental health, health education, maternal and child health,
vital statistics, and programs for adults, children, handicapped children, and schools
• Provides direction and advice regarding policies and procedures directed by the state immunization board
• Works closely with the agency director and health services managers to monitor performance and effect changes
in practice to improve quality of services
• Confers with members of the public and representatives of federal, state, and local agencies regarding health
department programs; cooperates with federal and state public health groups in the enforcement of health and
sanitary matters
• Supervises, directs, and evaluates assigned staff, to include assigning work, handling employee concerns and
problems, and counseling
• Reviews technical requirements, reports, and procedures generated by the health department
• Prepares public health information materials and news releases
• Consults with physicians, nurses, patients, staff members, other governmental agencies, or other individuals in
the diagnosis of, and investigation of, cases of suspected communicable diseases and exchanges information or
provides recommendations; takes measures to prevent and control epidemics
• Serves on emergency medical services and public health emergency preparedness committees
• Represents the jurisdiction on committees, boards, at meetings, or otherwise as assigned
Public Health Emergency Preparedness and Response Coordinator
Public health emergency preparedness and response coordinators perform planning functions for a local public health
agency, ensuring compliance with federal and state planning guidelines and regulations. These positions coordinate
response plans with the state health department as well as other federal, state, and local government entities; perform
all hazard, bioterrorism, and emergency planning; and coordinate plans with various response agencies, volunteer
organizations, businesses, and private industries.
Massive federal bioterrorism preparedness funding for state and local public health agencies stimulated a rapid
increase in the number of emergency preparedness and response positions in the United States, making this title one
of the fastest growing within the public health workforce. There was no information on public health emergency
response coordinators available in the Public Health Workforce Enumeration 2000 report.
Important and essential duties for a public health emergency response coordinator include
• Performs administrative, technical, and planning duties to integrate bioterrorism and public health emergency
preparedness and response plans with activities for other emergency management programs
• Develops and maintains the local public health agency’s various emergency operations plans
• Reviews and maintains bioterrorism response appendices to meet Centers for Disease Control and Prevention
(CDC) planning guidance and local standard operating guidelines
• Assists with coordination, integration, and implementation of emergency response plans and procedures from
various jurisdictions, governmental entities, private industries, utility companies, among others
• Reviews specialized studies and reports, formulates comments and summarizes content, and provides
emergency planning recommendations
• Coordinates with the local jurisdiction’s emergency management agency and the state health emergency
management agency in continual development and review of effective emergency preparedness and response
activities
• Identifies unique planning considerations for bioterrorism threats
• Assists the public health community in developing jurisdictional emergency plans by attending meetings and
facilitating discussions, reviewing concepts and procedures, and coordinating emergency response efforts of
various agency units
• Acts as a resource for the public health community and governmental public health agencies in documenting
their standard operating guidelines and operational checklists
• Coordinates overall emergency planning activities
• Conducts regular review of local, state, federal, and private industry emergency response plans, employing
standard emergency management concepts and strategic methodologies
• Works in conjunction with the executive director, environmental health supervisor, risk communicator,
epidemiologist, and public information officer to promote awareness of local public health agency emergency
response plans and procedures
• Provides requisite planning activity reports, budget submissions, and other required documentation for federal
and state emergency response funding sources
• Assists with the development of operational drills and exercise scenarios designed to train, test, and evaluate
emergency response concepts or standard operating guidelines
• Adjusts emergency plans, procedures, or protocols to reflect changes and improve efficiency as appropriate
• Demonstrates continuous effort to improve operations, decrease turnaround times, streamline work processes,
and work cooperatively and jointly to provide quality seamless customer service
MINIMUM QUALIFICATIONS
Public health administrators can emerge from either a professional occupational category or from a career in other
management positions. Those arising from the professional ranks may acquire management skills either as part of
their education, such as in a relevant master’s degree program. Relevant degrees include the master’s of public health
(MPH), master’s of public administration (MPA), master’s of health administration (MHA), or master’s of business
administration degree (MBA) or, less commonly, a public health doctoral degree program. Schools of public health
commonly target the doctor of public health degree (DrPH) for leaders and other high-level public health practitioners.
Doctor of philosophy (PhD) and doctor of science (ScD) degrees in public health sciences and disciplines are also
offered by many institutions.
More commonly, however, public health administrators and managers lack formal training at the master’s or
doctoral level in public health. For example, only 20–25% of chief administrators of LHDs reported formal training in
public health in recent surveys of LHDs.3 This includes administrators whose public health training was in their
primary profession (such as nursing, environmental health, medicine, or health education), suggesting that few
received public health training in programs preparing administrators. Many public health administrators acquire
public health practice management skills on a nondegree basis through a variety of means including management
academies and leadership development institutes. Several dozen states have developed such institutes for workers in
their own and collaborating states. There are also national public health leadership institutes for state and local public
health officials and a national public health management academy.
Public health administrators represent a significant portion of the public health workforce for which career
pathways are particularly unclear. Efforts to establish a greater professional identity for public health administrators
are receiving increased attention. Management and leadership development programs are one example. Credentialing
of public health administrators is another option under consideration. Several states license public health
administrators, and one program credentials public health administrators through an independent review board. Some
public health administrators view degrees from programs accredited by the Accrediting Commission on Education for
Health Services Administration (ACHESA) or subsequent recognition from the American College of Healthcare
Executives as meaningful credentials.
To be considered as qualified for a position as a public health administrator, both experience and education are
important. Typical minimum qualifications for health services managers, local public health administrators, health
officers, and emergency response coordinators are detailed in the following section.
Typical Minimum Qualifications for Health Services Manager
Knowledge, Skills, and Abilities
A health services manager generally has knowledge of:
• Principles and practices involved in the administration of health, public health, and regulatory programs and
services
• The organization and operation of public agencies at the national, state, and local levels that are involved in
health, public health, and regulatory programs and services
• The philosophy and objectives of state health and public health regulatory programs and services
• Programs and objectives of state and local public health agencies and of the interprofessional relationships in
the implementation of their programs
• Current human service issues and theories
• The organization and functions of advocacy groups, voluntary agencies, civic organizations, and similar groups
interested in health, public health, and regulatory programs and services and activities
• Managerial techniques and administrative practices
A health services manager generally has the skills and ability to:
• Plan, promote, and direct complex public health programs or services at the state level
• Analyze complex health data and formulate plans for coordinating and establishing new or improved health
services and programs
• Secure active cooperation from other public and private agencies in developing and guiding health, public
health, regulatory, and senior programs and services
• Develop, implement, and administer assigned programs or services to achieve positive program and client
outcomes
• Establish and maintain working relationships with departmental officials, legislators, staff associates, the
general public, and others
• Analyze and evaluate policies and operations and formulate recommendations
• Communicate effectively
• Provide leadership and supervision to professional, technical, and related program staff
• Manage change, provide program management, and achieve results
• Develop short- and long-range plans that meet established objectives and contribute to the overall goals and
mission of the agency
Experience and Education
In many personnel systems, any combination of training and experience that provides the required knowledge and
abilities qualifies an individual for this position. A typical career pathway for health services managers is through 3 or
more years of professional experience in public health, healthcare delivery, environmental health or regulation,
protective services for adults or the disabled, in-home services, or long-term care. In addition, a qualified applicant
would have graduated from an accredited 4-year college or university with specialization in public health; healthcare
administration; public, personnel, or business administration; biological, physical, environmental, or social sciences;
nursing; nutrition/dietetics; social work; human services; gerontology; physical rehabilitation; education; or closely
related areas. Graduate work in specified educational areas may sometimes be substituted on a year-for-year basis for
1 or more years of the required experience. Additional qualifying experience in the specified areas may be substituted
on a year-for-year basis for any deficiencies in the stated education.
Typical Minimum Qualifications for Local Health Department Director
Knowledge, Skills, and Abilities
The LHD director generally has knowledge of:
• Basic principles of medical science and their application to local public health programs
• Public health problems and issues and their relationship to the development and operations of public health
programs and services
• Federal, state, and local laws, ordinances, and regulations applicable to public health programs and
communicable disease control
• Clinical skills and procedures
• Grant development and administration
• Principles, techniques, and practices of business and public health administration
• Budget development and expenditure control
• Principles and techniques of effective employee supervision, training, and development
• Public personnel management
The LHD director generally has the skills and ability to:
• Plan, organize, supervise, and administer the functions and programs of the local public health agency
• Ensure proper enforcement of public health statutes, laws, and regulations
• Provide direction, supervision, and training for agency staff
• Develop and administer budgets and control expenditures
• Develop and administer grants
• Review the work of agency staff and resolve problems
• Oversee the development, maintenance, and preparation of public health statistics, medical records, and reports
• Direct the preparation of and prepare clear, concise reports
• Effectively represent the local public health agency in contact with the public, community organizations, and
other government agencies
• Establish and maintain cooperative working relationships
• Coordinate assigned activities with community organizations and other government agencies
Experience and Education
Any combination of training and experience that provides the required knowledge and abilities can qualify an
individual for this position. A typical pathway to obtain the required knowledge and abilities is through broad and
extensive experience in the development, analysis, and administration of public health programs and services with 3
years of the background and experience in a management or full supervisory capacity. Ideally this experience includes
work in the areas of fiscal management, personnel management, and program development. In addition, a master’s
degree in public health, public administration, or healthcare administration is highly desirable.
Typical Minimum Qualifications for Health Officer
Knowledge, Skills, and Abilities
The health officer generally has knowledge of:
• Principles, practices, and responsibilities of medicine and of contemporary public health programs and service
needs
• Applicable federal and state laws and regulations
• Organization, purpose, and function of federal and state health agencies
• Local medical associations and community health groups
• Principles and methods of public and community relations, and public information practices and techniques
• Principles and methods of determining and servicing public health needs
• Socioeconomic and psychological factors that can impact the effectiveness of health services delivery
• Communicable diseases and methods of control of sexually transmitted diseases
• Basic principles of budgeting
• Principles and practices of management necessary to plan, analyze, develop, evaluate, and direct diverse and
complex activities of major health programs
The health officer generally has the skills and ability to:
• Plan, organize, and direct public health programs within professional standards, legal requirements, and
financial constraints
• Direct and supervise professional and technical personnel
• Analyze situations accurately and take effective actions
• Interpret laws, regulations, and standards pertaining to public health
• Prepare clear and comprehensive records and reports
• Maintain accurate records
• Communicate effectively, both orally and in writing
• Speak effectively in public
• Establish and maintain effective working relationships with staff members, other departments, agencies, public
groups, and organizations
Education and Experience
Any combination of training and experience that provides the required knowledge and abilities will qualify an
individual for this position. A typical pathway to obtain the required knowledge and abilities is through 3 years of
administrative or supervisory public health medical experience or possession of an MPH from an accredited school of
public health and one year of public health medical experience. In some states, health officers must be a graduate of a
medical school in good standing and possess a valid license to practice medicine in that state.
Typical Minimum Qualifications for Emergency Preparedness and Response Coordinator
Knowledge, Skills, and Abilities
Relevant knowledge, skills, and abilities for public health emergency response coordinators include
• Skill in organization and planning techniques
• Skill in public relations and public speaking
• Skill in computer and communication equipment operation
• Knowledge of basic budget development and fiscal management
• Knowledge of public health and epidemiology
• Ability to establish and maintain effective working relationships with other government and public health
officials, employees, agencies, volunteers, and the public
• Ability to communicate effectively, verbally and in writing
• Ability to learn the principles, practices, and techniques involved in emergency management
• Knowledge of principles and practices of governmental and public health agency structures and resources
• Minimum qualifications call for the equivalent of a master’s degree in public health, biologic sciences,
community health, emergency management, planning, hazard assessment, business or public administration, or
other related field; and 2 years of emergency management, community planning, or other related work
experience. Selected applicants are subject to, and must pass, a full background check. In addition, emergency
response coordinators generally are required to possess a valid state driver’s license. Other organizations may
require 5 years of responsible experience in public administration, research and finance, including 3 years of
emergency management experience and a master’s degree in public or business administration, government
management, industrial engineering, or a related field. Other combinations of experience and education that
meet the minimum requirements may be substituted.
WORKPLACE CONSIDERATIONS
Every organization has a management structure with various levels of management positions. Larger and more
complex organizations have greater numbers of managers and administrators, although their scope of responsibility is
often limited to a specific program or constellation of programs. Smaller organizations are more likely to be dominated
by professionals, with administrative positions often filled by workers with professional backgrounds and credentials.
For example, more than one half of the directors of the approximately 3,000 local public health agencies in the United
States hold a health professional degree but no degree in public health.3 For several decades, there has been a general
trend toward more nonprofessional managers rather than elevating professionals into top management positions. This
has been occurring at all governmental levels but somewhat more frequently among state and federal health agencies
than for local public health agencies.
Work settings also influence the typical physical requirement for positions in this occupational category. Similar to
administrators and managers throughout the health sector, public health administrators work long and irregular
hours. Most public health administration positions call for workers to be able to sit for extended periods and to
frequently stand and walk short distances. Normal manual dexterity and eye-hand coordination, hearing, and vision
corrected to within the normal range are also important considerations. Normally, public health administrators will be
able to communicate verbally and use office equipment including computers, telephones, calculators, copiers, and fax
machines. Although much of the work is performed in an office environment, frequent and/or continuous contact with
staff and the public is also necessary. In many situations, administrators may be required to possess a valid driver’s
license.
Special requirement for public health emergency preparedness and response manager positions may include the
ability to travel and to be on call 24 hours a day, 7 days a week. Emergency preparedness and response managers may
be required to complete training courses a recommended and made available through federal or state public health
and emergency management agencies. In some instances, emergency preparedness and response managers may be
required to complete the Certified Emergency Manager program through the National Coordinating Council on
Emergency Management within some specified period of time after employment.
Working conditions for these positions include most work being performed in an office, library, computer room, or
other environmentally controlled room. Emergency response activities may require work in a full-body protective suit
with respirator protection from potential biologic, chemical, or nuclear material hazards
OUTSIDE-THE-BOOK THINKING 8-3
What features make public health administration a career worth pursuing?
POSITIONS, SALARIES, AND CAREER PROSPECTS
In 2013, there were 300,000 medical and health services managers employed in the United States, with 25,000
working for federal, state, and local governmental agencies. Federal agencies employed 11,000 health administrators
and managers, while state and local governments employed another 14,000 (Table 8-3 and Table 8-4). Although the
total number of medical and health services managers has been increasing faster than most other occupational
categories in recent decades, a trend projected to continue through this decade, the number working in the public
sector has been steady. This trend is projected to continue through 2022. Public Health Enumeration 2000 data
suggests there were 21,200 public health administrators at the turn of the century.
The median annual salary for all public sector medical and health managers was $95,000 in 2013 with the middle
50% earning between $76,000 and $118,000 (Table 8-4). Entry-level salaries were in the $60,000–$70,000 range.
Small LHDs have notoriously lower salary scales (often in the $50,000–$70,000 range), making it difficult to attract
administrators with graduate degrees or with extensive previous experience. Larger governmental agencies can often
offer salaries that are competitive with those found in private and voluntary sector agencies. Administrators with
professional credentials, especially physicians, dentists, veterinarians, epidemiologists, and nurses, may be able to
attract salaries in the six-figure category.
The number of positions for medical and health services managers is expected to grow to nearly 390,000 by the
year 2022, but with only 26,000 employed by government agencies (Table 8-3). Job growth in the government sector
will lag behind the growth rate for medical and health administrator positions in the overall economy. Based on the
growth in the number of positions and the need to fill other positions due to job changes and retirement, nearly
150,000 positions for medical and health administrators will be filled between 2012 and 2022 but with relatively few of
these in the government sector.
TABLE 8-3 Number of Workers in 2013 and Projected for 2022 for All Industries and Government and Number
of Positions to Be Filled 2012–2022 for All Industries
Data from Bureau of Labor Statistics, U.S. Department of Labor. Selected Occupational Projections Data. Available at www.bls.gov/data/.
Accessed June 15, 2014.
TABLE 8-4 Number and Salary Profile for Federal and State/Local Workers for Selected Occupations, 2013
Notes: Federal: excludes postal service; State/Local: excludes hospitals and education
Data from Bureau of Labor Statistics, U.S. Department of Labor. Employment and Wages from Occupational Employment Statistics (OES) Survey.
Available at www.bls.gov/data/. Accessed June 15, 2014.
Similar data and information for social and community services managers and for emergency management directors
are provided in Tables 8-3 and 8-4. Numbers and trends for social and community services managers working for
government closely parallel those for medical and health services managers. There were 25,000 public sector social
and community services managers in 2013 with little growth forecasted through 2022. A greater proportion of social
and community services managers work in the public sector compared with medical and health services managers.
Salaries for social and community services managers are well below those for medical and health services managers.
Most emergency management directors are employed in the public sector, most frequently in emergency
management agencies. Some, however, work for state health agencies and LHDs serving large populations. The
number of these positions has been increasing over the past decade and some growth is anticipated through 2022.
Average salaries for emergency preparedness and response managers fall in the $80,000–$110,000 range.4 Salaries for
emergency management directors in general, however, are somewhat below those for social and community services
managers, and well below those for medical and health services managers.
Turnover among health managers is relatively frequent and, in addition to the wide range of qualifications required
by potential employers, often results in vacant administrative and management positions being filled even when there
are not many applicants with the optimal desired qualifications. This is easy to appreciate, because organizations must
have people in leadership and management positions.
It is not uncommon to hear public health officials express concerns over difficulties in filling administrative
positions with qualified candidates. It is not clear, however, whether this is a supply and demand issue or whether
there are not adequate systems in place to recognize, reward, and value competent performance. Lack of succession
planning within public health organizations may also be an important factor. Because administration and management
require fairly nonspecific and generic skills, these positions are many times filled with individuals who are new to the
field of public health. Public health professionals within such organizations often view such administrators as not
necessarily committed to the same values and ethics as the professional staff. In any event, overall demand for public
health administrators appears to be relatively steady and stable.
Public health administrators often have a general academic degree at the bachelor’s or associate degree level and
rise through the ranks of public service in the governmental sector. It is also common for an experienced public health
professional such as an environmental health practitioner or public health nurse to be promoted into an agency
leadership position. In sum, career pathways are many and varied for public health administration positions.
OUTSIDE-THE-BOOK THINKING 8-3
In which organizations and geographic regions will the need for public health administrators expand most rapidly in the
next two decades?
ADDITIONAL INFORMATION
There are many good sources of information on public health administration as a career. Several sources are available
for information on educational programs for health administration as well as for continuing education and leadership
development for practicing public health administrators.
The Association of University Programs in Health Administration (AUPHA) web site (www.aupha.org) provides
information on approximately 150 undergraduate and graduate degree programs in health administration in the
United States. AUPHA works closely with the Commission on Accreditation of Healthcare Management Education
(www.cahme.org/) and ACHESA, the organization that accredits master’s-level programs. Only ACHESA-accredited
programs can become a full member of AUPHA.
Both AUPHA and ACHESA are linked with the American College of Healthcare Executives (www.ache.org), which
credentials health administrators. A similar, but considerably smaller, program that certifies public health
administrators is operated by the Public Health Practitioner Certification Board (www.phpcb.org).
Schools of public health are among the institutions offering graduate degrees in health administration. The
Association of Schools and Programs of Public Health (www.aspph.org) has identified a battery of core health
administration competencies appropriate for all students receiving the MPH degree (Table 8-5). These competencies
provide a useful baseline for professional public health administration and indicate what, upon graduation, a student
with an MPH should be able to do.
TABLE 8-5 Health Administration Competency Expectations for Graduates of MPH Degree Programs
1. Identify the main components and issues of the organization, financing, and delivery of health services and public
health systems in the United States.
2. Describe the legal and ethical bases for public health and health services.
3. Explain methods of ensuring community health safety and preparedness
4. Discuss the policy process for improving the health status of populations.
5. Apply the principles of program planning, development, budgeting, management, and evaluation in organizational and
community initiatives.
6. Apply principles of strategic planning and marketing to public health.
7. Apply quality and performance improvement concepts to address organizational performance issues
8. Apply “systems thinking” for resolving organizational problems.
9. Communicate health policy and management issues using appropriate channels and technologies
10. Demonstrate leadership skills for building partnerships.
Reproduced from the Association of Schools of Public Health (ASPH). MPH Core Competency Development Process, Version 2.3. Washington,
DC: ASPH. 2006. Available at http://www.aspph.org. Accessed June 15, 2014.
The American Public Health Association’s (APHA) Health Administration Section is another good source of
information for public health administration. Its web site can be accessed through the main APHA site (www.apha.org).
The Health Administration Section has a nearly 100-year history, beginning as a section for medical health officers but
expanding to include a broader spectrum of public health administrators.
The Public Health Leadership Society (www.phls.org) includes graduates of the National Public Health Leadership
Institute (www.phli.org), operating from the University of North Carolina School of Public Health, as well as alumni of
approximately 20 state and regional public health leadership development institute. These programs serve public
health practitioners through an intensive leadership development curriculum undertaken on a continuing education
basis. The University of North Carolina also offers a Management Academy for Public Health, serving public health
managers and administrators from states in the southeast region of the United States.
CONCLUSION
Public health administrators are one of the largest and most important of the professional occupational categories in
the public health workforce. There are more than 25,000 health administrators working in governmental health
settings. This group is also one of the most diverse in terms of academic credentials and previous work experiences.
Public health administration offers a variety of work settings, especially at the local level, and a broad range of career
pathways that are open to both individuals trained in public health and those new to the field. Because of the diverse
backgrounds and skill levels, ongoing education and training are especially relevant issues for this occupational
category. Demand for these positions in the private and voluntary sectors is steady to slightly increasing and likely to
remain so over the near term. Prospects in the public sector are not so bright.
REFERENCES
1. Bureau of Labor Statistics, U.S. Department of Labor. Databases and tables. www.bls.gov/data/. Accessed June 15, 2014.
2. Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Information and Analysis
and Center for Health Policy, Columbia School of Nursing. Public Health Workforce Enumeration 2000. Washington, DC: HRSA; 2000.
3. National Association of County and City Health Officials. 2013 National Profile of Local Health Departments. Washington, DC: NACCHO; 2014.
4. Association of State and Territorial Health Officials. Profile of State Public Health, Volume Three, 2012. Washington, DC: ASTHO; 2014.
CHAPTER 9
Environmental and Occupational Health
LEARNING OBJECTIVES
Given the need for environmental and occupational health workers in the public health system, describe key
features of occupations and careers in environmental and occupational health and how these contribute to
carrying out public health’s core functions and essential services. Key aspects of this competency expectation
include being able to
• Describe several different occupational titles in this category
• Identify specific essential public health services that are critical for positions in this category
• Describe important and essential duties for several job titles in this category
• Identify minimum qualifications and describe general workplace considerations, salary expectations, and career
prospects for positions in this category
Environmental and occupational health is an expansive field that has been an important part of public health practice
for more than 150 years. The exploits of John Snow in battling cholera in England in the 1850s elucidated the link
between communicable disease and sanitary conditions. As described in our review of public health history, the
pioneering efforts of Chadwick in England and Shattuck in the United States resulted in blueprints for early public
health responses and systems. Many public health successes in the latter part of the 1800s and the early decades of
the 20th century were the direct result of environmental engineering and sanitation advances. The people carrying out
these duties have been an integral part of the public health workforce and remain so. These workers are employed in
public health and environmental protection agencies at all levels of government and throughout the private sector as
well. The Bureau of Labor Statistics (BLS) reported nearly 193,000 workers in environmental engineering, specialist,
and technician positions and another 100,000 in occupational and industrial health and safety positions in 2013.1
There were nearly 90,000 environmental and occupational health workers employed by federal, state, and local
governmental agencies. Public Health Workforce Enumeration 2000 data identified 40,000 working for federal, state,
and local public health agencies in the year 2000.2 Surveys conducted in 2012 and 2013 reported about 20,000
environmental health workers in state and local public health agencies.3,4 Data from these key sources are used
throughout this chapter. Differences among these various sources indicate that many environmental and occupational
health personnel work in nonhealth agencies at all levels of government, such as environmental protection agencies,
departments of natural resources, and sanitation agencies. In any event, environmental and occupational health
workers are one of the largest occupational groupings within the public health workforce today. Environmental and
occupational public health workers are increasingly finding positions in private sector organizations that offer a wide
variety of environmental and occupational health services. Table 9-1 provides a snapshot of an average day in the life
of an environmental health practitioner.
OCCUPATIONAL CLASSIFICATION
There are seven specific standard occupational categories (SOCs) for environmental health workers. These include
environmental engineer, environmental engineering technician, environmental scientist/specialist, environmental
science and protection technician, health and safety engineer, occupational health and safety specialist, and
occupational health and safety technician. Four of these titles are professional occupations (environmental engineer,
environmental scientist/specialist, health and safety engineer, and occupational health and safety specialist). The
others are technical occupations.
TABLE 9-1 A Typical Day for an Environmental Health Practitioner
7:30 a.m. Visit septic field inspection site to assist environmental health specialists on site
8:30 a.m. Office time for paperwork and information sharing with staff
9:00 a.m. Staff meeting to review priorities for week
10:15 a.m. Interview candidates for vacant entry-level environmental health specialist position
10:45 a.m. Meet with communicable disease control, epidemiology, and public health nursing staff regarding community
concerns over West Nile Virus threat
11:45 a.m. Brown bag lunch with other environmental health staff; today’s guest is a professor from a state university
undergraduate degree program in environmental health
1:00 p.m. Brief agency director regarding status of West Nile Virus threat
1:30 p.m. Supervise inspection of food services, swimming pools, and septic systems at county fair site
3:00 p.m. Conference call meeting with epidemiology and environmental health staff of neighboring jurisdictions and
state health department regarding current status of West Nile Virus
4:00 p.m. Review information suggested by staff for tonight’s community meeting
4:30 p.m. More paperwork related to permit approvals
5:15 p.m. Prepare remarks for tonight’s community meeting
7:00 p.m. Represent agency at community meeting regarding West Nile Virus concerns
• Environmental engineers (e.g., water supply or waste-water engineers, solid waste engineers, air pollution
engineers, sanitary engineers) apply engineering principles to control, eliminate, ameliorate, and/or prevent
environmental health hazards. There were 53,000 environmental engineers in the United States in 2013. Private-
sector companies (architectural and engineering companies, management and technical consulting firms) employ
the largest numbers of environmental engineers. Federal, state, and local government agencies employed 15,000
environmental engineers in 2013. Public Health Workforce Enumeration 2000 data suggest that about 7,000 were
working in governmental public health agencies in 2000.
• Environmental engineering technicians (e.g., water or wastewater plant operators, water or wastewater testing
technicians, air pollution technicians) assist environmental engineers and other environmental health professions
in controlling, eliminating, ameliorating, and/or preventing environmental health hazards. There were 18,000
environmental engineering technicians working in the United States in 2013. Architectural and engineering
companies employ the largest number of environmental engineering technicians, followed by local government
and scientific research and development companies. Governmental agencies employed only 3,200 environmental
engineering technicians in 2013, 600 of whom were identified in the Public Health Workforce Enumeration 2000
study.
• Environmental scientists or specialists (e.g., environmental researchers, environmental health specialists, food
scientists, soil and plant scientists, air pollution specialists, hazardous materials specialists, toxicologists, water
or wastewater or solid waste specialists, sanitarians, entomologists) apply biological, chemical, and public health
principles to control, eliminate, ameliorate, and/or prevent environmental health hazards. There were 87,000
environmental specialists working in the United States in 2013. State governments are the leading source of
employment for environmental specialists. Local government and private sector companies also employ large
numbers of environmental specialists. Governmental agencies employed 38,000 environmental specialists in
2013; the Public Health Workforce Enumeration 2000 study identified 23,000 in federal, state, and local public
health agencies in 2000.
• Environmental science and protection technicians (e.g., air pollution technicians, vector control workers) assist
environmental scientists and specialists and other environmental health professionals in the control, elimination,
and/or prevention of environmental health hazards. There were nearly 35,000 workers in the United States in
environmental science and engineering technician positions in 2013. Local governments are the largest employer
of environmental science technicians. Private companies and state governments are other important employment
sources. Nearly 9,000 environmental science and protection technicians worked for government agencies in
2013. The Public Health Workforce Enumeration 2000 study identified 700 working in governmental public health
agencies in 2000.
• Health and safety engineers (e.g., aerospace safety engineers, fire prevention and protection engineers, product
safety engineers, and systems safety engineers) develop procedures and design systems to prevent people from
getting sick or injured and to keep property from being damaged. They combine knowledge of systems
engineering and of health or safety to make sure that chemicals, machinery, software, furniture, and consumer
products will not cause harm to people or property. Health and safety engineers also investigate industrial
accidents, injuries, or occupational diseases to determine their causes and to determine whether the incidents
could have been or can be prevented. They interview employers and employees to learn about work environments
and incidents that lead to accidents or injuries. They also evaluate the corrections that were made to remedy
violations found during health inspections. There were nearly 24,000 health and safety engineers in 2013 with
only 3,000 working for public sector agencies. Health and safety engineers were not one of the categories
included in the Public Health Workforce Enumeration 2000 study.
• Occupational health and safety specialists (e.g., industrial hygienists, occupational health specialists, radiologic
health inspectors, safety inspectors) review, evaluate, and analyze workplace environments and exposures. These
workers design programs and procedures to control, eliminate, ameliorate, and/or prevent disease and injury
caused by chemical, physical, biological, and ergonomic risks to workers. There were 63,000 occupational health
and safety specialists in the United States in 2013. Local and state governments are the largest employment
sources for occupational safety and health specialists; hospitals are another large employer. Government agencies
employed nearly 19,000 occupational health and safety specialists in 2013. The Public Health Workforce
Enumeration 2000 study identified nearly 9,000 working in governmental public health agencies.
• Occupational health and safety technicians collect data on workplace environments and exposures for analysis
by occupational safety and health specialists; they also implement programs and conduct evaluation of programs
designed to limit chemical, physical, biologic, and ergonomic risks to workers. There were 14,000 occupational
health and safety technicians in the United States in 2013, with 2,700 working for federal, state, and local
governmental agencies. The Public Health Workforce Enumeration 2000 study identified only 150 working in
governmental public health agencies in 2000.
OUTSIDE-THE-BOOK THINKING 9-1
What will be the most important new or expanded roles for environmental and occupational health workers in the 21st
century?
As is apparent from these occupational categories, both professional and technical positions are common in the
environmental health component of the public health workforce. Among the 40,000 environmental and occupational
health positions identified in the Public Health Workforce Enumeration 200 study, more than one half were
professional titles. Among professional positions, environmental health ranks second only to nursing within the public
health workforce. Professional titles include engineers, scientists, and specialists. Technical titles include technicians
and technologists.
PUBLIC HEALTH PRACTICE PROFILE
Environmental and occupational health workers generally function at a program or unit level within public health
agencies at all levels of government, but especially those at the local and state level. They are most frequently involved
in public health responsibilities that focus on protecting against environmental hazards, preventing injuries, and
preventing epidemics and the spread of disease. Environmental and occupational health workers may also be key
components of efforts to prepare and respond to public health emergencies, especially natural disasters for which
protection of water and food supplies can be critical.
OUTSIDE-THE-BOOK THINKING 9-2
What are the most important contributions to improving the health of the public that environmental and occupational
health workers make today?
Among the 10 essential public health services, environmental and occupational health workers are most likely to be
involved in diagnosing and investigating health problems and health hazards in the community, enforcing laws and
regulations that protect health and ensure safety, monitoring health status to identify community health status, and
evaluating the effectiveness and quality of environmental and occupational health services in the community. With
much of their work done in community settings, environmental and occupational health workers also inform, educate,
and empower people about important health issues. Table 9-2 summarizes public health purposes and essential public
health services at the core of positions for environmental and occupational health workers.
IMPORTANT AND ESSENTIAL DUTIES
There are many different job titles and positions used for environmental and occupational health workers. This chapter
will focus on five representative positions: (1) environmental engineer; (2) entry-level environmental health specialist;
(3) midlevel environmental health specialist; (4) senior-level environmental health specialist; and (5) mid-level
occupational health and safety specialist. Each of these positions and a representative panel of their important and
essential duties are described in this section.
TABLE 9-2 Public Health Practice Profile for Environmental Health
Environmental and Occupational Health Workers Make a Difference by:
Public Health Purposes
Preventing epidemics and the spread of disease
Protecting against environmental hazards
Preventing injuries
Promoting and encouraging healthy behavior
Responding to disasters and assisting communities in recovery
Ensuring the quality and accessibility of health services
Essential Public Health Services
Monitoring health status to identify community health problems
Diagnosing and investigating health problems and health hazards in the community
Informing, educating, and empowering people about health issues
Mobilizing community partnerships to identify and solve health problems
Developing policies and plans that support individual and community health efforts
Enforcing laws and regulations that protect health and ensure safety
Linking people with needed personal health services and ensuring the provision of health care when otherwise
unavailable
Ensuring a competent public health and personal healthcare workforce
Evaluating effectiveness, accessibility, and quality of personal and population-based health services
Researching new insights and innovative solutions to health problems
Environmental Engineer
This is a professional environmental engineering position with duties within an assigned environmental program
involving the protection of public health and/or the protection or restoration of the environment. There are often
several grades for this position. Entry-level titles generally do not have any supervisory responsibilities. Higher level
environmental engineer titles may supervise or lead assigned engineers and/or other staff. Workers in this title are
responsible for the performance of professional engineering duties in performing field surveys and investigations of
water supplies, sewage systems, streams, industrial waste facilities, solid and hazardous waste facilities, air pollution
control systems, and/or dams and reservoirs. Work includes preparing reports of findings, and making
recommendations to improve the public health, safety, and the environment. Environmental engineers work under
general technical supervision and receive work assignments from a designated superior. There may be several levels of
positions with this title.
Important and essential duties for environmental engineers include
• Participates in the engineering review of the hydraulics and details of water supply systems and plants,
industrial and domestic waste treatment systems, solid and hazardous waste management systems, air pollution
control systems, dams and reservoirs, etc.
• Gathers and interprets data on pollution, contamination, and construction and design features relevant for
environmental engineering projects
• Reviews engineering plans and specifications for sewage and industrial waste treatment plants, water supply
systems, solid and hazardous waste disposal areas, air pollution control systems, and dams and reservoirs for
compliance with approved standards
• Confers with officials and owners/operators of plants and establishments with regard to laws, regulations, and
engineering requirements of appropriate state and local agencies
• Collects samples of water and sewage for bacteriologic, chemical, or biologic analysis
• Examines and prepares charts, tables, and maps for the interpretation of engineering data, and prepares reports
of findings and analysis
• Prepares papers and lectures on subjects relating to the environment and/or dam safety
• Prepares technical and detailed reports of engineering surveys
• Participates in special investigations of fish kills and unusual stream conditions with representatives of other
agencies
• Supervises, assigns, and assists in the work of a unit composed of a small group of professional personnel
• Trains subordinate engineers and other technical staff
Environmental Specialist (Entry Level)
This position serves as an entry-level environmental specialist performing one or more of the following functions under
close direction and supervision: conducting routine compliance and enforcement activities; assisting in the
development of draft legislation, policies, and regulations; conducting routine scientific analyses and technical
services on assigned office or field projects; providing regulatory assistance; providing project administration and
environmental technical assistance for grants, contracts, or loans; interpreting policy and technical assistance;
conducting less complex surveys and analyses; recording field conditions; gathering and analyzing information to
assist in developing recommendations and decision making; and assisting in permit development. The number of levels
for this position varies from one personnel system to another. In many personnel systems there are three to five levels
of environmental health specialist positions that allow for career advancement.
Important and essential duties for entry-level environmental health specialists include
• Assists in the installation, operation, and maintenance of environmental monitoring/sampling equipment; assists
in performing field and office surveys and studies; performs surveillance and other special projects
• Assists in routine repairs and calibrations of environmental monitoring/sampling equipment, in accordance with
specifications and standard operating procedures; performs basic sampling data review for precision and
accuracy
• Assists in responding to complaints, routine inspections/surveillance, and permit review to meet compliance
requirements
• Assists in the research and compilation of basic information for use in regulation or policy development
• Enters and maintains basic databases or inventories
• Assists in preparing for public meetings, hearings, and workshops
• Assists with routine inspections or investigations of facilities or project sites that require specialized knowledge
of industry processes, pollutant sources, or natural processes
• Responds to routine inquiries or requests for technical assistance regarding the scientific background and
technical implementation of agency programs
• Reviews plans for technical accuracy and makes recommendations to higher-level staff
• Conducts routine sampling and testing; analyzes, evaluates, and interprets data; writes reports; and assists
higher-level staff
• Maintains and utilizes computerized environmental databases in support of technical projects
• Reviews routine permit applications for technical accuracy and makes recommendations regarding the scientific
merit of proposals
• Provides technical and administrative assistance to grant, contract, or loan recipients in the planning, design,
construction, and implementation of environmental protection projects
Environmental Specialist (Midlevel)
This position serves as a staff environmental specialist performing one or more of the following functions
independently with little direction and supervision: conducting compliance and enforcement activities; developing
draft legislation; developing, performing, coordinating, implementing, and evaluating scientific analyses, plans, or
services involving office or field projects; conducting surveys, analyses, and recording field conditions; providing
project administration and environmental technical assistance for grants, contracts, and loans; gathering and
analyzing information to develop recommendations for decision making and permit development, review, and
oversight. This position may lead or supervise assigned staff.
Important and essential duties for midlevel environmental specialists include
• Independently performs the installation, operation, and maintenance of environmental monitoring/sampling
equipment; on an area or site list basis performs and/or provides guidance for surveys, field studies, or other
special data-gathering activities
• Performs complex equipment repair and calibrations; reviews monitored data for evaluation of equipment
performance
• Responds to and investigates complex or highly technical complaints or violations; performs complex inspections
or field investigations; coordinates complaint and enforcement priorities, schedules, and assists in negotiating
agreements and settlements; prepares final permit evaluation or report for approval; may impose on-site
enforcement action; performs follow-up inspections to ensure corrective action is implemented
• Plans, develops, researches, and conducts or oversees technical data collection and analyzes, evaluates, and
interprets data; analyzes or interprets information requirements and coordinates information gathering for a
team or other assignment outside of a team; writes reports and reviews draft reports
• Determines database or inventory requirements; works with agency and nonagency sources on data submittals;
evaluates databases or inventories for analysis, reporting, or compliance purposes; may design and/or develop
databases or inventories to be utilized in support of technical projects
• Reviews permit applications for technical accuracy, negotiates permit conditions, conducts conflict resolution,
and makes decisions regarding the scientific merit of proposals; serves as a senior permit writer or
historical/institutional memory for geographic area or complex site
• Develops and/or implements project plans, consent decrees, orders, or scientific studies for cleanups, resource
management, or policy/regulation development; conducts research for technical projects; reviews project plans
for technical accuracy and makes decisions on the scientific merit of proposals
• Oversees contractor or consultant services for compliance and certifies performance; provides assistance to
other staff, agencies, and the public
• Makes recommendations to senior staff regarding new or modified sampling and analytical testing methods, best
management practices, and technical operating procedures
• Makes technical and scientific recommendations regarding the development, coordination, and implementation
of environmental technical assistance programs involving pollution prevention, pollution control, or natural
resource management
• Evaluates data to determine technical compliance with regulatory requirements
• Plans, facilitates, and represents the program or agency in public meetings, hearings, and workshops
• Conducts literature evaluations to assess evidence-based practice; formulates grant proposals; proposes and
designs assessment and research projects
• Develops evidence-based protocols for specific program interventions and services
• Independently provides technical and administrative assistance to grant, contract, or loan recipients in the
planning, design, construction, or implementation of environmental protection projects
• Coordinates the development of policies, procedures, statutes, and regulations of a high degree of complexity
• Directs or coordinates nonagency employees at large spills or complex sites
Environmental Specialist (Senior Level)
This position serves as a senior program expert in one or more program subject areas as designated in writing by a
program manager, agency director, or higher. A senior environmental specialist performs, directs, implements, and
evaluates activities that are of critical agency, regional, statewide or national interest, sensitivity, or complexity. Such
activities may include planning and directing surveys and analyses of projects that are a high priority for the agency or
involve participation in the resolution of major environmental questions. In most circumstances, this position
supervises five or more professional environmental staff.
Important and essential duties for senior-level environmental specialists include
• Advises program management on monitoring and sampling policies, priorities, effectiveness, and cross-media or
agency issues and requirements
• Evaluates equipment inventories for material readiness, amortization, and technology transfer; management of
contracted services and equipment utilization; conducts equipment needs assessments
• Advises program management on violations of critical or controversial agency interest; evaluates rule
effectiveness and recommends enforcement/compliance rule making; may represent the program on multimedia
or highly complex or controversial enforcement/compliance actions involving other programs or agencies
• Works with other programs and agencies in identifying information required for policy development, legislation,
regulations, and recommended priorities, scheduling requirements, and information parameters for program
management
• Evaluates databases and inventories for policy or regulation development; determines new, changing, or
emerging requirements for databases and inventories; may work with other programs or agencies on
database/inventory requirements
• Conducts literature evaluations to assess evidence-based practice; formulates grant proposals; proposes and
designs assessment and research projects
• Develops evidence-based protocols for specific program interventions and services
• Coordinates controversial or critical plans for resource management, policy or regulation development, or
statewide cleanup priorities
• Advises program or agency management on the need for contractor or consultant services versus agency staff
and expertise
• Identifies critical or emerging issues and recommends preventive or corrective measures
• Represents agency and testifies at legal or public hearings or conferences and before legislative bodies
• Provides expertise or historical background not otherwise available to the agency that is used as a basis for
agency management decisions
• Serves as an agency representative to regional and national commissions and environmental or professional
organizations relevant to assigned responsibilities with the agency
Occupational Health and Safety Specialist
This is midlevel professional scientific work in evaluating work and indoor environments for safety and health hazards.
Occupational health and safety specialists make comprehensive safety and health hazard evaluations, including the
more difficult evaluations, of all general industry and indoor environments, involving office buildings and factories. A
comprehensive safety and health hazard evaluation may consist of the following: conducting a physical survey;
establishing appropriate sampling techniques; collecting samples as necessary to assess the presence of chemical,
physical, and microbial agents in accordance with the requirements of the Occupational Safety and Health Act;
analyzing the data generated by sampling and making a professional judgment using accepted industrial hygiene
practices and federal standards to determine the degree of hazard present; interviewing employers and employees and
other potentially exposed individuals to determine possible sources of safety and health hazards; preparing a technical
report of the safety and health hazard evaluation that can be understood and followed by lay personnel; and making
recommendations within this report that will reduce or correct the health hazard. Occupational health and safety
specialists receive minimal supervision from an administrative superior.
Important and essential duties for midlevel occupational health and safety specialists include
• Conducts initial conferences with employers to introduce the services offered by the agency
• Consults with employers on the existence, utilization, and operating condition of powered mechanical ventilation
devices, personal safety equipment and procedures, noise abatement equipment and procedures, material safety
data sheets, hazardous chemical correction, and safety and health programs
• Performs difficult safety and health hazard evaluations requiring literature research, analysis, and scientific
design
• Determines the magnitude of exposure or nuisance to workers and the public; selects or devises methods and
instruments suitable for measurements; studies and tests materials associated with the work operation
• Collects samples from office buildings and other workplaces to determine the presence of toxic substances and
other potential hazards; evaluates building ventilation systems for possible deficiencies; and provides technical
advice on remedial action
• Interprets results of the examination of the work environment in terms of the potential of causing a community
nuisance or damage or impairing worker safety, health, and efficiency; and presents specific conclusions to
appropriate interested parties by means of a technical report
• Determines the need for, or effectiveness of, control measures, and when necessary, recommends procedures
that will be suitable and effective in achieving those measures
• Interprets occupational safety and health laws, rules, and regulations; determines compliance with safety and
health laws; holds conferences with management to discuss identified violations and deficiencies and
recommends corrections
• Reviews facility safety and health programs required by the federal Occupational Safety and Health
Administration
MINIMUM QUALIFICATIONS
Environmental and occupational health includes a mix of professional and technical occupations, both of which
generally have several levels of positions. This provides a natural career pathway and allows environmental and
occupational health workers to remain in this field for many years. Comparable positions exist in local public agencies
of all sizes, making career advancement from a small to larger employer a common pathway for these workers.
Although environmental and occupational health professionals are produced by schools of public health, there are
also many undergraduate and graduate degree programs specializing in environmental sciences. It is these programs
that are even larger producers of environmental and occupational health practitioners. Many workers in technical
positions have less than a bachelor degree; some have no more than a high school degree.
As with virtually all public health positions, both experience and education are important considerations for hiring
and promotion. Experience and education both contribute to necessary knowledge, skills, and abilities required for
workers in this field. Typical minimum qualifications for environmental engineers, three levels of environmental health
specialists, and occupational health and safety specialists are detailed below.
Typical Minimum Qualifications for Environmental Engineer
Knowledge, Skills, and Abilities
An environmental engineer will generally have knowledge of:
• Principles and practices of environmental engineering and/or environmental sanitation
• Design, construction, and operation of air quality control, water supply and treatment, and sewage and industrial
waste disposal systems
• Laws and regulations governing sanitation
• Physical and biologic sciences, including chemistry, bacteriology, and physical properties of ambient air, water,
sewage, and liquid waste as related to environmental engineering
• Mathematics, geometry, calculus, and engineering formulas
An environmental engineer will generally have the skills and ability to:
• Develop designs involving environmental engineering theory and judgment
• Establish and maintain cooperative working relationships with public officials and community groups
• Perform investigations involving the application of professional theory and interpretation of laws, regulations,
and requirements
• Plan, promote, and conduct engineering projects
• Analyze significant environmental engineering and sanitation data
• Consult with and advise plant owners and operators on proper design, construction, and operation of plants
• Prepare engineering reports and papers and lectures related to the environment
Experience and Education
Any combination of training and experience that provides the requisite knowledge and abilities will qualify an
individual for this position. A typical way to obtain the required knowledge and abilities is through acquisition of a
master’s degree with major study in one of the engineering fields (such as sanitary, water resource, civil, geotechnical,
environmental, chemical, or mechanical engineering) and 1 year of experience in environmental engineering. Another
path is through acquisition of an engineer-in-training certificate or a bachelor degree with a major study in one of the
engineering fields listed above and 2 years of environmental engineering experience. Some jurisdictions may require
registration as a professional engineer within the state or another state with equivalent requirements for registration
or an engineer-in-training certificate. In some instances, a doctoral degree in an engineering field may substitute for 1
or more years of environmental engineering experience. Requirements for professional registration as an engineer in
some states may require up to 8 years of professional experience (which may include up to 4 years of college-level
engineering education) and successful completion of professional licensing exams.
Typical Minimum Requirements for Entry-Level Environmental Specialist
Knowledge, Skills, and Abilities
An entry-level environmental health specialist will generally have knowledge of:
• Field investigative techniques, including data gathering and basic research
• Practices and methods of environmental problem solving
• Soil, water, or air sampling methods and techniques
• Characteristics of pollutants
• Principles, practices, and methods of environmental science, natural resource management, pollution
prevention, and pollution control
• Applicable federal, state, and local environmental regulations
An entry-level environmental health specialist will generally have the skills and ability to:
• Use sound judgment in performing assigned tasks
• Understand and apply environmental regulations and related laws
• Write clearly and concisely, and prepare maps, plans, charts, and graphs
• Communicate effectively with agency staff, other agencies, industry, and the general public
Experience and Education
Entry-level environmental health specialists come from a wide range of educational levels and previous work
experiences, which generally include:
• A bachelor degree involving major study in environmental, physical, or one of the natural sciences;
environmental planning; or other allied field
• Experience at or above the environmental technician level, or equivalent will substitute, year for year, for
education
Typical Minimum Requirements for Midlevel Environmental Specialist
Knowledge, Skills, and Abilities
A midlevel environmental health specialist will generally have knowledge of:
• Principles, practices, and methods of environmental or resource management and environmental pollution
prevention and pollution control
• Methods and techniques of field sampling, testing, data gathering, basic research, and field investigations
• Soil science, geology, hydrology, hydrogeology, metrology, and toxicology
• Applicable federal, state, and local environmental regulations and policies
• Characteristics and health effects of pollutants
• Technical report writing methods
A midlevel environmental health specialist will generally have the skills and ability to:
• Use sound, independent judgment in making decisions on environmental problems and completing assigned
tasks
• Understand and interpret plans, maps, and equipment specifications
• Prepare clear and concise written reports and make oral presentations
• Analyze and prepare plans and reports
• Understand and communicate complex environmental regulations and statutes
• Communicate effectively with agency staff, other agencies, industry, and the general public
Experience and Education
Any combination of training and experience that provides the requisite knowledge and abilities will qualify an
individual for this position. A typical pathway to obtain the required knowledge and abilities is through acquisition of a
bachelor degree involving major study in environmental, physical, or one of the natural sciences; environmental
planning; or other allied field; and 2 years of professional-level experience in environmental analysis, control, or
planning. Additional qualifying experience may substitute, year for year, for education. A master’s degree in one of the
above fields may also substitute for 1 year of the required experience. Another way to meet these qualifications is
through acquisition of a doctoral degree in one of the above fields or through 1 year of experience in the next lower-
level environmental specialist position.
Typical Minimum Qualifications for Senior-Level Environmental Specialist
Knowledge, Skills, and Abilities
A senior-level environmental specialist will generally have knowledge of:
• Applicable federal, state, and local environmental regulations and policies
• Soil science, geology, hydrology, hydrogeology, metrology, and toxicology
• Methods for the development of an environmental program or complex study
• Multimedia environmental principles and practices
A senior-level environmental specialist will generally have the skills and ability to:
• Identify and assess program or agency service delivery needs and requirements
• Recognize emerging issues and conduct advanced planning to address those issues
• Represent program or agency management on complex or controversial issues with other agencies, jurisdictions,
or interest groups
• Effectively negotiate and resolve conflict
• Effectively communicate technical information clearly, both orally and in writing
• Demonstrate a high degree of technical expertise in a particular field or specialty as shown through the
publication of papers in peer-reviewed, scientific, or technical journals or the presentation of papers at
professional conferences
Experience and Education
Any combination of training and experience that provides the requisite knowledge and abilities will qualify an
individual for this position. A typical pathway to obtain the required knowledge and abilities is through a bachelor
degree involving major study in environmental, physical, or one of the natural sciences; environmental planning; or
other allied field; and 6 years of professional-level experience in environmental analysis, control, or planning, which
includes 2 years equal to the midlevel environmental specialist position. Additional qualifying experience may
substitute, year for year, for education. Another pathway to satisfy these qualifications is through acquisition of a
master’s degree in one of the preceding fields and 4 years of professional-level experience that include 2 years equal
to a midlevel environmental specialist. Yet another way to satisfy these requirements is through acquisition of a
doctoral degree in one of the preceding fields and 3 years of professional-level experience that include 2 years equal to
a midlevel environmental specialist.
Typical Minimum Qualifications for Occupational Health and Safety Specialist
Knowledge, Skills, and Abilities
An occupational health and safety specialist generally has knowledge of:
• Sampling and direct measuring techniques for gas, vapor, dust, noise, and radiation
• Microbiology, radiology, physiology, and chemistry
• Common diseases and health hazards related to indoor environments and industrial occupations and of their
possible sources
• The standard types of machinery and equipment used in industrial and commercial establishments
• The Occupational Safety and Health Act and the applicable regulations of the U.S. Environmental Protection
Agency (EPA) that relate to workplace safety and health
An occupational health and safety specialist generally has the skills and ability to:
• Analyze complex problems of environmental hazard reduction and arrive at sound decisions regarding actions to
be taken
• Develop, organize, and present training through a comprehensive company-specific safety program
• Analyze and interpret technical reports and criteria documents on exposure limits
• Operate and maintain detection and measurement apparatus
• Communicate thoughts and ideas clearly and concisely
• Establish and maintain effective working relationships with plant managers, safety directors, employees, and the
public
Experience and Education
Any combination of training and experience that provides the requisite knowledge and abilities will qualify an
individual for this position. A typical way to obtain the required knowledge and abilities is through 1 year of
experience as an entry-level occupational safety and health specialist or 1 year of professional experience in safety and
health consultation in a governmental agency or program or in private industry as an industrial hygienist, industrial
safety professional, safety manager, or other closely related position in the occupational safety or health field, and
graduation from an accredited 4-year college or university with specialization in industrial hygiene or safety or a
closely related area. In some instances, graduate work in industrial hygiene or safety may be substituted on a year-for-
year basis for the stated experience. Certification as a certified industrial hygienist (CIH) by the American Board of
Industrial Hygiene or as a certified safety professional (CSP) by the Board of Certified Safety Professionals (BCSP)
may be substituted for 6 months of the stated experience. Some states may require specific certifications and
licensing.
WORKPLACE CONSIDERATIONS
Federal, state, and local governmental agencies employ nearly 90,000 environmental and occupational health workers
(both professional and technical titles), making governmental agencies the largest sources of jobs for environmental
and occupational health workers.
Work settings and working conditions influence the typical physical requirement for positions in environmental and
occupational health categories. For example, entry-level and midlevel environmental and occupational health
specialists spend considerable time outside the office. Environmental health specialists often find themselves at
various environmental sites; occupational health specialists often do their work at business sites. Environmental
engineers and higher-level environmental and occupational health specialists spend somewhat more time in an office
setting.
Most positions call for workers to be able to sit for extended periods and to frequently stand and walk extended
distances. Normal manual dexterity and eye-hand coordination, hearing, and vision corrected to within the normal
range are also important considerations. This work requires good vision to peruse and review correspondence,
statutes, and related material and to perform visual inspections required for work activities conducted on site. Also
important are the ability to stand, walk, and have full use of upper and lower extremities to effect investigations and
collection efforts in business establishments and in the field. At times, this work may require climbing ladders and
entering confined areas for investigations.
Normally, environmental and occupational health workers can communicate verbally and use office equipment
including computers, telephones, calculators, copiers, and fax machines. For work performed in an office environment,
frequent or continuous contact with staff and the public is also necessary. In many situations, environmental and
occupational health workers must be mobile and may be required to possess a valid driver’s license. Important
attributes are verbal and reasoning ability in order to read and understand a variety of written matter; to process
directives, reports, and correspondence; and to initiate action required. These positions require emotional stability and
good judgment to deal with the public and personnel whose business activities are being inspected or investigated.
OUTSIDE-THE-BOOK THINKING 9-3
What features make public health environmental and occupational health a career worth pursuing?
POSITIONS, SALARIES, AND CAREER PROSPECTS
In 2013, there were 300,000 environmental and occupational health professionals and technicians employed in the
United States, with nearly 90,000 working for federal, state, and local governmental agencies. Table 9-3 identifies the
number of total workers and the number employed by government for the seven standard occupational categories
considered in this chapter. Projections for the year 2022 are also provided. Each of the four professional categories
(environmental engineers, environmental scientists and specialists, health and safety engineers, and occupational
health and safety specialists) grew significantly over the past decade. The technical categories (environmental
engineering technicians, environmental health and safety technicians, and occupational health and safety technicians)
also grew but not nearly as rapidly as the professional occupational categories. Job growth was somewhat less for
government employment than outside government. This trend is expected to continue for at least the next decade.
The total number of positions for environmental and occupational health workers is expected to grow to 334,000 by
the year 2022 with about one fourth employed by government agencies. Based on the growth in the number of
positions and the need to fill other positions because of job changes and retirement, nearly 125,000 positions will be
filled between 2012 and 2022. Environmental scientists and specialists and occupational health and safety specialists
represent the largest categories of positions to be filled.
Salaries vary considerably across environmental and occupational health categories, depending on whether they
are professional or technical titles as well as on educational attainment and previous work experience. Median salaries
in 2013 for public sector environmental engineers averaged $81,000, with the middle 50% earning between $63,000
and $97,000 (Table 9-4). Average salaries were lower for environmental engineers working in state and local
governmental agencies and higher for those in the private sector (architectural and engineering companies and
management and technical consulting companies). Entry-level salaries were in the $47,000–$55,000 range.
The median salary for environmental engineering technicians employed by government agencies in 2013 was
$51,000, with the middle 50% earning between $41,000 and $63,000. Entry-level salaries were in the $30,000–
$35,000 range.
The median salary for environmental health scientists and specialists employed by government agencies in 2013
was $63,000, with the middle 50% earning between $48,000 and $80,000. Average salaries were lower for
environmental health scientists and specialists working in governmental agencies and higher for those working in the
private sector. Entry-level salaries were in the $40,000–$45,000 range.
TABLE 9-3 Number of Workers in 2013 and Projected for 2022 for All Industries and Government and Number
of Positions to Be Filled 2012–2022 for All Industries
Data from Bureau of Labor Statistics, U.S. Department of Labor. Selected Occupational Projections Data. Available at www.bls.gov/data/.
Accessed June 15, 2014.
TABLE 9-4 Number and Salary Profile for Federal and State/Local Workers for Selected Occupations, 2013
Notes: Federal: excludes postal service; State/Local: excludes hospitals and education
Data from Bureau of Labor Statistics, U.S. Department of Labor. Employment and Wages from Occupational Employment Statistics (OES) Survey.
Available at www.bls.gov/data/. Accessed June 15, 2014.
The median salary for environmental engineering technicians employed by government agencies in 2013 was
$44,000, with the middle 50% earning between $34,000 and $56,000. Entry-level salaries were in the $28,000–
$34,000 range.
The median salary for public sector health and safety engineers in 2013 was $87,000 with the middle 50% earning
between $59,000 and $103,000. Entry-level salaries were in the $60,000–$75,000 range.
The median salary for occupational health and safety specialists employed by government agencies in 2013 was
$66,000, with the middle 50% earning between $51,000 and $80,000. Average salaries were lower for occupational
health and safety specialists working in governmental agencies and were similar to those working in the private sector.
Entry-level salaries were in the $40,000–$50,000 range.
The median salary for occupational health and safety technicians employed by government agencies in 2013 was
$48,000, with the middle 50% earning between $39,000 and $57,000. Entry-level salaries were in the $30,000–
$35,000 range.
Over the next 10 years, the Bureau of Labor Statistics projects that job growth will be greater than average for
environmental engineers, environmental health specialists, occupational health and safety specialists, and
environmental technicians. There are several reasons for these projections. There is increasing recognition of
environmental engineering as a specialty distinct from civil and other engineering fields of endeavor. In addition, there
has been an increasing recognition of the importance of regulatory compliance for industries and businesses in order
to protect and maintain the environment and ensure the safety of workers. An increasing emphasis on prevention as
an overall strategy to safeguard environmental and human resources also fosters new job opportunities for these
occupations. Opportunities in the public sector, however, will be limited in comparison to those in other industries.
Although environmental and occupational health is a broad category, career pathways can be somewhat limited.
Specific academic preparation and experience are necessary for environmental engineers. For example, there is little
opportunity for a technician in this field to advance to engineer status without completing the academic degrees
required for the field. The academic requirements for environmental and occupational health and safety specialists are
somewhat less restrictive. It is possible for technicians to advance into some of these professional positions through
continuing education and work experience.
Technicians often begin work as trainees in routine positions under the direct supervision of a professional title or a
more experienced senior technician. Technicians with previous hands-on experience with equipment used in that field
usually require shorter periods of on-the-job training. As they become more experienced and proficient, technicians
progress to become more independent in carrying out their duties. Their ability to move beyond technical titles,
however, may be limited unless they acquire additional education or secure specific professional certifications.
Most of these occupational categories do provide a reasonable job ladder with several levels of titles for entry-level
to midlevel to senior-level positions. Over a span of several decades, these can comprise a satisfactory framework for a
career. At higher levels, professional titles can lead to appointments into management and leadership positions. A
substantial number of local public health agency directors, for example, come from the ranks of environmental health
professionals.
OUTSIDE-THE-BOOK THINKING 9-4
In which organizations and geographic regions will the need for environmental and occupational health workers expand
most rapidly in the next two decades?
ADDITIONAL INFORMATION
There are many good sources of information on environmental and occupational health as a career. Several sources
are available for information on educational programs for environmental and occupational health as well as for
continuing education and leadership development for practitioners.
The National Environmental Health Association (NEHA) (www.neha.org) offers several nationally recognized
credentials within the environmental health profession. Each credential signifies a level of expertise and competence
based on education and experience. Eligibility to sit for these credentialing exams is determined by the NEHA.
Certifications and credentials available through NEHA include
• Onsite wastewater system installers: This credential was developed through a cooperative agreement with the
EPA. Credentialing and licensing is one of the goals of the EPA Voluntary Management Guidelines and is also
recommended by the National Onsite Wastewater Recycling Association Model Code.
• Registered environmental health specialist/registered sanitarian (REHS/RS): The REHS/RS is the premiere
NEHA credential. It is available to a wide range of environmental health professionals. Individuals holding the
REHS/RS credential show competency in environmental health issues, direct and train personnel to respond to
routine or emergency environmental situations, and frequently provide education to their communities on
environmental health concerns. The advantages of NEHA’s REHS/RS registration program are (1) the nationwide
recognition of the REHS/RS credential, (2) the continual update of the REHS/RS examination and study guide
based on an ongoing assessment of the environmental health field, and (3) the tracking of an individual’s
continuing education by NEHA.
• Certified food safety professional (CFSP): NEHA has created a credential especially for food safety professionals.
The CFSP is designed for individuals within the public and private sectors whose primary responsibility is the
protection and safety of food. The exam for this prestigious credential integrates food microbiology, Hazard
Analysis and Critical Control Point principles, and regulatory requirements into questions that test problem-
solving skills and knowledge.
• Certified environmental health technician (CEHT): The CEHT is for individuals who are interested in field-
intensive environmental health activities (e.g., testing, sampling, and inspections) and who are required to
provide information on safe environmental health practices and to eliminate environmental health hazards.
• Registered environmental technician (RET): NEHA’s RET is a baseline credential for entry-level hazardous
materials professionals. The credential is an excellent way for recent, 2-year graduates (associate degrees) or
career-changing professionals to demonstrate competency in the core requirements of hazardous materials
handling and management.
• Registered hazardous substances professional (RHSP): The RHSP provides technically qualified professionals
with national recognition for proven expertise in hazardous materials and toxic substances management.
• Registered hazardous substances specialist (RHSS): The RHSS credential is for individuals who follow protocols
for field-intensive hazardous materials activities (e.g., testing, sampling, and handling) and who ensure personal,
public, and site safety.
• BCSP offers the Certified Safety Professional CSP credential.
TABLE 9-5 Environmental Health Competency Expectations for Graduates of MPH Degree Programs
1. Describe the direct and indirect human, ecological, and safety effects of major environmental and occupational
agents.
2. Describe genetic, physiologic, and psychomotor factors that affect susceptibility to adverse health outcomes following
exposure to environmental hazards.
3. Describe federal and state regulatory programs, guidelines, and authorities that control environmental health issues.
4. Specify current environmental risk assessment methods
5. Specify approaches for assessing, preventing, and controlling environmental hazards that pose risks to human health
and safety.
6. Explain the general mechanisms of toxicity in eliciting a toxic response to various environmental exposures.
7. Discuss various risk management and risk communication approaches in relation to issues of environmental justice
and equity.
8. Develop a testable model of environmental injury.
Reproduced from the Association of Schools of Public Health (ASPH) MPH Core Competency Development Process, Version 2.3. Washington,
DC: ASPH, 2006. Available at http://www.asph.org. Accessed June 15, 2014.
• American Board of Industrial Hygiene offers the Certified Industrial Hygienist (CIH) and Certified Associate
Industrial Hygienist (CAIH) credentials.
• Council on Certification of Health, Environmental, and Safety Technologists offers the Occupational Health and
Safety Technologist certification, which has requirements that are less stringent than for CSP, CIH, or CAIH
credentials. This remains a voluntary credential, although many employers encourage or require certification.
In addition to NEHA, the web site of the American Academy of Environmental Engineers (www.aaees.net) is another
useful resource for environmental engineers. The Environmental Health Section of the American Public Health
Association’s web site (www.apha.org) is another good source of information for environmental health. Schools and
graduate programs of public health are among the institutions that offer graduate degrees in environmental and
occupational health. The Association of Schools of Public Health (www.aspph.org) has identified a panel of core
environmental health competencies appropriate for all students receiving the master’s of public health (MPH) degree.
These competencies provide a useful baseline for professional practice and summarize what an MPH graduate should
be able to do (Table 9-5).
CONCLUSION
Careers in environmental and occupational health cover a wide range of duties and roles at a variety of levels. Career
development opportunities in this area of public health practice are plentiful. A mix of education and experience
prepares environmental health workers for increasing responsibility in public-sector agencies as well as the private
sector. The field already well down the path toward competency-based credentials and certifications. Ongoing
education and training are especially relevant concerns for this occupational category. Demand for these positions is
steady, and prospects will likely increase over the next few decades, except within the public sector.
REFERENCES
1. Bureau of Labor Statistics, U.S. Department of Labor. Databases and tables. www.bls.gov/data/. Accessed June 15, 2014.
2. Health Resources and Services Administration (HRSA), Bureau of Health Professions, National Center for Health Workforce Information and
Analysis and Center for Health Policy, Columbia School of Nursing. Public Health Workforce Enumeration 2000. Washington, DC: HRSA; 2000.
3. National Association of County and City Health Officials. 2013 National Profile of Local Health Departments. Washington, DC: NACCHO; 2014.
4. Association of State and Territorial Health Officials. Profile of State Health, Volume Three, 2012. Washington, DC: ASTHO; 2014.
CHAPTER 10
Public Health Nursing
LEARNING OBJECTIVES
Given the need for nurses in the public health system, describe key features of occupations and careers in
public health nursing and how these contribute to carrying out public health’s core functions and essential
services. Key aspects of this competency expectation include being able to
• Describe several different occupational titles in this category
• Identify specific essential public health services that are critical for positions in this category
• Describe important and essential duties for several job titles in this category
• Identify minimum qualifications and describe general workplace considerations, salary expectations, and career
prospects for positions in this category
The title public health nurse designates a nursing professional with educational preparation in public health and
nursing science with a primary focus on population-level outcomes. The primary aim of public health nursing is to
promote health and prevent disease for entire population groups. This may include assisting and providing care to
individual members of the population. It also includes the identification of individuals who may not request care but
who have health problems that put themselves and others in the community at risk, such as those with infectious
diseases.
The focus of public health nursing is not on providing direct care to individuals in community settings. Public health
nurses support the provision of direct care through a process of evaluation and assessment of the needs of individuals
in the context of their population group. Public health nurses work with other providers of care to plan, develop, and
support systems and programs in the community to prevent problems and provide access to care.
As defined by the Public Health Nursing section of the American Public Health Association (APHA), public health
nursing is the practice of promoting and protecting the health of populations using knowledge from nursing, social,
and public health sciences. Public health nursing practice is a systematic process by which
• The health and healthcare needs of a population are assessed in order to identify subpopulations, families, and
individuals who would benefit from health promotion or who are at risk of illness, injury, disability, or premature
death.
• A plan for intervention is developed with the community to meet identified needs that takes into account
available resources, the range of activities that contribute to health, and the prevention of illness, injury,
disability, and premature death.
• The plan is implemented effectively, efficiently, and equitably.
• Evaluations are conducted to determine the extent to which the interventions have an impact on the health
status of individuals and the population.
• The results of the process are used to influence and direct the delivery of care, deployment of health resources,
and the development of local, regional, state, and national health policy and research to promote health and
prevent disease.
Table 10-1 illustrates an average day in the life of a public health nurse.
TABLE 10-1 A Typical Day for a Public Health Nurse
7:30 a.m. Breakfast meeting with visiting nursing agency to discuss interagency coordination
8:30 a.m. Consult with clinic staff on issues requiring follow-up, such as missed appointments
9:00 a.m. Visit home of family missing recent appointments
10:15 a.m. Back in office for meeting to update director of nursing
10:45 a.m. Meeting with communicable disease control and epidemiology staff regarding community concerns over West
Nile Virus threat
11:45 a.m. Informal lunch meeting with community college faculty and students to promote interest in public health
nursing careers
1:00 p.m. Back in office to discuss referrals from clinic and communicable disease staff
1:30 p.m. Visit patient receiving directly supervised therapy for tuberculosis; identify need for job training assistance
and assist with referral
3:00 p.m. Back in office, assist clinic staff with back-to-school physicals and immunizations
4:30 p.m. Time to complete paperwork and follow-up phone calls for today’s activities
5:15 p.m. Review and plan tomorrow’s schedule
7:00 p.m. Attend community meeting regarding West Nile Virus concerns to assist epidemiology and environmental
health staff
OCCUPATIONAL CLASSIFICATION
There is no standard occupational category specific to public health nurses. There is a more generic standard
occupational category registered nurse that encompasses professional nursing positions in any healthcare or health
services organization. This standard occupational category is one of the administrative occupations within the white
collar grouping of occupations.
Public health nurses plan, develop, implement, and evaluate nursing and public health interventions for individuals,
families, and populations at risk of illness or disability. This category covers all positions identified at the registered
nurse (RN) level, unless specified as performing work defined under some other professional occupational category
(such as epidemiologist or occupational health and safety specialist) and includes graduates of diploma and associate
degree programs with the RN license. Common job titles for public health nurses include community health nurse,
nurse consultant, school nurse, public health nurse, occupational health nurse, home health nurse, and RN case
manager. Public health nurses holding administrative positions have titles such as supervising nurse, nursing
coordinator, program director, and director of nursing. Public health nurses who provide clinical services often
function with titles such as staff nurse, nurse clinician, or nurse practitioner. Licensed practical (or vocational) nurses
(LPNs/LVNs) and nursing assistants are considered as technical rather than professional workers in this classification.
OUTSIDE-THE-BOOK THINKING 10-1
What will be the most important new or expanded roles for public health nursing in the 21st century?
There were 2.7 million RNs and 705,000 LPNs/LVNs employed in the United States in 2013. Only 13% of RNs
(300,000) work in community or public health settings. Bureau of Labor Statistics (BLS) data indicated that in 2013,
193,000 nurses (145,000 RNs and 48,000 LPNs) worked for federal, state, and local governmental agencies.1 Public
Health Workforce Enumeration 2000 data identified 64,000 public health nurses and an estimated 15,000–20,000
LPNs/LVNs working for governmental public health organizations, with another 8,000 RNs working for voluntary-
sector agencies in the year 2000.2 Surveys in 2012 and 2013 identified nearly 40,000 RNs and more than 3,000
LPNs/LVNs working in state and local public health agencies.3,4 Data from these various sources are used throughout
this chapter.
PUBLIC HEALTH PRACTICE PROFILE
Nurses have long been the professional core of the public health workforce. Nurses provide both clinical and
community health services in a wide variety of public and private organizations. Services are provided within maternal
and child health programs, communicable disease prevention and control, immunization, and school health programs,
to name just a few. Many nurses trained in public health take on supervisory and management roles and serve as chief
administrator or as part of the senior management team for many local public health agencies. Nurses also serve as
program coordinators and consultants for state and federal health agencies. Their broad expertise and professional
credibility assists in advocacy and coalition-building activities and in the evaluation of programs within the community.
Public health nurses are also active in community health planning and community health improvement initiatives
across the United States. Nurses are directly involved in a wide variety of health promotion and disease and injury
prevention efforts. Their skills are critical to achieving community health objectives and broader public health goals
through performing one or more of the essential public health services. As a result, public health nurses are involved
in a wider array of public health purposes and essential public health services than most other public health
occupational categories. It is somewhat misleading to highlight only a few public health purposes and essential public
health services that are most closely associated with public health nursing. Virtually all fit within the scope of their
professional expertise. For the sake of consistency with other public health occupations and titles addressed in this
book, three public health purposes and five essential public health services are identified for public health nurses in
Table 10-2.
TABLE 10-2 Public Health Practice Profile for Public Health Nurses
Public Health Nurses Make a Difference by:
Public Health Purposes
Preventing epidemics and the spread of disease
Protecting against environmental hazards
Preventing injuries
Promoting and encouraging healthy behaviors
Responding to disasters and assisting communities in recovery
Ensuring the quality and accessibility of health services
Essential Public Health Services
Monitoring health status to identify community health problem
Diagnosing and investigating health problems and health hazards in the community
Informing, educating, and empowering people about health issues
Mobilizing community partnerships to identify and solve health problems
Developing policies and plans that support individual and community health efforts
Enforcing laws and regulations that protect health and ensure safety
Linking people with needed personal health services and ensuring the provision of health care when otherwise
unavailable
Ensuring a competent public health and personal healthcare workforce
Evaluating effectiveness, accessibility, and quality of personal and population-based health services
Researching new insights and innovative solutions to health problems
IMPORTANT AND ESSENTIAL DUTIES
Nursing positions within public health organizations have many different titles. In some organizations, all RNs are
covered by one series usually termed public health nurse. In other organizations, RNs performing clinical duties may
be distinguished from those performing community and public health nursing duties. Some organizations employ
nurse practitioners to provide primary medical care. In addition to RNs, some public health organizations employ
LPNs or LVNs to provide supportive nursing services for clinical care programs. The focus in this chapter will be on
three nursing positions: entry-level public health nurse, senior-level public health nurse, and LVN.
OUTSIDE-THE-BOOK THINKING 10-2
What are the most important contributions to improving the health of the public that public health nurses make today?
Public Health Nurse (Entry Level)
Under direction, entry-level public health nurses provide public health nursing services, including health education,
the promotion of health awareness, and the prevention and control of diseases. This is the entry and first working level
in the public health nurse class series. Incumbents must have requisite public health nursing certification but have
limited public health nursing work experience. As experience is gained, incumbents learn to perform the full scope of
public health nursing duties. Entry-level public health nurses are distinguished from midlevel public health nurses who
independently perform a larger scope of public health nursing duties and activities. Midlevel public health nurses
perform a larger range of duties and activities on a more independent basis and are distinguished from senior public
health nurses in that senior public health nurses perform more complex, specialized assignments, as well as provide
lead direction, work coordination, and training for other professional nursing and support staff. Entry-level and
midlevel public health nurses generally report to a senior public health nurse or the director of nursing services.
Entry-level positions do not supervise other staff.
Important and essential duties for entry-level public health nursing positions may include
• Participate in planning, organizing, and providing public health nursing services, health instruction, counseling,
and guidance for individuals, families, and groups regarding disease control, health awareness, health
maintenance, and rehabilitation in a clinic setting
• Identify and interact with local care providers in the coordination of health care
• Provide referrals to other community-based health and social services
• Teach and demonstrate health practices to individuals and groups
• Instruct clients in immunization procedures, family planning, and sexually transmitted disease prevention and
follow-up
• Identify individual and family problems that are detrimental to good health
• Make home visits to assess a patient’s progress and intervene accordingly
• Work with families to alleviate health problems and promote good health habits
• Refer and coordinate the care of individuals and families with other public and private agencies
• Identify special health needs for assigned cases, recommending and implementing services to meet those needs
• Assist individuals and families with implementing physician recommendations
• Participate in planning, directing, and performing epidemiologic investigations in homes, schools, workplaces,
the community, and public health clinics
• Prepare appropriate records and case documentation, arranging follow-up services based on findings
• Confer with physicians, nursing staff, and other staff regarding public health programs, patient reports,
evaluations, medical tests, and related items
• Participate in multidisciplinary teams for the purpose of creating a plan of service for at-risk families
• Participate and collaborate with community groups to identify public health needs, develop needed public health
services, and improve existing public health services
• Prepare reports and maintain records
• Compile statistical information for appraisal and planning purposes
Public Health Nurse (Senior Level)
Under direction, senior public health nurses provide lead direction and work coordination for other professional
nursing and support staff. Senior public health nurses plan and conduct a variety of public health nursing clinics and
services and provide complex, specialized, and general nursing, health education, and health consulting services,
including the prevention and control of diseases and the promotion of health awareness. This is the advanced level and
lead class in the public health nurse series. Incumbents provide the more complex public health nursing services in a
specialized public health program, as well as provide lead direction and coordination for other professional nursing
staff. This class is distinguished from the midlevel public health nurse by assignment of a higher level of public health
program responsibilities and the performance of lead responsibilities for other professional nursing staff. Senior public
health nurses report to the director of nursing services and, in turn, provide lead direction and work coordination for
entry-level and midlevel public health nurses.
Important and essential duties for senior-level public health nurses may include
• Investigate outbreaks of communicable diseases
• Plan and implement programs for the prevention and control of communicable disease, including tuberculosis,
sexually transmitted diseases, and acquired immune deficiency syndrome
• Develop procedures to control the spread of communicable diseases and identify people needing public health
services
• Provide interpretations of public health laws and regulations for others
• Assess individuals and families, using health histories, observations of physical condition, and a variety of
evaluative methods to identify health problems, health deficiencies, and health service needs
• Identify psychosocial, cultural background, and environmental factors that may hinder the use of or access to
healthcare services
• Assist with determining funding needs for specific programs, and monitor budget expenditures within those
programs
• Plan and coordinate services for special programs such as family planning, or perinatal, maternal, child, or
adolescent programs
• Perform public health nursing activities to promote perinatal, child, and adolescent health
• Provide local case management and coordination within specific programs
• Participate in programs to enhance schoolchildren’s health
• Work with community groups to identify needs, develop and facilitate a variety of health services, and improve
existing programs
• Refer individuals and families to appropriate agencies and clinics for health services
• Participate in programs to enhance community health services and education
• Attend conferences and workshops related to community health issues
• Assist with the preparation of program and service policies and procedures
• Supervise paraprofessional staff and volunteers
• Prepare reports and maintain records
• Compile and analyze statistical information for appraisal and planning purposes
• Provide lead direction, training, and work coordination for other professional nurses
Licensed Vocational/Practical Nurse
Under general supervision, LPNs/LVNs perform a variety of health-related activities in the provision of basic nursing
care, including administering immunizations and vaccinations, hearing and vision screening, basic skin and blood
tests, and blood pressure monitoring. LPN/LVNs assist with a variety of activities related to implementation of various
agency health programs. Workers in this title do not have the necessary education, experience, or license
requirements to qualify as either an RN or a public health nurse. Workers perform a variety of clinical and basic
nursing duties consistent with their license and experience. LPN/LVNs report to a midlevel or senior-level public
health nurse or to the director of nursing. These positions do not carry supervisory responsibility.
Important and essential duties for LPN/LVN positions may include:
• Perform, read, and evaluate skin, hearing, vision, and blood tests
• Perform and evaluate blood pressure readings
• Provide health education sessions
• Administer immunizations and vaccinations
• Participate in healthcare clinics, coordinating activities as assigned
• Maintain a current inventory of clinic supplies
• Operate a mobile health van
• Evaluate medical records and determine the need for immunization or vaccination
• Prepare patients for physical examinations
• Weigh and measure patients
• Assist with examinations
• Refer clients to other healthcare providers
• Prepare specimens for mailing
• Provide basic health information and instruction to individuals and families
• Answer health-related questions from the public
• Sterilize equipment
• Maintain safety requirements in a clinical setting
• Triage requests for information
MINIMUM QUALIFICATIONS
Nurses working in public health come from a wide variety of backgrounds and academic preparation. The number of
RNs produced by 4-year baccalaureate programs is steadily increasing, but there are many RNs from diploma
programs in the public health workforce as well. Many nursing schools offer master’s-level preparation in community
health nursing, school health, and other public health specializations. As described later in this chapter, there is a
highly respected, competency-based credential that is offered for community health nurses. Nonetheless, many of
those working as nurses in public health settings, including those holding public health nursing titles, do not qualify
for this credential due to not having attained the necessary academic credentials.
Typical Minimum Qualifications for Entry-Level Public Health Nurse
Knowledge, Skills, and Abilities
The typical entry-level public health nurse generally has knowledge of:
• Principles, methods, practices, and current trends of general and public health nursing and preventive medicine
• Community aspects of public nursing including community resources and demography
• Federal, state, and local laws and regulations governing communicable disease, public health, and disabling
conditions
• Environmental, sociological, and psychological problems related to public health nursing programs
• Child growth and development
• Causes, means of transmission, and methods of control of communicable disease
• Methods of promoting child and maternal health and public health programs
• Principles of health education
A typical entry-level public health nurse has the skills and ability to:
• Learn to organize and carry out public health nursing activities in an assigned program
• Collect, analyze, and interpret technical, statistical, and health data
• Analyze and evaluate health problems of individuals and families, and take appropriate action
• Provide instruction in the prevention of diseases
• Develop and maintain health records, and prepare clear and concise reports
• Communicate effectively orally and in writing
• Interact tactfully and courteously with the public, community organizations, and other staff when explaining
public health issues and providing public health services
• Establish and maintain cooperative working relationships
• Effectively represent the agency and nursing division in contacts with public, other staff, and other
governmental agencies
Experience and Education
Any combination of training and experience that provides the required knowledge and abilities will qualify an
individual for this position. A typical way to obtain the required knowledge and abilities is to complete a bachelor
degree and have adequate work experience to meet existing state certification requirements. These often call for 1
year of previous public health nursing experience comparable to an entry-level public health nurse with the hiring
organization. Special requirements include possession of a valid state license as an RN. A state-issued certificate as a
public health nurse and possession of a valid state driver’s license may also be required by some agencies.
Typical Minimum Qualifications for Senior-Level Public Health Nurse
Knowledge, Skills, and Abilities
In addition to those required for entry-level public health nurses, senior-level public health nurses generally have
knowledge of:
• Unique psychosocial and cultural issues encountered in a rural health program
• Principles of health education
• Program planning, evaluations, and development principles
• Principles of lead direction, program and work coordination, and training
• Community health assessment principles, strategies, and tools
A senior-level public health nurse generally has the skills and ability to:
• Plan, organize, and carry out public health nursing activities and services for an assigned service area or
program
• Develop and maintain effective working relationships with clients, staff, community groups, and other
government organizations
• Collect, analyze, and interpret technical, statistical, and health data
• Analyze and evaluate health problems of individuals and families, and take appropriate action
• Provide work direction and coordination for other staff
• Provide instruction in the prevention and control of diseases
• Communicate effectively in writing and orally
• Develop and maintain health records and prepare clear and concise reports
Experience and Education
Any combination of training and experience that provides the required knowledge and abilities will qualify an
individual for this position. A typical way to obtain the required knowledge and abilities is to complete sufficient
education and experience to meet state certification requirements. This may require 1 year of public health nursing
experience comparable to a midlevel public health nurse. In addition, special requirements may include possession of
a valid state license as an RN, state certification as a public health nurse, and a valid state driver’s license.
Typical Minimum Qualifications for Licensed Practical/Vocational Nurses
Knowledge, Skills, and Abilities
An LPN/LVN generally has knowledge of:
• Principles, methods, and procedures of general nursing
• Causes, means of transmission, and methods of controlling communicable diseases
• Basic medical terminology
• Principles and procedures of medical record keeping
• Health problems and requirements of infants, children, adolescents, and the elderly
• State laws relating to reporting child abuse and neglect
An LPN/LVN generally has the skills and ability to:
• Operate a variety of standard medical testing equipment
• Communicate effectively in writing and orally
• Follow oral and written instructions
• Provide responsible nursing care and services
• Maintain confidentiality of material
• Interview patients and families to gather medical history
• Perform skin tests and interpret results
• Prepare medical forms and records
• Work responsibly with physicians and other members of the healthcare team
• Effectively represent the agency in contacts with the public, community organizations, and other government
agencies
• Establish and maintain cooperative working relationships with patients and others
Experience and Education
Any combination of training and experience that provides the required knowledge and abilities will qualify an
individual for this position. A typical way to obtain the required knowledge and abilities is through 1 year of vocational
nursing experience and completion of nursing studies and curriculum sufficient to obtain requisite state licenses. In
addition, special requirements may include possession of a valid state license as an LVN and a valid state driver’s
license.
WORKPLACE CONSIDERATIONS
Public health nurses have long been one of the most important, and most numerous, categories within the professional
public health workforce. Public health nurses are especially prominent in local public health agencies, where they are
involved in a wide range of disease prevention, health promotion, and health service programs. They are also found in
state and federal health agencies, although not as frequently today as in past decades. Public health nurses play key
roles in maternal and child health services, Women, Infants, and Children programs, immunization and communicable
disease control programs, and in the clinical operations of local public health agencies. Their professional background
also makes them effective links with other community health organizations and agencies, especially local hospitals and
schools. Public health nurses need to know medical terminology and how to perform various medical screening tests
and basic nursing procedures.
Work is performed in clinics and healthcare offices, at work sites, and in home environments with occasional
exposure to communicable diseases and blood borne pathogens as well as saliva, urine, and feces. Nurses are
expected to understand and follow recommended practices and precautions for prevention of disease transmission.
Ongoing contact with other staff and the public is part of the daily routine for public health nurses. Public health
nurses may need to travel to various locations within the community, including to remote or unsafe areas in all
weather conditions in order to perform their duties. Personal safety is enhanced through safety training, use of cell
phones and identification badges, and not traveling alone to neighborhoods with high crime rates.
Typical physical requirements for nurses at all levels include the ability to sit and stand for extended periods,
normal manual dexterity and eye-hand coordination, the ability to lift and move objects weighing up to 50 pounds,
hearing and vision corrected to normal range, verbal communication skills, and the ability to properly use medical and
office equipment, including computer, telephone, calculator, copiers, and fax machines.
OUTSIDE-THE-BOOK THINKING 10-3
What features make public health nursing a career worth pursuing?
POSITIONS, SALARIES, AND CAREER PROSPECTS
In 2013, there were 2,662,000 RNs employed in the United States, with 145,000 working for federal, state, and local
governmental agencies. In addition, there were 705,000 employed LPNs/LVNs, of whom 48,000 worked in government
agencies. Table 10-3 identifies the number of total workers and the number employed by government for the standard
occupational categories considered in this chapter. Projections for the year 2022 are also provided. The numbers of
both RNs and LPNs/LVNs has been increasing in recent years, a trend that is expected to continue well into the future.
For these two nursing categories, job growth has been somewhat less for government employment than outside
government.
The overall number of positions for RNs is expected to grow to 3,200,000 by the year 2022, but with no increase in
the number employed by government agencies. LPN/LVN positions are projected to increase to 921,000 during that
period with only a modest increase (to 50,000) for the number employed by government agencies. Based on the
growth in the number of positions and the need to fill other positions because of job changes and retirement, more
than 1 million RN positions and 363,000 LPN/LVN positions will be filled between 2012 and 2022. Only a small
percentage of these positions will be filled in the government sector. Public health nurses often move up into unit and
agency leadership positions and higher salaries. It is not uncommon for the director of a small- or medium-sized public
health agency to be an experienced public health nurse. Nonetheless, the ever expanding nongovernmental health
sector of the U.S. economy will offer the vast majority of RN positions over the next decade. Job growth for RNs in the
government sector will lag behind the growth rate for RN positions in the overall economy.
TABLE 10-3 Number of Workers in 2013 and Projected for 2022 for All Industries and Government and
Number of Positions to Be Filled 2012–2022 for All Industries
Data from Bureau of Labor Statistics, U.S. Department of Labor. Selected Occupational Projections Data. Available at www.bls.gov/data/.
Accessed June 15, 2014.
TABLE 10-4 Number and Salary Profile for Federal and State/Local Workers for Selected Occupations, 2013
Notes: Federal: excludes postal service; State/Local: excludes hospitals and education
Data from Bureau of Labor Statistics, U.S. Department of Labor. Employment and Wages from Occupational Employment Statistics (OES) Survey.
Available at www.bls.gov/data/. Accessed June 15, 2014.
Salaries differ considerably between the RN and LPN/LVN categories and even within the RN category itself, based
on academic degrees, credentialing, experience, and the market conditions related to the shortage of nurses in any
given area. The median salary for RNs employed by government agencies in 2013 was $69,000, with the middle 50%
earning between $56,000 and $84,000 (Table 10-4). Average salaries for RNs working in governmental agencies were
similar to those for nurses working in the private and voluntary sectors. Entry-level salaries were in the $44,000–
$52,000 range.
The median salary for LPNs/LVNs employed by government agencies in 2013 was $43,000, with the middle 50%
earning between $36,000 and $48,000. Entry-level salaries were in the $30,000–$34,000 range.
Nurses remain in short supply throughout the health sector, making the recruitment and retention of public health
nurses a continuing issue for potential employers, both public and private. Public sector agencies, such as local and
state health departments as well as community and national not-for-profit organizations, often are not able to match
salary and benefit levels available through private employers (such as hospitals, clinics, and health plans). Competition
with private-sector employers has increased nursing salaries to some extent and in some locations. Public health
agencies generally are not able to match the salaries and benefits (including signing bonuses) available within the
acute care and primary care sectors.
As the largest professional category employed by public health agencies, and because of the growing shortage of
RNs, there are many opportunities for all levels of nurses within the public health workforce. Working hours and
conditions for nurses working in public health agencies can be attractive, and many nurses appreciate the importance
and impact of working in public health. Still, public health nurses are the number one worker category identified as
needed now and in the future for public health agencies. Public Health Workforce Enumeration 2000 data identified
50,000 public health nurses in 2000, nearly all of whom worked in state and local public health agencies.
The number of undergraduate and graduate students entering nursing training programs has been increasing
steadily in recent years. As noted earlier, the demand for public health nurses is also increasing, and even faster than
the supply.
OUTSIDE-THE-BOOK THINKING 10-4
In which organizations and geographic regions will the need for public health nursing expand most rapidly in the next two
decades?
ADDITIONAL INFORMATION
There are many good sources of information on public health nursing. Several sources of information are available on
educational programs for these occupations as well as for continuing education and leadership development for public
health nurses.
The Public Health Nursing section of the APHA web site (www.apha.org) is a great source of information on public
health nursing. The Public Health Nursing section has a long history and currently has many members, making it one
of APHA’s largest and most active sections.
Schools of public health are among the institutions offering master’s and doctoral degrees in public health for
nurses. The Association of Schools and Programs of Public Health web site (www.aspph.org) provides information on
accredited schools and programs of public health and on the characteristics of public health students and degree
concentrations.
State licensing boards (which license RNs), schools of nursing, the American Nurses Association (ANA), and its
many state affiliates are also rich sources for additional information on public health nurses. The American Nursing
Credentialing Center (ANCC) is the credentialing arm of the ANA
(http://www.nursecredentialing.org/Certification.aspx) and awards a registered nurse, board certified certification.
ANCC certifies community health nurses who meet all the following requirements:
• Active RN license in the United States
• Two full years of public health nursing practice in the United States
• Bachelor or higher degree in nursing
• Two thousand or more hours of clinical practice within the past 3 years (can include nursing administration,
education, client care, and research)
• Thirty contact hours of continuing education within the past 3 years
The Quad Council of Public Health Nursing Organizations is an alliance of the four national nursing organizations
that address public health nursing issues. Its members are the Association of Community Health Nurse Educators, the
ANA’s Congress on Nursing Practice and Economics, the APHA’s Public Health Nursing Section, and the Association of
State and Territorial Directors of Nursing. The Quad Council was founded in the early 1980s to address priorities for
public health nursing education, practice, leadership, and research, and to serve as a unified voice for public health
nursing. Public health nursing competencies are an ongoing priority for the Quad Council.
The current Quad Council public health nursing competency framework is designed to be consistent with other
competency principles and frameworks of its partner organizations. The framework complements the definition of
Public Health Nursing adopted by the APHA’s Public Health Nursing Section, the ANA’s Scope and Standards of Public
Health Nursing Practice, and the Public Health Practitioner Competencies established by the Council on Linkages
between Academia and Public Health Practice.5-7
Practice competencies for public health nurses were revised by the Quad Council in 2011, in part to promote
consistency with the domains and three tiers of public health practitioner competencies established by the Council on
Linkages between Academia and Public Health Practice. Eight competency domains address:
• Analytic and assessment skills
• Policy development and program planning skills
• Communication skills
• Cultural competency skills
• Community dimensions of practice skills
• Public health science skills
• Financial planning and management skills
• Leadership and systems thinking skills7,8
Similar to the approach taken by the Council on Linkages between Academic and Public Health Practice, the Quad
Council also established three tiers of competencies for public health nurses.
• Tier 1 Core Competencies apply to generalist public health nurses who carry out day-to-day functions in state
and local public health organizations, including clinical, home visiting and population-based services, and who are
not in management positions. Responsibilities of the PHN may include working directly with at-risk populations,
carrying out health promotion programs at all levels of prevention, basic data collection and analysis, field work,
program planning, outreach activities, programmatic support, and other organizational tasks. Although the
Council on Linkages competencies and the Quad Council competencies are primarily focused at the population
level, public health nurses must often apply these skills and competencies in the care of individuals, families, or
groups. Therefore, Tier 1 competencies reflect this practice.
• Tier 2 Core Competencies apply to PHNs with an array of program implementation, management and/or
supervisory responsibilities, including responsibility for clinical services, home visiting, community-based and
population-focused programs. For example, responsibilities may include implementation and oversight of
personal, clinical, family focused, and population-based health services; program and budget development;
establishing and managing community relations; establishing timelines and work plans, and presenting
recommendations on policy issues.
• Tier 3 Core Competencies apply to PHNs at an executive/senior, management level and leadership levels in
public health organizations. In general, these competencies apply to PHNs who are responsible for oversight and
administration of programs or operation of an organization, including setting the vision and strategy for an
organization and its key structural units, e.g., a public health nursing division. Tier 3 professionals generally are
placed at a higher level of positional authority within the agency/organization, and they bring similar or higher
level knowledge, advanced education and experience than their Tier 2 counterparts.5,8
In developing their competencies, the Quad Council determined that the generalist level would reflect preparation
at the bachelor level. Although recognizing that in many states much of the public health nursing workforce does not
have a bachelor degree, the Quad Council believes that those nurses may require job descriptions that reflect a
different level of practice or may require extensive orientation and education to achieve the competencies identified.
Further, the specialist-level competencies described in this document reflect preparation at the master’s level in
community/public health nursing or public health. Again, while recognizing that there may be other public health
nurses who are promoted or appointed to managerial or consultant positions that require specialist competencies, a
master’s degree prepares public health nurses for the specialist-level competencies identified in this document. At
both levels, it is expected that on-the-job training and continuing education for nurses hired for these positions who
have less than a bachelor or master’s degree (as appropriate to the level) will ensure that these competencies are
attained.
The Quad Council based its competency framework on several relevant assumptions. Public health nurses must first
possess the competencies common to all nurses with bachelor degrees and then demonstrate additional competencies
specific to their roles in public health. The progression from awareness to knowledge to proficiency is a continuum,
and there are no discrete boundaries between those levels of competence. Both levels reflect competencies for a
reasonably prudent public health nurse who has experience in the role (i.e., not a novice and not in a specialized or
limited focus role). Defined competencies are intended to reflect the standard for public health nursing practice, not
necessarily what is occurring in practice today. Importantly, in any practice setting, the job descriptions may reflect
components from each level, depending on the agency’s structure, size, leadership, and services.
CONCLUSION
Public health nurses remain the largest category of health professionals in the public health workforce. They are active
in community as well as clinical services and at all levels of public health organizations, including serving as public
health managers and administrators. Although there are 2.7 million nurses in the United States, only a small fraction
work for governmental public health organizations, and relatively few of those have formal training in public health.
The national nursing shortage, particularly acute for nursing positions in hospitals and long-term care facilities, also
limits the ability of public health organizations to attract and retain qualified nurses. Recruitment and retention
initiatives for public health nurses are now receiving widespread attention within the public health community, a
testimony to the continuing importance of public health nurses if public health goals and objectives are to be achieved.
REFERENCES
1. Bureau of Labor Statistics, U.S. Department of Labor. Databases and tables. www.bls.gov/data/. Accessed June 15, 2014.
2. Health Resources and Services Administration (HRSA), Bureau of Health Professions, National Center for Health Workforce Information and
Analysis and Center for Health Policy, Columbia School of Nursing. Public Health Workforce Enumeration 2000. Washington, DC: HRSA; 2000.
3. National Association of County and City Health Officials. 2013 National Profile of Local Health Departments. Washington, DC: NACCHO; 2014.
4. Association of State and Territorial Health Officials. Profile of State Health, Volume Three, 2012. Washington, DC: ASTHO; 2014.
5. Quad Council Competency Workgroup. Competencies for Public Health Nurses, Summer 2011. Available at
http://www.resourcenter.net/images/ACHNE/Files/QuadCouncilCompetenciesForPublic-HealthNurses_Summer2011 . Accessed June 18, 2014.
6. American Nurses Association. Scope and Standards of Public Health Nursing Practice.
7. Council on Linkages between Academia and Public Health Practice. Core Competencies for Public Health Professionals. Available at
http://www.phf.org/resourcestools/documents/core_public_health_competencies_iii . Accessed June 19, 2014.
8. Swider SM, Krothe J, Reyes D and Cravetz M. The Quad Council practice competencies for public health nursing. Public Health Nursing, 2013;
30: 519–536. doi: 10.1111/phn.12090.
CHAPTER 11
Epidemiology and Disease Control
LEARNING OBJECTIVES
Given the need for epidemiologists, biostatisticians, and disease control workers in the public health system,
describe key features of occupations and careers in epidemiology and disease control and how these
contribute to carrying out public health’s core functions and essential services. Key aspects of this competency
expectation include being able to
• Describe several different occupational titles in this category
• Identify several essential public health services that are critical for positions in this category
• Describe important and essential duties for several job titles in this category
• Identify minimum qualifications and describe general workplace considerations, salary expectations, and career
prospects for positions in this category
Epidemiology is often called the mother science of public health practice. Epidemiologists investigate and describe the
determinants and distribution of disease, disability, and other health outcomes and help develop the means for their
prevention and control. Epidemiology works hand in hand with biostatistics and field investigations to provide
information and insights into factors that contribute to health and disease in a population. John Snow’s methods of
examining cholera outbreaks in 1854 demonstrated the usefulness of epidemiologic methods even when little was
known about the microorganism causing these outbreaks. Epidemiology and biostatistics are essential tools for
research and evaluation into causative factors as well as into the effectiveness of clinical and community interventions.
Recent concerns over bioterrorism threats and events have raised awareness of the important role played by
epidemiologists and related occupations. One of the major objectives of increased funding for bioterrorism
preparedness and response is to rapidly increase the number of epidemiologists working in state and local public
health agencies. Table 11-1 provides a snapshot of an average day in the life of an epidemiologist.
OCCUPATIONAL CLASSIFICATION
Two standard occupational categories used for public health workers (epidemiologist and statistician) are addressed in
this chapter. Epidemiologist is a standard occupational category that is commonly found in public health organizations.
Biostatisticians are a subset of statisticians. Both categories are professional white-collar categories. Another
important and related occupational category, disease investigators, is not included among the standard occupational
titles but will also be described in this chapter, because their work complements that of epidemiologists and
biostatisticians.
• The role of epidemiologist encompasses positions that investigate, describe, and analyze the distribution and
determinants of disease, disability, and other health outcomes, and develop the means for their prevention and
control. Epidemiologists also describe and analyze the efficacy of programs and interventions. This category
includes individuals specifically trained as epidemiologists as well as those trained in another discipline (such as
medicine, nursing, or environmental health) working as epidemiologists under such job titles as nurse
epidemiologist. Bureau of Labor Statistics (BLS) data indicate that in 2013 there were 5,300 epidemiologists in
the United States, with state and local governments employing 2,800 of these workers.1 The Public Health
Workforce Enumeration 2000 study identified 1,400 epidemiologists working in federal, state, and local
governmental public health agencies in 2000.2 The combined results of surveys conducted in 2012 and 2013
identified nearly 4,500 epidemiologists working in state and local public health agencies.3,4 These findings likely
reflect a combination of disease investigators and actual epidemiologists. Data from these various sources are
used throughout this chapter. Hospitals, scientific research and development companies, and educational
institutions are also important sources of employment for epidemiologists. A 2004 survey conducted by the
Council of State and Territorial Epidemiologists (CSTE) identified 2,600 epidemiologists working in state and
local public health agencies, although it is likely that this number also included some disease investigator
positions.5
TABLE 11-1 A Typical Day for an Epidemiologist
7:30 a.m. Phone discussion from home with state epidemiologist regarding current status of West Nile Virus and follow-
up on last week’s foodborne illness outbreak involving local fast-food establishment
8:30 a.m. Meeting with public health student completing internship project analyzing childhood asthma morbidity
9:00 a.m. Staff meeting to review priorities for week
10:15 a.m. Meet with agency director, health education, and planning staff regarding completion of community health
assessment
10:45 a.m. Meet with communicable disease control and public health nursing staff regarding community concerns over
West Nile Virus threat
11:45 a.m. Interview candidates for vacant entry-level epidemiologist position
12:15 p.m. Lunch at desk while catching up with e-mail and phone messages
1:00 p.m. Grand Rounds presentation at community hospital on nosocomial infections
2:30 p.m. Office time to respond to e-mail and phone messages
3:00 p.m. Conference call with epidemiologists and environmental health staff of neighboring jurisdictions and state
health department regarding current status of West Nile Virus
4:00 p.m. Review information suggested by staff for tonight’s community meeting on West Nile Virus
4:30 p.m. Brief agency director on West Nile Virus
5:15 p.m. Complete final report on last week’s foodborne illness outbreak involving local fast-food establishment
7:00 p.m. Represent agency at community meeting regarding West Nile Virus concerns
• The role of infection control/disease investigator includes positions that assist in identifying and locating
individuals or groups at risk of specified health problems and incorporating those people into appropriate health
promotion and disease prevention programs. This category includes public health investigators or sexually
transmitted infection investigators without reference to educational preparation. Disease investigators may be
undercounted if individuals with specific professional preparation (such as nursing, environmental health, or
laboratory science) are primarily performing investigations but are employed under another professional title.
Because this title is not one of the standard occupational categories tracked by the Bureau of Labor Statistics, it
is not clear how many disease investigator positions exist. The Public Health Workforce Enumeration 2000 report
identified 1,200 infection control and disease investigator positions in governmental public health agencies.2 It is
likely that there is some overlap between these positions and those designated as epidemiologists or general
program specialists.
• Biostatisticians apply statistical reasoning and methods in addressing, analyzing, and solving problems in public
health; health care; and biomedical, clinical, and population-based research. The precise number of
biostatisticians is not known. BLS data indicates that there were 25,000 statisticians in the United States in 2013,
with 6,400 working for governmental agencies.1 The federal government alone employed over 4,300 statisticians.
The Public Health Workforce Enumeration 2000 study identified 1,800 biostatisticians in governmental public
health agencies in 2000, the majority working for federal and state agencies.2
OUTSIDE-THE-BOOK THINKING 11-1
What will be the most important new or expanded roles for epidemiologists and biostatisticians in the 21st century?
PUBLIC HEALTH PRACTICE PROFILE
Epidemiologists, biostatisticians, and disease investigators primarily address public health responsibilities for
preventing disease and injury and protecting against environmental hazards. These occupational groups may also be
involved in emergency preparedness and response and, not infrequently, with assessing the impact and quality of
health services within a community.
OUTSIDE-THE-BOOK THINKING 11-2
What are the most important contributions to improving the health of the public that epidemiologists and biostatisticians
make today?
Among the 10 essential public health services, epidemiologists and related occupations are especially important for
four: monitoring health status, diagnosing and investigating health events and threats in the community, assessing the
impact and quality of services, and researching innovative solutions to health problems. Table 11-2 summarizes public
health purposes and essential public health services at the core of positions for epidemiologists and disease control
professionals.
TABLE 11-2 Public Health Practice Profile for Epidemiology and Disease Control
Epidemiology and Disease Control Professionals Make a Difference by:
Public Health Purposes
Preventing epidemics and the spread of disease
Protecting against environmental hazards
Preventing injuries
Promoting and encouraging healthy behaviors
Responding to disasters and assisting communities in recovery
Ensuring the quality and accessibility of health services
Essential Public Health Services
Monitoring health status to identify community health problems
Diagnosing and investigating health problems and health hazards in the community
Informing, educating, and empowering people about health issues
Mobilizing community partnerships to identify and solve health problems
Developing policies and plans that support individual and community health efforts
Enforcing laws and regulations that protect health and ensure safety
Linking people with needed personal health services and ensuring the provision of health care when otherwise
unavailable
Ensuring a competent public health and personal healthcare workforce
Evaluating effectiveness, accessibility, and quality of personal and population-based health services
Researching new insights and innovative solutions to health problems
IMPORTANT AND ESSENTIAL DUTIES
There are many job titles and positions in the public health workforce that investigate and analyze health problems
and risks. The focus in this chapter will be on four positions: communicable disease investigator, entry-level
epidemiologist, senior-level epidemiologist, and biostatistician. Each of these positions and a representative panel of
their important and essential duties are described in this section.
Communicable Disease Investigator
This position investigates confirmed or suspected cases of communicable diseases to ensure patient treatment and
follow-up. Duties are often characterized by the responsibility to implement key aspects of a communicable disease
control program. This position performs communicable disease investigative work, bringing to treatment those
patients with positive laboratory tests and providing information on sexually transmitted and other communicable
diseases. Communicable disease investigator titles may include higher level titles responsible for supervising the work
of communicable disease investigators and providing the more difficult and sensitive pretest and posttest counseling
to patients and families. Entry-level and midlevel communicable disease investigators exercise no supervision over
other workers.
Operational duties related to identifying and obtaining treatment for carriers of communicable diseases include
identifying target populations, conducting epidemiologic investigations, testing patients, and making referrals for
social or community services. This position administers tuberculin skin tests, obtains laboratory samples, and performs
epidemiologic investigations. Many personnel systems have several levels for disease investigators.
Important and essential duties of a communicable disease investigator include
• Interviews clients and contacts; performs risk assessment and counseling; performs disease testing; performs
partner counseling and referral service to contacts of infected persons; counsels patients diagnosed as having a
communicable disease regarding the disease process (such as the sequence of symptoms), appropriate
medications, complications, and prevention so that they will be encouraged to be treated and give names,
addresses, and phone numbers of contacts who have been exposed when this is appropriate
• Provides referrals to service providers
• Provides transportation for infected clients and their partners to get appropriate medical care
• Manages cases to closure including successful treatment or failure to comply
• Locates contacts by phone or field visits and informs contacts of infected persons of possible exposure to a
sexually transmitted or other communicable disease; maintains confidentiality of information
• Reviews information (such as epidemiologic reports) from other jurisdictions regarding persons exposed to
sexually transmitted and other communicable disease; initiates and provides such information for use by other
agencies; consults with medical providers regarding a specific client’s diagnosis, treatment plan, infection history,
and location; consults with laboratory microbiologist regarding complex test results
• Attends meetings and inservice training on identification, testing, and treatment protocols for sexually
transmitted and other communicable diseases; may serve as an agency resource or act on behalf of the program
coordinator in that person’s absence in an assigned program area
• Maintains professional knowledge in applicable areas and keeps abreast of changes in job-related rules, statutes,
laws, and new business trends; makes recommendations for the implementation of changes; reads and interprets
professional literature; attends training programs, workshops, and seminars as appropriate
• Identifies, contacts, and recruits high-risk patients for participation in communicable disease education and
prevention programs
• Provides health education to community organizations, schools, and groups about risky lifestyles and contracting
communicable diseases
• Maintains epidemiologic control record of patients, contacts, and suspects
• Maintains a central record file on communicable diseases
• Maintains records of locations where high risk activity occurs
• Participates as member of a multidisciplinary team on disease surveillance and investigations with
epidemiologists, biostatisticians, healthcare professionals, environmental health practitioners, health information
specialists, and staff of regulated industries (such as restaurants, hospitals, and nursing homes)
• Maintains cooperative relationships with officials of the armed forces, state department of public health, and
local police departments
Epidemiologist (Entry Level)
This position performs epidemiologic investigations of human morbidity and mortality; compiles, maintains, and
analyzes health data and reports; identifies causative agents resulting in adverse health conditions and proposes
corrective actions; and provides public health information and consultative services. This is the entry-level professional
epidemiologist performing duties under the direct supervision of a higher level epidemiologist.
Entry-level epidemiologists work in the investigation, analysis, prevention, and control of injuries or communicable,
chronic, or environmentally induced diseases. An entry-level epidemiologist is responsible for conducting ongoing
epidemiologic studies in order to investigate, identify, and analyze incidence, prevalence, trends, and causes of injuries
or communicable, chronic, or environmentally induced diseases. An entry-level epidemiologist is also responsible for
assisting with the development of intervention strategies, policies, and procedures and the evaluation of new and
existing prevention and control programs based on epidemiologic findings. Work involves communicating with
healthcare providers; social service agencies; schools; federal, state, and local officials; the media; and others
concerning disease and injury investigation, prevention, and control. This position may supervise subordinate staff,
such as communicable disease investigators. Work is subject to general review and direction by a higher level
epidemiologist, program administrator, or other designated superior; however, an entry-level epidemiologist works
with considerable independence within established policies and procedures.
Important and essential duties of an entry-level epidemiologist include
• Assists in the design of or conducts epidemiologic studies of disease or injury occurrence, including evaluation of
behavioral and clinical interventions
• Reviews and evaluates disease or injury reporting and surveillance systems and advises program administrators
of important incidence or prevalence changes within reporting areas
• Conducts or assists in investigations of disease clusters using epidemiologic methods, including gathering
information and biologic specimens
• Conducts field interviews of case subjects, potential case and control subjects, government officials, and others
to ascertain disease incidence and prevalence
• Maintains contact with community physicians, hospital staff, and other healthcare professionals to encourage
proper reporting of injuries and communicable, chronic, or environmentally induced diseases and conditions
• Participates as member of a multidisciplinary team on disease surveillance and investigations with disease
investigators, biostatisticians, healthcare professionals, environmental health practitioners, health information
specialists, and staff of regulated industries (such as restaurants, hospitals, and nursing homes)
• Communicates with healthcare providers; social service agencies; schools; federal, state, and local officials; the
media; and others concerning disease and injury investigation, prevention, and control
• Conducts epidemiologic investigations, surveys, and special studies relating to public health, including
assessment of risk behaviors or continuing risk of exposure to specific agents
• Conducts evaluations of control measures related to communicable, chronic, or environmentally induced
diseases or injuries
• Prepares investigation reports, statistical analyses, and summaries on completed epidemiologic studies and
evaluations
• Participates in preparing grant applications, research reports, and other public health documents
Epidemiologist (Senior Level)
This position coordinates, conducts, analyzes, interprets, and reports the findings from public health surveillance
systems and advanced epidemiologic studies that identify the causes of morbidity and mortality; designs and
coordinates appropriate preventive health measures based upon investigative results; and determines which specific
public health issues require further epidemiologic studies. Medical epidemiologists (such as physicians, veterinarians,
dentists, and nurses) provide professional medical consultation in the performance of these duties. This is the highest
level position in the series. Incumbents at this level independently propose and direct epidemiologic investigations or
act as the principal investigator on local, state, or federal health research grants. Positions at this level may supervise
or lead lower-level epidemiologists or other research staff.
Important and essential duties of senior-level epidemiologists include
• Conducts case control, cohort, or cross-sectional studies to identify the incidence, prevalence, or causes of
human morbidity or mortality; prepares formal written reports of findings, including a description of the methods
used, the findings, and the interpretation of the findings
• Conducts disease outbreak investigations to identify causative agents and environmental conditions resulting in
disease outbreaks
• Performs statistical analyses of health data, such as analysis of variance, trend analysis, multiple logistic
regression, survival analysis, and so on
• Trains interviewers and clerical staff in project-specific tasks as necessary
• Obtains, as necessary, approval from human subject review boards to conduct investigations or research
• Interacts during the course of investigations with health providers or other persons performing clinical or health
research
• Collects surveillance information of reportable human morbidity and mortality as required by state law
• Compiles, maintains, and analyzes health data and reports using statistical methods
• Identifies corrective actions to environmental conditions resulting in adverse health conditions
• Independently proposes and supervises epidemiologic investigations of human morbidity or mortality
• Participates as member of a multidisciplinary team on disease surveillance and investigations with disease
investigators, biostatisticians, healthcare professionals, environmental health practitioners, health information
specialists, and staff of regulated industries (such as restaurants, hospitals, and nursing homes)
• Collaborates with a broad spectrum of public health constituents and participants including federal, state, and
local public health officials, as well as government officials, private individuals, and senior researchers in
academic settings
• Communicates health risks to public officials, the media, and the public
• Coordinates local, state, and federal health research programs
• Serves as principal investigator on local, state, and federal health research grants
• Supervises the work of lower level epidemiologists
Biostatistician
This position conducts statistical analyses of morbidity and mortality data, quality assurance, clinical data, surveillance
and other data, and serves as a resource for epidemiology and other agency staff.
Important and essential duties of a biostatistician include
• Provides usable reports to epidemiology, program, and clinical staff
• Advises and assists epidemiology staff with research design, statistical design, and statistical analysis of
quantitative research projects and databases
• Designs research protocols
• Provides direction on sample size and distribution
• Directs appropriate measures for proper data handling and cleaning
• Analyzes statistical databases, such as birth, death, or disease records, for proper organization and treatment of
data
• Suggests revisions based on statistical and research implications
• Writes research design and statistical portions of proposals and papers
• Works closely with epidemiologists to appropriately frame information for reports or papers
• Cultivates sources of population-based data and information available from other public and private agencies
• Participates as member of a multidisciplinary team on disease surveillance and investigations with
epidemiologists, disease investigators, healthcare professionals, environmental health practitioners, health
information specialists, and staff of regulated industries (such as restaurants, hospitals, and nursing homes)
• Assists with outbreak investigations, when needed; in unusual instances, such as a bioterrorism event or disease
outbreak, the biostatistician may need to assist with interviewing victims, analyzing data, arranging sample
collection, and so on, as directed by the agency leadership team
MINIMUM QUALIFICATIONS
Epidemiologists come from a variety of professional and experiential backgrounds. Among positions in state health
agencies, 10% are physicians, another 16% have some other doctoral degree, 45% have a master’s degree, 24% have a
bachelor degree, and 5% have less than a bachelor degree.3
Epidemiologists and communicable disease investigators work together in investigations of disease patterns and
outbreaks. Epidemiologists often have graduate degrees, and some possess other professional credentials. Biostatistics
is a specialized field in which master’s and doctoral degrees are common. Communicable disease investigators may or
may not have education and training equivalent to a bachelor degree. Typical minimum qualifications for
communicable disease investigators, entry-level and midlevel epidemiologists, and biostatisticians are detailed below.
Typical Minimum Qualifications for Communicable Disease Investigator
Knowledge, Skills, and Abilities
A typical communicable disease investigator generally has knowledge of:
• Transmission, diagnosis, and treatment of sexually transmitted and other communicable disease
• Symptoms of sexually transmitted and other communicable diseases
• Methods and techniques used to conduct disease investigations
• Methods of infection control
• Laws and legal issues related to the control of communicable diseases
• Diagnostic and therapeutic problems involved in the control of communicable diseases
• Basic medical terminology, clinical practices, and medical procedures
• Principles and practices of customer service
• Available community and social service agencies
• Diverse cultural practices and customs
• Personal computers and related software
A typical communicable disease investigator generally has the skills and ability to:
• Understand, interpret, and apply laws, regulations, policies, and procedures relating to communicable disease
reporting
• Interview tactfully and effectively, and work cooperatively with other agencies involved in the control of sexually
transmitted and other communicable diseases
• Deal firmly and fairly with clients of various socioeconomic backgrounds and temperaments
• Maintain accurate records and document actions
• Make referrals to local and regional providers of social, medical, and other specialized services
• Maintain confidentiality of information; recognize and respect limits of authority and responsibility
• Conduct interviews of a highly personal nature
• Exercise initiative and tact in tracing contacts and bringing them in to seek treatment
• Gain the confidence of many varied personalities
• Communicate and work effectively with coworkers, supervisors, and the general public sufficient to exchange or
convey information and to receive work direction
• Communicate effectively both orally and in writing
• Understand program objectives in relation to departmental goals and procedures
• Establish and maintain effective working relationships with officials, the general public, and personnel from
other government agencies
• Operate personal computers, including spreadsheet database, word processing, presentation, and other related
software
Experience and Education
Any combination of training and experience that provides the required knowledge and abilities will qualify an
individual for this position. A typical way to obtain the required knowledge and experience is through 1 year of
experience in a clinical or other healthcare setting requiring contact with the general public, and at least an associate
degree or trade school diploma, preferably as a medical assistant or a closely related field with college-level course
work in psychology, health education, or social work. Another path to these qualifications is through an associate
degree in allied health or a related field and 2 years of experience providing emergency medical treatment as an
emergency medical technician, medical technician, military corpsman, or related experience; or an equivalent
interchange of related education and experience sufficient to successfully perform the essential duties of the job. Still
another path is through graduation from an accredited college with a degree in biologic or behavioral sciences or a
related field and 1 year of professional experience in public health, hospital services, or a related field. Qualifying
experiences may substitute for the required education on a year-for-year basis.
Special requirements often necessary for this position include a valid driver’s license, ability to travel
independently, bilingual skills, and the ability to work in an environment that may include exposure to communicable
diseases. Disease investigators may be required to work outside normal business hours and sign a statement agreeing
to comply with state laws and regulations relating to child abuse reporting.
Typical Minimum Qualifications for Entry-Level Epidemiologists
Knowledge, Skills, and Abilities
A typical entry-level epidemiologist generally has knowledge of:
• Modern epidemiologic principles and practices, including the symptoms, causes, means of transmission, and
methods of control of communicable and chronic diseases
• Microbiology and pathophysiology
• Basic medical terminology
• Modern research procedures including biostatistical methodology
• Computers and programming in database management and statistical software
• Community organizations and resources related to the field of public health and epidemiology
• Epidemiologic techniques, methods, and surveillance systems, particularly those related to communicable,
chronic, or environmentally induced diseases or injury control
• Current research and analytical methods related to public health and epidemiology
• Scientific methods and the pathobiology of disease or injury occurrence
• Nature and objectives of statewide public health programs addressing individual and community health
problems
• Organization and operation of federal, state, and local governmental agencies relating to public health
A typical entry-level epidemiologist generally has the skills and ability to:
• Apply laws, rules, and regulations to problems of disease control
• Communicate clearly and concisely orally and in writing on both technical and nontechnical levels
• Prepare grant proposals and budgets
• Implement and evaluate program activities relating to the prevention and control of injuries and communicable,
chronic, or environmentally induced diseases
• Analyze and interpret epidemiologic data
• Assess a disease outbreak situation and make appropriate decisions
• Prepare or assist in preparing scientific articles, making presentations to professional groups, and clearly
communicating the findings of epidemiologic studies
• Establish and maintain effective working relationships with other employees, healthcare providers, social service
agencies, schools, the media, the public, and federal, state, and local officials
Experience and Education
Any combination of training and experience that provides the required knowledge and abilities will qualify an
individual for this position. A typical pathway to obtain the required knowledge and experience is through a master’s
degree in epidemiology or a master’s degree in public health (MPH) with specialization in epidemiology and 1 year of
experience in epidemiology research and analysis. Another path is through 1 year of professional experience in chronic
disease, communicable disease, human nutrition, injury control, environmental epidemiology, or infection control,
which includes disease or injury investigation and risk assessment, and a master’s degree from an accredited college
or university in nursing, nutrition/dietetics, healthcare administration, biostatistics, sociology, psychology,
anthropology, or a biological, physical, or environmental science. Another pathway is through 2 years of professional
experience above the entry level in chronic disease, communicable disease, human nutrition, injury control,
environmental epidemiology, or infection control, which includes disease or injury investigation and risk assessment,
such as a position as a research analyst, program specialist, environmental specialist, nutritionist, community health
nurse, or health educator.
Typical Minimum Qualifications for Senior-Level Epidemiologists
Knowledge, Skills, and Abilities
In addition to the knowledge and abilities required for the entry-level epidemiologist just listed, this position requires
knowledge of disease control methods, recent developments in the field of epidemiology, and basic management skills.
It also requires the skill and ability to supervise and lead lower-level staff and develop grant proposals.
Experience and Education
Any combination of training and experience that provides the required knowledge and abilities will qualify an
individual for this position. A typical pathway to obtain the required knowledge and experience is through a doctoral
degree in epidemiology or biostatistics and 2 years of experience in epidemiology research and analysis. Another path
is through a doctoral degree in a health science field, with a master’s degree in epidemiology or an MPH with
specialization in epidemiology and 2 years of experience in epidemiology research and analysis. A third pathway is
through a master’s degree in epidemiology, or an MPH with specialization in epidemiology and 6 years of experience in
epidemiology research and analysis. Yet another pathway is through a medical degree with a master’s degree in
epidemiology or an MPH with specialization in epidemiology and 2 years of experience in epidemiology research and
analysis. It is possible that completion of related training or experience such as with the Centers for Disease Control
and Prevention (CDC) or the National Institutes of Health could substitute for the MPH degree. When a medical doctor
is selected, a license to practice medicine in the state is necessary.
Biostatistician
Knowledge, Skills, and Abilities
A typical biostatistician generally has knowledge of:
• Biostatistics and statistics with basic knowledge of medicine and epidemiology, including research designs,
probability, distributions, rates, proportions, odds, categorical variable analyses, regression, logistic regression,
survival analysis, sample size calculations, and power analysis essentials
• Modern, high-level database management and statistical languages such as SAS and SPSS (and possibly S-Plus,
StatXact and SigmaPlot), in addition to Microsoft Office software including Excel and Access
• Both parametric and nonparametric statistics
• Sample survey design and analysis including the survey software SUDAAN, FoxPro, Dbase, Oracle, SQL, Visual
Basic languages, and database formats
A typical biostatistician generally has the skills and ability to:
• Effectively interact with multidisciplinary teams and outside investigators
• Develop novel approaches for new situations and exhibit the leadership skills needed for successful
implementation
• Prioritize conflicting tasks in a fast-paced environment with minimal supervision
• Communicate easily and successfully, both orally and in writing, remain calm under pressure, work as part of a
team, and meet deadlines while paying meticulous attention to detail
• Relate well with others and be flexible in unpredictable, ever changing work environments
Experience and Education
Any combination of training and experience that provides the required knowledge and abilities will qualify an
individual for this position. A typical way to obtain the required knowledge and experience is through a master’s
degree in biostatistics, epidemiology, or a related field and 4 years of experience in research analysis and database
management, either as part of an educational process or as paid employment. Experience should be in a science, social
science, or community-based research setting and involve extensive use of statistical methodologies.
WORKPLACE CONSIDERATIONS
Physical requirements for positions in this occupational category are similar to those for many other public health
occupations. Most epidemiologist, biostatistician, and communicable disease investigator positions call for workers to
be able to sit for extended periods and to frequently stand and walk short distances. Normal manual dexterity and eye-
hand coordination and hearing and vision corrected to within the normal range are also important considerations.
Normally, public health professionals must be able to communicate verbally and be able to use office equipment
including computers, telephones, calculators, copiers, and fax machines. Although much of the work is performed in
an office environment, frequent or continuous contact with staff and the public is also necessary. In some situations, a
valid driver’s license may be required.
Physical abilities necessary for most public health occupations include the ability to exert light physical effort in
sedentary to light work, which may involve some lifting, carrying, pushing, and pulling of objects and materials of light
weight (5–10 pounds). Tasks may involve extended periods of time at a keyboard or workstation. When epidemiologists
and communicable disease investigators work outside the office, they must have the ability to work under conditions in
which exposure to communicable disease risks and environmental factors poses a risk of moderate injury or illness.
OUTSIDE-THE-BOOK THINKING 11-3
What features make epidemiology and biostatistics a career worth pursuing?
POSITIONS, SALARIES, AND CAREER PROSPECTS
In 2013, there were 5,300 epidemiologists and 25,000 statisticians employed in the United States, with 2,800
epidemiologists and 6,400 statisticians working for federal, state, and local governmental agencies. Table 11-3
identifies the number of total workers and the number employed by government for the two standard occupational
categories considered in this chapter. Projections for the year 2022 are also provided. The numbers of both
epidemiologists and statisticians have been increasing in recent years, a trend that is expected to continue well into
the future. For these two occupational categories, job growth has been somewhat less for government employment
than outside government.
TABLE 11-3 Number of Workers in 2013 and Projected for 2022 for All Industries and Government and
Number of Positions to Be Filled 2012–2022 for All Industries
Data from Bureau of Labor Statistics, U.S. Department of Labor. Selected Occupational Projections Data. Available at www.bls.gov/data/.
Accessed June 15, 2014.
The total number of positions for epidemiologists is expected to grow to 5,700 by the year 2022 with about 2,800
employed by government agencies. Statistician positions are projected to increase to 35,000 during that period with
only a modest increase (to 7,800) for the number employed by government agencies. Based on the growth in the
number of positions and the need to fill other positions because of job changes and retirement, more than 1,600
epidemiologist positions and 16,100 statistician positions will be filled between 2012 and 2022. Job growth in the
government sector, notably, will lag behind the growth rate for epidemiologist and statistician positions in the overall
economy.
Salaries differ considerably between the epidemiologists and statisticians. The median salary for epidemiologists
employed by government agencies in 2013 was $61,000, with the middle 50% earning between $50,000 and $75,000
(Table 11-4). Average salaries for epidemiologists working in governmental agencies were notably lower than those
for epidemiologists working in the private and voluntary sectors. Entry-level salaries were in the $40,000–$48,000
range. Many midsize and small local health departments do not employ an epidemiologist. Larger local health
departments and state health agencies often have several. Larger governmental public health agencies can offer
salaries that are somewhat competitive with those in the private and voluntary sectors. Epidemiologists with
professional credentials, especially physicians, dentists, veterinarians, and nurses, may be able to attract salaries in
the six-figure range.
A 2004 CSTE survey found the highest ratios of epidemiologists to population on the East and West Coasts (1 per
100,000). The South and the Midwest lag behind, with 0.7 and 0.8 epidemiologists per 100,000 population,
respectively.
The median salary for statisticians employed by government agencies in 2013 was $82,000, with the middle 50%
earning between $56,000 and $105,000. Entry-level salaries were in the $39,000–$52,000 range. Salary information
for biostatisticians is not very straightforward, because biostatisticians are lumped with other types of statisticians in
employment and wage surveys. Mean salaries for statisticians working for federal agencies are notably higher than
those for statisticians working in state and local agencies.
Based on information from current job postings, salaries for communicable disease investigators fall in the $35,000–
$55,000 range.
According to surveys of state and territorial health agencies, epidemiologic capacity needs to be increased by 50%.5
Recent increases in epidemiologists have largely benefited bioterrorism preparedness and response efforts, often at
the expense of communicable disease, chronic disease, injury, and environmental epidemiologic capacity. As a result,
there is consensus that additional epidemiologists are needed, especially infectious disease, chronic disease, and
terrorism-related epidemiologists. The Bureau of Labor Statistics also identifies epidemiologists as an occupation that
will grow more rapidly than the average for all occupations over the next 10 years.
TABLE 11-4 Number and Salary Profile for Federal and State/Local Workers for Selected Occupations, 2013
Notes: Federal: excludes postal service; State/Local: excludes hospitals and education
Data from Bureau of Labor Statistics, U.S. Department of Labor. Employment and Wages from Occupational Employment Statistics (OES) Survey.
Available at www.bls.gov/data/. Accessed June 15, 2014.
OUTSIDE-THE-BOOK THINKING 11-4
In which organizations and geographic regions will the need for epidemiologists and biostatisticians expand most rapidly
in the next two decades?
ADDITIONAL INFORMATION
There are many good sources of information on epidemiologists, disease investigators, and biostatisticians. Several
sources are available for information on educational programs for these occupations as well as for continuing
education and leadership development for practitioners.
The CSTE Web site (www.cste.org) and the CDC Epidemiologic Intelligence Service (EIS) Web site
(www.cdc.gov/eis/) head the list of useful information sources. CSTE has more than 1,000 members working in state
and local public health agencies. The EIS is an elite unit of CDC that provides technical assistance and human
resources to state and local governments during unusual or large outbreaks.
Schools of public health are among the institutions offering graduate degrees in health administration. The
Association of Schools and Programs of Public Health (www.aspph.org) has identified a battery of core epidemiology
and biostatistics competencies appropriate for all students receiving the MPH degree. These competencies provide a
useful baseline for professional practice and summarize what an MPH graduate should be able to do (see Table 11-5).
The epidemiology section and statistics section of the American Public Health Association’s (APHA) Web site
(www.apha.org) are also good sources of information for epidemiologists and biostatisticians. The epidemiology section
has a long history and currently has 3,000 members, making it one of APHA’s largest and most active sections.
TABLE 11-5 Epidemiology and Biostatistics Competency Expectations for Graduates of MPH Degree Programs
1. Identify key sources of data for epidemiologic purposes.
2. Identify the principles and limitations of public health screening programs.
3. Describe a public health problem in terms of magnitude, population affected, time, and place.
4. Explain the importance of epidemiology for informing scientific, ethical, economic, and political discussion of health
issues.
5. Comprehend basic ethical and legal principles pertaining to the collection, maintenance, use, and dissemination of
epidemiologic data.
6. Apply the basic terminology and definitions of epidemiology.
7. Calculate basic epidemiology measures.
8. Communicate epidemiologic information to lay and professional audiences.
9. Draw appropriate inferences from epidemiologic data.
10. Evaluate the strengths and limitations of epidemiologic reports.
11. Describe the role biostatistics serves in the discipline of public health.
12. Describe basic concepts of probability, random variation, and commonly used statistical probability distributions.
13. Describe preferred methodological alternatives to commonly used statistical methods when assumptions are not met.
14. Distinguish among the different measurement scales and the implications for selection of statistical methods to be
used based on these distinctions.
15. Apply descriptive techniques commonly used to summarize public health data.
16. Apply common statistical methods for inference.
17. Apply descriptive and inferential methodologies according to the type of study design for answering a particular
research question.
18. Apply basic informatics techniques with vital statistics and public health records in the description of public health
characteristics and in public health research and evaluation.
19. Interpret results of statistical analyses found in public health studies.
20. Develop written and oral presentations based on statistical analyses for both public health professionals and educated
lay audiences.
Reproduced from the Association of Schools of Public Health (ASPH). MPH Core Competency Development Process, Version 2.3. Washington,
DC: ASPH: 2006. Available at http://www.asph.org. Accessed June 15, 2014.
Additional sources of relevant information include the American College of Preventive Medicine (www.acpm.org),
the American College of Epidemiology (www.acepidemiology.org), the American Epidemiology Society
(www.americanepidemiologicalsociety.org), the Association for Professionals in Infection Control and Epidemiology
(www.apic.org), the International Epidemiological Association (www.ieaweb.org), and the Society for Epidemiologic
Research (www.epiresearch.org).
CONCLUSION
Epidemiology is one of the virtual operating systems for public health practice, and epidemiologists are in great
demand. Although recent events have emphasized bioterrorism threats and events, epidemiologists, biostatisticians,
and disease investigators work across the entire spectrum of diseases, conditions, and health risks. Due to a variety of
highly visible developments and events, such as the anthrax letters in 2001, epidemiologists and other disease
investigators have been spotlighted and interest in these careers has grown. Because disease investigators acquire
practical skills in the field, they often seek to complement their experience with additional education and training,
establishing a practical career ladder. Current and future public threats will serve to ensure that epidemiologists,
biostatisticians, and disease investigators remain vital components of the public health workforce.
REFERENCES
1. Bureau of Labor Statistics, U.S. Department of Labor. Databases and tables. Available at www.bls.gov/data/. Accessed June 15, 2014.
2. Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Information and Analysis
and Center for Health Policy, Columbia School of Nursing. Public Health Workforce Enumeration 2000. Washington, DC: HRSA; 2000.
3. National Association of County and City Health Officials. 2013 National Profile of Local Health Departments. Washington, DC: NACCHO; 2014.
4. Association of State and Territorial Health Officials. State Health Profile, Volume Three, 2012. Washington, DC: ASTHO; 2014.
5. Council of State and Territorial Epidemiologists. 2004 National Assessment of Epidemiologic Capacity: Findings and Recommendations.
Washington, DC: CSTE; 2004. Available at www.cste.org. Accessed March 20, 2014.
CHAPTER 12
Public Health Education and Information
LEARNING OBJECTIVES
Given the need for public health educators, public information specialists, and community health workers in
the public health system, describe key features of occupations and careers in public health education and
information and how these contribute to carrying out public health’s core functions and essential services. Key
aspects of this competency expectation include being able to
• Describe several different occupational titles in this category
• Identify specific essential public health services that are critical for positions in this category
• Describe important and essential duties for several job titles in this category
• Identify minimum qualifications and describe general workplace considerations, salary expectations, and career
prospects for positions in this category
Public health education has been one of the fastest growing public health professions. Public health educators play
important roles in a variety of public health programs and in community relations in general. Chronic disease
prevention programs, injury prevention and control activities, and community health planning and community health
improvement initiatives all rely heavily on the expertise of health educators. At the state and local level, about one half
of the public health educators are professionally certified. Table 12-1 provides a snapshot of an average day in the life
of a public health educator.
Health education is closely linked with two other occupations increasingly found in public health agencies—public
information specialists and community health workers. Recent concerns over bioterrorism threats and events have
raised awareness as to the importance of risk communication and public information skills within the public health
workforce. This has prompted public health agencies to employ individuals with public relations and public
information skills. At the same time, public health agencies have been utilizing community health workers for outreach
and community engagement activities. Together these three occupations comprise one of the few growth areas within
the public health workforce.
OCCUPATIONAL CLASSIFICATION
Three standard occupational categories for public health workers are addressed in this chapter—health educators,
public relations specialists, and community health workers.
A health educator is a white collar, professional category encompassing positions that promote, maintain, and
improve individual and community health by assisting individuals and communities to adopt healthy behaviors. Health
educators collect and analyze data to identify community needs prior to planning, implementing, monitoring, and
evaluating programs designed to encourage healthy lifestyles, policies, and environments. Health educators serve as
resources to individuals, other professionals, and the community, and may administer fiscal resources for health
education programs. Data from the Bureau of Labor Statistics (BLS) indicate that in 2013 there were 57,000 health
educators working in the United States.1 Federal, state, and local governmental agencies are among the largest
employers of health educators; these agencies employ 13,000 health educators. Public Health Workforce Enumeration
2000 data identified 3,500 public health educator positions in governmental public health agencies in the year 2000.2
Aggregated data from surveys conducted in 2012 and 2013 identified more than 7,500 health educators working in
state and local public health agencies.3,4 Data from these various sources are used throughout this chapter.
TABLE 12-1 A Typical Day for a Public Health Educator
7:30 a.m. Breakfast meeting with steering committee of community health coalition for community health improvement
plan
8:30 a.m. Office time for phone messages and e-mail
9:00 a.m. Staff meeting to review priorities for week
10:15 a.m. Meeting with agency director, epidemiology, and planning staff on community health assessment
10:45 a.m. Set up conference room for satellite downlink program
11:00 a.m. Satellite downlink program on establishing a medical reserve corps unit, followed by staff discussion
12:15 p.m. Lunch at desk revising presentation slides for staff orientation
1:00 p.m. Staff orientation presentation on “What Is Public Health, and Where Do I Fit In?”
2:00 p.m. Review draft for agency press release if West Nile Virus outbreak occurs
3:00 p.m. Conference call meeting with technical program committee for state public health association annual meeting
4:00 p.m. Review information to be distributed at tonight’s community meeting on West Nile Virus threat
4:30 p.m. Review and analyze participant evaluations from today’s orientation program for new employees; revise
presentation materials for next month’s orientation
5:15 p.m. Prepare remarks for tonight’s community meeting
7:00 p.m. Represent agency at community meeting regarding West Nile Virus concerns
Public information specialist is a position title comparable to the standard occupational classification public
relations specialist, which includes positions that engage in promoting or creating goodwill for individuals, groups, or
organizations by writing or selecting material and releasing it through various communications media. Public relations
and media specialists present public health issues to the media and the public, often serving as spokespersons for
public health agencies. These positions may prepare and arrange displays and make speeches and other presentations.
There were nearly 21,000 public relations and public information positions in federal, state, and local governmental
agencies in 2013. The Public Health Workforce Enumeration 2000 study identified 900 public information positions in
governmental public health agencies.2 More recent surveys of state and local public health agencies identified nearly
900 public information specialists.3,4
OUTSIDE-THE-BOOK THINKING 11-4
What will be the most important new or expanded roles for health educators, public information specialists, and
community health workers in the 21st century?
Community health workers may perform a variety of duties including assisting individuals and communities to
adopt healthy behaviors, conducting outreach for medical personnel or health organizations to implement programs in
the community that promote, maintain, and improve individual and community health, providing information on
available resources, providing social support and informal counseling, advocating for individuals and community
health needs, and providing services such as first aid and blood pressure screening. Community health workers may
collect data to help identify community health needs. There were 46,000 community health workers in 2013, with
8,000 working for public sector agencies. The Public Health Enumeration 2000 study did not specifically identify
community health workers, but NACCHO’s 2013 survey of LHDs reported an estimated 6,700 working in LHDs
nationally.3
TABLE 12-2 Public Health Practice Profile for Public Health Education and Information Professionals
Public Health Education and Information Professionals Make a Difference by:
Public Health Purposes
Preventing epidemics and the spread of disease
Protecting against environmental hazards
Preventing injuries
Promoting and encouraging healthy behaviors
Responding to disasters and assisting communities in recovery
Ensuring the quality and accessibility of health services
Essential Public Health Services
Monitoring health status to identify community health problems
Diagnosing and investigating health problems and health hazards in the community
Informing, educating, and empowering people about health issues
Mobilizing community partnerships to identify and solve health problems
Developing policies and plans that support individual and community health efforts
Enforcing laws and regulations that protect health and ensure safety
Linking people with needed personal health services and ensuring the provision of healthcare when otherwise
unavailable
Ensuring a competent public health and personal healthcare workforce
Evaluating effectiveness, accessibility, and quality of personal and population-based health services
Researching new insights and innovative solutions to health problems
PUBLIC HEALTH PRACTICE PROFILE
Health education and information occupations are primarily involved with addressing public health responsibilities for
promoting healthy behaviors and preventing disease and injury. These occupational categories may also be involved in
emergency preparedness and response and sometimes in assessing the impact and quality of health services within a
community.
OUTSIDE-THE-BOOK THINKING 12-2
What are the most important contributions to improving the health of the public that health educators, public information
specialists, and community health workers make today?
Among the 10 essential public health services, public health education and information workers are especially
important for four—informing and educating the public, mobilizing community partnerships, developing policies and
plans that support community health improvement, and ensuring a competent workforce. Community health workers
also play an especially important role in linking individuals and communities to needed services. Table 12-2
summarizes public health purposes and essential public health services at the core of positions for public health
education and information occupations.
IMPORTANT AND ESSENTIAL DUTIES
There are several job titles and positions in the public health workforce that specialize in public health education and
information services. The focus in this chapter will be on three professional positions: (1) entry-level public health
educator, (2) senior-level public health educator, and (3) public information specialist/coordinator. Each of these
positions and a representative panel of their important and essential duties are described in the following section.
Community health workers, a technical occupation, will be addressed in relevant sections later in this chapter.
Public Health Educator (Entry Level)
This position encompasses entry-level professional work in the development and coordination of public health
education and health promotion activities. Public health educators assist in the formulation of the health education
plan and in the development and implementation of health promotion programs. Work includes providing technical
assistance and training to local health professionals, schools, community organizations, government agencies,
businesses, and individuals. Supervision is received from a higher level health educator or other designated
administrative superior; however, the employee is expected to work with considerable independence within
established policies and procedural guidelines.
Essential and important duties for an entry-level public health educator include
• Assists in the development and implementation of health education, behavioral risk reduction, and health
promotion programs for schools, work sites, communities, and individuals; provides healthy intervention
strategies that meet specified and measurable objectives
• Collects, analyzes, and disseminates information regarding major health problems, behavioral risk factors, and
health attitudes and knowledge using epidemiologic procedures; assists in the formulation of disease prevention
and health promotion strategies
• Develops various educational materials, such as brochures, exhibits, videotapes, and slides; employs mass
media, group process, and counseling techniques in health education, health promotion, and behavioral risk
reduction program activities
• Assists in development of training programs and works with others to plan and implement health promotion
programs, policies, and legislation
• Maintains knowledge and skills in health education and health promotion research through review of
professional literature, participation in conferences, and continuing education
• Provides assistance in the submission of applications for health education, behavioral risk reduction, and health
promotion program funds; monitors existing programs for compliance with federal and state regulations
Public Health Educator (Senior Level)
Under direction, this position plans, develops, supervises, evaluates, and monitors specific health education programs
for the agency. Senior-level public health educators are distinguished from lower-level public health educators by their
responsibility for the preparation, administration, and evaluation of specific public health education programs, grant
contracts, and budgets. In addition, a senior public health educator supervises staff assigned to specific programs.
This position is distinguished from the health education program manager in that the latter manages the overall
agency public health education program, but this position is responsible for the preparation, administration, and
evaluation of the public health education efforts of specific programs.
Essential and important duties of senior-level public health educators include
• Plans, implements, and evaluates specific public health education programs
• Assesses and identifies community needs for educational services in specific program areas
• Plans, organizes, designs, develops, and evaluates public health education activities; carries out or directs others
to carry out public health education activities, including educational presentations and workshops
• Assists in the development and adaptation of data collection instruments and designs for assessment and
evaluation activities
• Develops educational literature and flyers and provides information to the community
• Selects, trains, directs, evaluates, and handles disciplinary problems of subordinate staff
• Seeks funding sources for specific public health education programs
• Prepares grant proposals
• Develops memoranda of understanding and budgets
• Negotiates and monitors contracts with funding agencies and other subcontractors
• Develops and maintains contact with state and local public health agencies, community organizations, and the
media
• Serves as the community leader of public health education efforts for specific programs
• Inputs, accesses, and analyzes data in a computer database
Public Information Specialist/Coordinator
This position is a midlevel informational and public relations professional for a public health organization. Public
information specialists prepare and disseminate informational materials to support and promote the programs and
services of their agency. Work includes composing and editing copy for press releases, articles, bulletins, newsletters,
pamphlets, and other publications. Work may involve interpreting and communicating agency programs to employees,
special interest groups, and the general public. Supervision is received from an administrative superior who reviews
work in progress and upon completion.
Public health information coordinators perform more advanced duties in the coordination of informational and
public relations activities in an agency or specialized program and serve as assistants to a public information
administrator, or perform a comparable level of work. Work involves collecting, preparing, and disseminating
informational material to support and promote agency programs and services, including composing and editing text
and producing graphic and photographic illustrations for publication or distribution to the news media and other
groups. Work includes interpreting and communicating agency programs to employees, special interest groups, and
the general public. Supervision may be exercised over professional, technical, or clerical staff. General supervision is
received from a public information administrator or other administrative superior; consequently, the employee is
expected to work with considerable independence and technical skill in the area of communication and public
relations.
Essential and important duties of public information specialists/coordinators include
• Gathers, compiles, and verifies information; composes and edits copy for newsletters, brochures, web pages, and
other publications
• Prepares news releases to inform and educate the public concerning agency programs and services
• Composes or edits articles for internal agency news bulletins; edits articles or correspondence for staff members
• Develops spot announcements and scripts for radio and television
• Answers requests for literature and information; maintains files of photographs, clippings, and agency
publications
• Meets with agency officials and attends staff meetings for the purpose of discussing activities and securing
newsworthy information
• Researches available material to assist in the preparation of speeches for agency officials
• Operates still and video cameras
• Creates illustrations and does layout work
• Assists with agency-sponsored and interagency public relations activities and special events
• Coordinates informational and public relations activities in a specialized program, serves as an assistant to a
public information administrator, or performs work of comparable level and scope
• Provides assistance to higher level management on matters pertaining to public relations and informational
policy
• Develops and maintains working relationships with media representatives and public, private, labor, business,
and civic organizations to ensure the effective dissemination of informational material
• Estimates costs, develops specifications, and makes recommendations on securing and accepting bids for
printing; maintains contact with printing contractors to ensure quality control; reviews and corrects printers’
galley proofs
• Arranges public appearances and media engagements for agency officials; prepares or edits the material to be
presented
• Makes presentations and serves as a spokesperson for assigned agency programs to special interest groups,
employee groups, and the general public
• Informs management of public reaction to programs, suggests strategies for future communications, and makes
recommendations for modified or new programs
• Coordinates special events and develops materials, displays, and programs to promote agency services, missions,
and goals and to enhance consistency and accuracy in those efforts
• Provides training to improve the techniques of supervisory and professional staff in furthering public
understanding of the services offered by the agency
• Supervises, trains, and evaluates subordinate staff
MINIMUM QUALIFICATIONS
Public health educators and public information staff work in professional positions often supported by administrative
support and clerical positions. There are generally several steps in the health educator and public information series
that allow for advancement and career development. Comparable positions exist in local public health agencies of all
sizes, making career advancement from a small to larger employer not uncommon for these workers.
Public health training programs in schools of public health and other academic institutions produce health
educators and other communications specialists. The vast majority of current workers in these titles, however, do not
have a public health degree. This allows for variability in the types of experience and training that agencies require
when filling these positions. As with virtually all public health positions, both experience and education are important
considerations for hiring and promotion. Experience and education both contribute to necessary knowledge, skills, and
abilities required for workers in this field. Typical minimum qualifications for entry-level and senior-level health
educators and public information specialists/coordinators are detailed in this section.
Typical Minimum Qualifications for Entry-Level Public Health Educator
Knowledge, Skills, and Abilities
A typical entry-level public health educator generally has knowledge of:
• Current principles, practices, and processes employed in the health education and health promotion component
of a public health program
• Principles, techniques, and application of behavioral epidemiology as related to health education and health
promotion
• The psychological, social, economic, and cultural determinants of behavior and methods to promote healthy
lifestyles
• Educational methods and techniques of developing and presenting health education to individuals and groups
• Community organization principles and resources, and community health needs
• Current trends and developments in public health, medical sciences, and health care
• Research methods as applied to health education and health promotion
A typical entry-level public health educator has the skills and ability to:
• Assist in the planning, development, implementation, and evaluation of effective health education and health
promotion programs for various populations
• Perform statistical computations
• Explain complex medical information to civic and community groups and to public officials, and present ideas
effectively
• Establish and maintain effective working relationships with other employees, community groups, and the public
Experience and Education
Any combination of training and experience that provides the required knowledge and abilities will qualify an
individual for this position. A typical way to obtain such knowledge and abilities is through graduation from an
accredited 4-year college or university with a bachelor degree with major specialization in health education or health
promotion, or a master’s degree in health education, health promotion, or public health with specialization in health
education.
Typical Minimum Qualifications for Senior-Level Public Health Educator
Knowledge, Skills, and Abilities
A typical senior-level public health educator generally has knowledge of:
• The principles of public health education, including program planning and evaluation
• Public health education methods and materials, including teaching methods and curriculum design
• Assessment techniques to identify community health problems in specific program areas
• Existing methods of intervention and control and the health education needs of various target groups
• Principles and practices of community organization for enhancing public health
• The philosophy, concepts, and principles of public health
• The functions and services of local community health agencies and community organizations
• Publicity and media practices and procedures
• Grant proposal writing and budgeting techniques
• Principles and practices of staff supervision and training
A typical senior-level public health educator has the skills and ability to:
• Plan, organize, implement, and evaluate public health education services
• Design, effectively use, and evaluate public health education methods and materials
• Provide public health education consultation, and develop cooperative relationships with a wide range of
individuals and representatives of organizations and the news media
• Prepare and present a variety of clear and concise written and oral reports
• Develop and nurture funding sources
• Analyze and prepare grant proposals, contracts, and related budgets
• Negotiate and monitor contracts
• Originate, prepare, and distribute informational and publicity materials
• Plan, assign, direct, and evaluate the work of staff
• Interpret legislation regulations, administrative policies, and procedures
• Input, access, and analyze data in a computer database
Experience and Education
Any combination of training and experience that provides the required knowledge and abilities will qualify an
individual for this position. A typical way to obtain such knowledge and abilities is through 2 years of experience in
public health education, promotion, or a related field that provides the knowledge and abilities previously identified.
Some agencies may require a master’s degree in health education from an accredited college and a valid driver’s
license.
Typical Minimum Qualifications for Public Information Specialist/Coordinator
Knowledge, Skills, and Abilities
A typical public information specialist/coordinator generally has knowledge of:
• Journalism, photography, film/video production, graphic arts, publication, and printing
• News media operation and its proper utilization for dissemination of information
• Principles and methods of establishing and maintaining good public relations
• Community resources and organizations
• Commercial art methods and the general principles of layout and design
• Marketing and advertising practices and techniques
• Journalistic principles and practices, including techniques of planning, composing, and editing informational
materials
• Use of methods and techniques of disseminating information to the public
• Public relations techniques and procedures
• Agency organizational structure, including programs, administrative rules and regulations, and staff
• Operation of still and video cameras and developing, processing, and editing the film or video
A typical public information specialist/coordinator generally has the skills and ability to:
• Compose and produce a variety of informational materials
• Use a variety of desktop publishing software packages and Web formatting languages
• Establish and maintain working relationships with media representatives, agency officials, other employees, and
the general public
• Communicate with special interest groups, employee groups, and the general public
• Produce graphic art, photographs, and other materials
• Interpret and explain agency policies, laws, and operations
• Stimulate public interest and gain support for agency programs
• Compose and produce a variety of informational materials for release to the media or other publications
• Conduct research to find pertinent and newsworthy information
• Advise and train agency staff in public relations methods and techniques
Experience and Education
Any combination of experience and training that results in the acquisition of the knowledge and skills described above
will qualify an individual for this position. A typical way to acquire these qualifications is through graduation from an
accredited 4-year college or university with specialization in journalism, communications, English, public relations,
advertising, marketing, or closely related areas. Professional experience in the areas of journalism, advertising,
marketing, film/video production, or public relations and information may be substituted on a year-for-year basis for
the required education. For a public information coordinator, requirements may include 1 year as public information
specialist or 2 years of professional experience in public relations, advertising, or journalism; and graduation from an
accredited 4-year college or university with specialization in journalism, communications, English, public relations,
advertising, marketing, or closely related areas. Professional experience in the areas of journalism, advertising,
marketing, film/video production, or public relations and information may be substituted on a year-for-year basis for
the stated education. Graduate work in the educational areas previously listed may be substituted on a year-for-year
basis for 1 or more years of the stated experience.
WORKPLACE CONSIDERATIONS
In 2013, state and local governmental agencies employed approximately 13,000 health educators and 8,000
community health workers, and there is every indication that even greater numbers will be employed by these
agencies over the next decade.
Physical requirements for positions in this occupational category are similar to those for other professional public
health positions. Most health educator, public information, and community health worker positions call for workers to
be able to sit for extended periods and to frequently stand and walk short distances. Normal manual dexterity and eye-
hand coordination and hearing and vision corrected to within the normal range are also important considerations.
Normally, public health educators and public information staff will be able to communicate verbally and be able to use
office equipment including computers, telephones, calculators, copiers, and fax machines. Although much of the work
is performed in an office environment, frequent or continuous contact with staff and the public is also necessary. In
many situations, people filling these positions may be required to possess a valid driver’s license.
OUTSIDE-THE-BOOK THINKING 12-3
What features make health education and public information careers worth pursuing?
POSITIONS, SALARIES, AND CAREER PROSPECTS
In 2013, there were 57,000 health educators, 203,000 public relations/public information specialists, and 46,000
community health workers employed in the United States, with 13,600 health educators, 20,700 public information
specialists, and 8,000 community health workers working for federal, state, and local governmental agencies. Table
12-3 identifies the number of total workers and the number employed by government for the three standard
occupational categories considered in this chapter. Projections for the year 2022 are also provided. The numbers of
health educators, public information specialists, and community health workers have been increasing in recent years,
a trend that is expected to continue well into the future. For these occupational categories, job growth has been
somewhat less for government employment than for outside government. This trend in all likelihood will continue.
The total number of positions for health educators is expected to grow to 70,000 by the year 2022 with 14,000
employed by government agencies. Community health workers are forecast to grow to 51,000 with 8,500 employed by
government agencies. Public information specialist positions are projected to increase to 257,000 during that period
with only a modest increase (to 21,500) for the number employed by government agencies. Based on the growth in the
number of positions and the need to fill other positions because of job changes and retirement, nearly 276,000 health
educator positions, 21,000 community health worker positions, and 59,000 public relations/public information
specialist positions will be filled between 2012 and 2022. Only about one fourth of these positions will be filled in the
government sector. Job growth in the government sector will lag well behind the growth rate for health educator,
community health worker, and public relations specialist positions in the overall economy.
TABLE 12-3 Number of Workers in 2013 and Projected for 2022 for All Industries and Government and
Number of Positions to Be Filled 2012–2022 for All Industries
Data from Bureau of Labor Statistics, U.S. Department of Labor. Selected Occupational Projections Data. Available at www.bls.gov/data/.
Accessed June 15, 2014.
TABLE 12-4 Number and Salary Profile for Federal and State/Local Workers for Selected Occupations, 2013
Notes: Federal: excludes postal service; State/Local: excludes hospitals and education
Data from Bureau of Labor Statistics, U.S. Department of Labor. Employment and Wages from Occupational Employment Statistics (OES) Survey.
Available at www.bls.gov/data/. Accessed June 15, 2014.
The median salary for health educators employed by government agencies in 2013 was $52,000, with the middle
50% earning between $40,000 and $78,000 (Table 12-4). Average salaries for health educators working in
governmental agencies were higher than those for health educators working in the private and voluntary sectors.
Entry-level salaries were also higher for government employment ($31,000–$37,000) than for all industries ($26,000–
$33,000). Many small local health departments do not employ health educators. Larger local health departments and
state health agencies often have several.
The median salary in 2013 for community health workers employed by government was $37,000 with the middle
50% earning between $29,000 and $48,000.
The median salary in 2013 for public information specialists employed by government agencies was $60,000, with
the middle 50% earning between $44,000 and $78,000. Entry-level salaries were in the $33,000–$40,000 range. Salary
information for public relations/public information specialists for all industries is difficult to interpret because the
duties outside government vary considerably.
As is the case with several other public health occupations, health educators and public information specialists can
advance from entry-level to midlevel to senior-level positions in their specialty. But in view of their strong
communication and information skills, these workers may be used by agencies for both program-specific work (i.e., as
program staff for an assigned program) and at the agency level to deal with community and other public interactions.
For example, health educators play a major role in organizing and coordinating community health planning efforts that
lead to community health needs assessments, community health report cards, and ultimately to community health
improvement initiatives. Because community health improvement efforts have become a central role of local and state
public health agencies, and as they continue to grow over the next decade, the need for health educators will continue
to grow in comparison with other public health occupations. This greater emphasis on community planning and
partnerships, as well as the need for more effective risk communication capabilities for bioterrorism and other threats,
also increases the need and demand for public information specialists and coordinators.
Community health workers are considered technical or paraprofessional staff and there is no formal career ladder
to positions such as health educators. A career ladder, however, is possible in some situations. It is likely that several
elements of the Affordable Care Act, including the need for patient navigators, community liaisons, and program
outreach workers, will foster the growth and professionalization of this occupational category.
Public health education, an increasingly recognized and important occupational category within the public health
workforce, has developed a credential for highly skilled health educators. Certified health education specialists
(CHES) illustrate the movement toward credentialing as a means of increasing the professional stature of an
occupation. Many public health workers currently providing health education services, however, do not qualify to sit
for the CHES exam because they have not completed a degree program in health education at the bachelor or master’s
level. For either group, however, ongoing continuing education initiatives will be important to strengthen the corps of
workers providing health education services to the public.
OUTSIDE-THE-BOOK THINKING 12-4
In which organizations and geographic regions will the need for health educators, public information specialists, and
community health workers expand most rapidly in the next two decades?
ADDITIONAL INFORMATION
There are many good sources of information on health education and public information as careers. Several sources
are available for information on educational programs for health education as well as for continuing education and
leadership development for practicing health educators seeking a professional credential.
Schools of public health are among the institutions offering graduate degrees in health administration. The
Association of Schools and Programs of Public Health (www.aspph.org) has identified a battery of behavioral science
competencies appropriate for all students receiving the master’s of public health (MPH) degree. These competencies
provide a useful baseline for professional practice and summarize what an MPH graduate should be able to do (Table
12-5).
Additional sources of information on health education include the web sites of several other organizations, including
the Directors of Health Promotion and Education (www.dhpe.org), the American College Health Association
(www.acha.org), the American School Health Association (www.ashaweb.org), the Association of State and Territorial
Directors of Health Promotion and Public Health Education (www.astdhpphe.org), and the Coalition of National Health
Education Organizations (www.cnheo.org). The coalition, for example, has as its primary mission the mobilization of
the resources of the health education profession in order to expand and improve health education, regardless of the
setting.
The American Public Health Association Web site (www.apha.org) has several sections active in health education
issues, including the public health education and health promotion section and the school health education section. Yet
another useful resource for health education and information is the Healthy People 2020 web site.
Central to making health education a profession are the efforts of the Society of Public Health Educators and the
National Commission for Health Education Credentialing (www.nchec.org) with its competency-based credentialing
program for professional health educators (CHES). CHES competencies focus on: assessing needs, assets and capacity
for health education; planning, implementing, managing, and evaluating health education interventions; and
communicating, advocating, and serving as a resource for health education.5
TABLE 12-5 Social and Behavioral Science Competency Expectations for Graduates of MPH Degree Programs
1. Identify basic theories, concepts, and models from a range of social and behavioral disciplines that are used in public
health research and practice.
2. Identify the causes of social and behavioral factors that affect the health of individuals and populations.
3. Identify individual, organizational, and community concerns, assets, resources, and deficits for social and behavioral
science interventions.
4. Identify critical stakeholders for the planning, implementation, and evaluation of public health programs, policies, and
interventions.
5. Describe steps and procedures for the planning, implementing, and evaluating of public health programs, policies,
and interventions.
6. Describe the role of social and community factors in both the onset and solution of public health problems.
7. Describe the merits of social and behavioral science interventions and policies.
8. Apply evidence-based approaches in the development and evaluation of social and behavioral science interventions.
9. Apply ethical principles to public health program planning, implementation, and evaluation.
10. Specify multiple targets and levels of intervention for social and behavioral science programs and/or policies.
Reproduced from the Association of Schools of Public Health (ASPH). MPH Core Competency Development Process, version 2.3. Washington,
DC: ASPH: 2006. Available at http://www.asph.org. Accessed June 15, 2014.
CONCLUSION
In an age of communications and information technology and community engagement, it is no wonder that public
health educators, public information professionals, and community health workers play key roles in public health
practice. Public health agencies are increasingly adding staff with these capabilities and utilizing existing staff across
programs to address community-wide concerns and issues. Public health educators have led the way in establishing a
credential that is based on relevant practice competencies and respected in practice settings. It is expected that
opportunities will continue to grow for public health educators, public information specialists, and community health
workers over the next decade.
REFERENCES
1. Bureau of Labor Statistics, U.S. Department of Labor. Databases and tables. www.bls.gov/data/. Accessed June 15, 2014.
2. Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Information and Analysis
and Center for Health Policy, Columbia School of Nursing. Public Health Workforce Enumeration 2000. Washington, DC: HRSA; 2000.
3. National Association of County and City Health Officials. 2013 National Profile of Local Health Departments. Washington, DC: NACCHO; 2014.
4. Association of State and Territorial Health Officials. State Health Profile, Volume Three, 2012. Washington, DC: ASTHO; 2014.
5. National Commission for Health Education Credentialing, Inc. (NCHEC), Society for Public Health Education (SOPHE), American Association
for Health Education (AAHE). (2010a). A competency-based framework for health education specialists, 2010. Whitehall, PA: NCHEC; 2010.
CHAPTER 13
Additional Public Health Professional and Technical
Occupations
LEARNING OBJECTIVES
Given the need for a wide variety of professional and technical workers in the public health system, describe
key features of these occupations and careers, and how they contribute to carrying out public health’s core
functions and essential services. Key aspects of this competency expectation include being able to
• Describe several different public health professional and technical occupations
• Identify specific essential public health services that are critical for each of these professional and technical
occupations
• Describe important and essential duties for each of these professional and technical occupations
• Identify minimum qualifications and describe general workplace considerations, salary expectations, and career
prospects for each of these professional and technical occupations
This chapter is organized a bit differently from the other chapters focusing on public health professional and technical
occupations. This chapter highlights selected professional and technical public health occupations within the public
health workforce, as well as several commonly used position titles that do not fit neatly into one of the standard
occupational classifications (SOCs) established by the United States Bureau of Labor Statistics (BLS) These
professional occupational categories, their related technical occupational categories, and several commonly used
position titles are addressed individually in this chapter, except for those that are closely related in practice settings.
To a large degree, the career links are not as clear for these occupations as for those addressed in earlier chapters.
Many SOCs carry out professional roles or perform technical duties in support of professionals. Within the public
health workforce, these include a variety of professional occupations, including nutritionists and dietitians, healthcare
social workers, mental health and substance abuse social workers, substance abuse and behavioral disorder
counselors, medical and clinical laboratory technologists, physicians, veterinarians, pharmacists, optometrists, oral
health professionals, and administrative judges/hearing officers—just to name a few. A variety of technical occupations
support the efforts of these professional categories. Home health aides, nursing assistants, emergency medical
technicians, and laboratory technicians represent a few of the technical occupations in the public health workforce.
This chapter provides information and data for 20 such SOCs.
Nutritionists and dietitians work in a variety of settings for governmental public health agencies, voluntary
organizations, and healthcare providers. Public health social workers often have positions in maternal and child health
programs or in mental health services offered by public agencies. Mental health substance abuse social workers and
substance abuse and behavioral disorder counselors work with psychologists and other mental health providers in
programs that offer mental health services.
Not all public health agencies have laboratories, but those that provide public health and clinical laboratory
services employ medical and clinical laboratory technologists and technicians. Those labs also employ public health
laboratory scientists with special expertise in microbiology, chemistry, and physics.
Physicians were once one of the largest and most active professional occupational categories in the public health
workforce. Today, however, they represent only a small percentage of the public health workforce. Veterinarians now
play key roles in animal control and communicable disease control programs, and pharmacists and emergency medical
technicians are increasingly involved in clinical and emergency preparedness and response roles. Oral health
professionals, including dentists and dental hygienists, coordinate oral health programs within public health agencies
as well as provide clinical dental services. Administrative law judges/hearing officers are important personnel in a
variety of administrative and regulatory processes of governmental public health agencies. Together, these varied
occupational categories, and several not yet identified, demonstrate the multidisciplinary and interdisciplinary nature
of modern public health practice.
In addition to these 20 occupations, there are several important positions within public health organizations that
don’t fall neatly into one of the existing BLS SOCs, or may actually fall into several. Public health program
specialists/coordinators, policy analysts, and public health information specialists are prime examples. This chapter
will also discuss these positions, although BLS data on numbers, salary distribution, and forecasted job openings are
not available. When possible, information and data from other sources is included.
This chapter examines this veritable army of public health professional and supporting technical occupations that
make up key subsets of the overall public health workforce. Data from several sources are used throughout this
chapter, including the Bureau of Labor Statistics (BLS), the Public Health Workforce Enumeration 2000 study, and the
most recent survey of local health departments (LHDs) and state health agencies (SHAs) conducted by the National
Association of County and City Health Officials (NACCHO) and the Association of State and Territorial Health
Officials.1-4
The professional and technical occupations addressed in this chapter are presented in alphabetical order except for
a few occupational groupings that share similar functions and duties. There is no attempt to treat each occupation
equally in terms of functions, skills, qualifications, and data. Greater attention and detail are devoted to those that
have the greatest overall impact or that play unique roles in public health practice. Table 13-1 offers a general public
health practice profile for each of these groupings or separate occupational categories, pointing out the prime public
health purposes and essential public health services addressed by each. Table 13-2 summarizes BLS data on the
number of jobs in all industries and government for each SOC in 2013 and projected for 2022, as well as the number of
job openings anticipated between 2012 and 2022 due to job growth and turnover. Table 13-3 offers additional detail
for these SOCs on the number of workers for each level of government as well as salary data for workers employed by
government.
TABLE 13-1 Public Health Practice Profile for Selected Public Health Professional and Technical Occupations
Notes: Nutr: nutritionists and dietitians; BH: behavioral health professionals; Lab: public health laboratory workers; Docs: physicians,
veterinarians, optometrists, pharmacists; Oral: oral health professionals; Law: administrative judges and hearing officers: Spec; public health
program specialists/coordinators; Pol: policy analysts.
TABLE 13-2 Number of Workers in 2013 and Projected for 2022 for All Industries and Government and
Number of Positions to Be Filled 2012–2022 for All Industries
Note: Comparable data for public health program specialists, public health policy analysts, and public health information specialists not
available.
Data from Bureau of Labor Statistics, U.S. Department of Labor. Selected Occupational Projections Data. Available at www.bls.gov/data/.
Accessed June 15, 2014.
TABLE 13-3 Number and Salary Profile for Federal and State/Local Workers for Selected Occupations, 2013
Notes: Federal: excludes postal service; State/Local: excludes hospitals and education. Comparable data for public health program specialists,
public health policy analysts, and public health information specialists not available.
Data from Bureau of Labor Statistics, U.S. Department of Labor. Employment and Wages from Occupational Employment Statistics (OES) Survey.
Available at www.bls.gov/data/. Accessed June 15, 2014.
OUTSIDE-THE-BOOK THINKING 13-1
Which of the occupations covered in this chapter is likely to play important new or expanded roles in the public health
system of the 21st century?
ADMINISTRATIVE LAW JUDGES AND HEARING OFFICERS
Administrative law judges, adjudicators, and hearing officers conduct hearings to recommend or make decisions on
claims concerning government programs or other government-related matters. Duties often include determining
liability, sanctions, or penalties, or recommending the acceptance or rejection of claims or settlements.
Administrative judges and hearing officers provide legal advice to public health agencies, provide legal
representation of public health officials in courts and administrative law proceedings, and preside over administrative
law hearings of various kinds. The Public Health Workforce Enumeration 2000 study identified 900 administrative
judges/hearing officers working in federal, state, and local public health agencies. There were 14,000 administrative
judges/hearing officers in the United States in 2013. Virtually all worked for government agencies. The median salary
in 2013 was $87,000 with the middle 50% earning between $58,000 and $116,000. Job growth is expected to be very
slow with only about 2,400 positions to be filled through increased demand and job turnover over the next decade.
Jobs in the public sector, however, are not expected to increase.
ANIMAL CONTROL WORKERS
Animal control workers handle animals for the purpose of investigations of mistreatment, or control of abandoned,
dangerous, or unattended animals. Animal control programs are sometimes operated by local health departments, but
in many communities these programs are located in other agencies of local government. BLS data document nearly
14,000 animal control workers with about 90% working for local governments. Only 1,200 of these positions were in
LHDs.3 The median salary for public sector animal control workers in 2013 was $32,000, with the middle 50% earning
between $25,000 and $41,000. Job growth is expected to be modest with about 4,500 positions to be filled through
increased demand and job turnover over the next decade. Jobs in the public sector, however, are not expected to
increase.
AUDIOLOGISTS
Audiologists assess and treat persons with hearing and related disorders. Duties may include fitting hearing aids,
providing auditory training, and performing research related to hearing problems. Of the nearly 12,000 audiologists
employed in the United States in 2013, only 140 worked for government agencies. The median salary for these public
sector audiologists in 2013 was $64,000, with the middle 50% earning between $52,000 and $75,000. This occupation
is expected to grow substantially with 7,000 positions to be filled through increased demand and job turnover over the
next decade. Positions will likely increase in government agencies.
BEHAVIORAL, SOCIAL, SUBSTANCE ABUSE, AND MENTAL HEALTH
PROFESSIONALS
Public health social workers, mental health and substance abuse social workers, and mental health, substance abuse
and behavioral disorder counselors promote and encourage healthy behaviors and often participate in responses to
disasters and public health emergencies. These professionals diagnose and investigate health problems; inform,
educate, and empower people about issues; mobilize community partnerships; and link people with needed personal
health services. Throughout the first decade of the 20th century, public health organizations increasingly employed a
variety of behavioral and mental health workers, including mental health and substance abuse social workers,
substance abuse and behavioral disorder counselors, and psychologists and other mental health providers. This trend
was interrupted by the national recession of 2008/2009, which forced many public health organizations to cut or
reduce programs that provide personal health services. This aggregate category examines 4 SOCs: healthcare social
workers, mental health and substance abuse social workers, mental health counselors, substance abuse and behavioral
disorder counselors. More than 50,000 workers in these SOCs are employed by government agencies, although fewer
than 10,000 work in local and state public health agencies.3,4
Healthcare social workers provide individuals, families, and groups with the psychosocial support needed to cope
with chronic, acute, or terminal illnesses. Services include advising family care givers, providing patient education and
counseling, and making referrals for other services. Healthcare social workers may also provide care and case
management or interventions designed to promote health, prevent disease, and address barriers to access to health
care. In 2013, there were 142,000 healthcare social workers in the United States, with 15,000 working for government
agencies, virtually all at the state and local levels. The median salary for healthcare social workers employed by
government agencies in 2013 was $50,000 with the middle 50% earning between $40,000 and $61,000. Growth
prospects for this occupation are strong, with 70,000 positions expected to be filled through increased demand and job
turnover over the next decade. Job growth will be especially strong for positions outside the public sector.
Mental health and substance abuse social workers assess and treat individuals with mental, emotional, or substance
abuse problems, including abuse of alcohol, tobacco, and/or other drugs. Activities may include individual and group
therapy, crisis intervention, case management, client advocacy, prevention, and education. There were 110,000 mental
health and substance abuse social workers in the United States in 2013, with 16,000 employed by state and local
governmental agencies. The median salary for public sector mental health and substance abuse social workers in 2013
was $46,000 with the middle 50% earning between $36,000 and $59,000. Job growth for this occupation is expected to
be moderate through 2022, with 50,000 positions to be filled due to increased demand and job turnover over the next
decade. Job growth will be slower for government employment.
Mental health counselors counsel with emphasis on prevention, work with individuals and groups to promote
optimum mental and emotional health, and help individuals deal with issues associated with addictions and substance
abuse, stress management, self-esteem, family, parenting, marital problems, and aging. There were 116,000 mental
health counselors in the United States in 2013, with 10,400 working for public sector agencies. The median salary for
public sector mental health counselors in 2013 was $49,000 with the middle 50% earning between $39,000 and
$62,000. Job growth for this occupation is expected to be strong through 2022, with 64,000 positions to be filled
through increased demand and job turnover. Jobs will increase but a lower rate for government agencies.
Substance abuse and behavioral disorder counselors counsel and advise individuals with alcohol, tobacco, drug, or
other problems, such as gambling and eating disorders. Duties may include counseling individuals, families, or groups
or engaging in prevention programs. There were 83,000 substance abuse and behavioral disorder counselors in the
United States in 2013, with 9,000 working for public sector agencies. The median salary for public sector substance
abuse and behavioral disorder counselors in 2013 was $44,500 with the middle 50% earning between $35,000 and
$55,000. Job growth for this occupation is expected to be strong through 2022, with 47,000 positions to be filled
through increased demand and job turnover. Jobs will increase but at a lower rate for government employment.
DENTAL/ORAL HEALTH PROFESSIONALS
Oral health professionals examine, diagnose, and treat diseases, injuries, and malformations of teeth and gums.
General dentists treat diseases of nerve, pulp, and other dental tissues affecting oral hygiene and retention of teeth, fit
dental appliances, and provide preventive care. Dental hygienists clean teeth and examine oral areas, head, and neck
for signs of oral disease. Many dental hygienists also educate patients on oral hygiene, take and develop x-rays, or
apply fluoride or sealants. In public health settings, oral health professionals also plan, develop, implement, and
evaluate oral health programs to promote and maintain optimum oral health of the public. The Public Health
Workforce Enumeration 2000 study identified 3,100 dental workers (both dentists and hygienists) in federal, state, and
local public health agencies. More recent surveys in 2012 and 2013 indicate a similar number of oral health
professionals working in local and state health agencies.3,4
There were 96,000 general dentists in the United States in 2013, with only about 2,000 working for public sector
agencies. The median salary for public sector general dentists in 2013 was $122,000 with the middle 50% earning
between $105,000 and $152,000. Job growth for this occupation is expected to be very strong through 2022, with
51,000 positions to be filled through increased demand and job turnover. Jobs will increase very little for government
agencies.
There were 192,000 dental hygienists in the United States in 2013, with only about 2,000 working for public sector
agencies. The median salary for public sector dental hygienists in 2013 was $54,000 with the middle 50% earning
between $48,000 and $63,000. Similar to that for general dentists, job growth for this occupation is expected to be
very strong through 2022, with 113,000 positions to be filled through increased demand and job turnover. Jobs will
increase very little for government agencies.
DIETITIANS AND NUTRITIONISTS
Dietitians and nutritionists plan and conduct food service or nutritional programs to assist in the promotion of health
and control of disease. Duties may include supervising activities of a department providing quantity food services,
counseling individuals, or conducting nutritional research. Dietitians and nutritionists primarily work toward
preventing the spread of diseases and conditions related to diet and exercise. These categories monitor health status
to identify community health problems; inform, educate, and empower people about health issues; and link people with
needed personal health services. They may also be involved in research activities.
Nutritionists and dietitians may supervise the activities of a program or unit providing nutrition or food services,
counsel individuals, or conduct nutritional research. Nutritionists, dietitians, and dietetic technicians work in
community-oriented programs such as the federally funded WIC program or state and locally funded maternal and
child health programs, as well as in clinical settings, such as prenatal and well child clinics.
BLS data indicate that there were 59,500 nutritionists and dietitians employed in the United States in 2013. Most
nutritionists and dietitians work for hospitals, long-term care facilities, and community care facilities for the elderly.
Only 8,700 nutritionists work for federal, state, and local governmental agencies, primarily public health departments.
The Public Health Workforce Enumeration 2000 study identified 6,700 public health nutritionists in governmental
public health agencies in 2000, largely based on information provided by the Association of State and Territorial Public
Health Nutrition Directors (ASTPHND). About the same number were identified in more recent surveys of state and
local public health agencies conducted in 2012 and 2013.3,4
Within state and local health agencies, most nutritionists work in WIC programs. WIC is short for Supplemental
Foods Program for Women, Infants, and Children, which is funded by the U.S. Department of Agriculture. Nutrition
positions are also found in regulatory programs for hospitals, nursing homes, day care centers, and other facilities as
well as in Child and Adult Care Food Program (food stamps) and state Medicaid and school lunch programs.
Entry-level public health nutritionists plan and conduct nutritional programs that assist in the promotion of health
and control of disease. Midlevel and senior-level nutritionists may supervise activities of a program or unit of an
agency providing quality food services, counsel individuals, or conduct nutritional research. Many nutritionists and
dietitians seek the registered dietitian (RD) credential.
Entry-level professional public health nutritionists are responsible for participating in the implementation of
nutrition programs and services. Work involves providing nutrition program services to local health units or health and
human services professionals. General supervision is received from an administrative superior, with professional
supervision received from a higher-level nutritionist.
Essential and important duties of an entry-level public health nutritionist include
• Carries out program policies and procedures in implementing nutritional components of general or specialized
public health programs
• Coordinates nutrition program services with other nutrition or public health programs within an assigned area
• Confers with public health personnel on food and nutrition related to health programs or problems
• Participates in conducting studies and surveys of the relationships of dietary factors to health and disease,
including compilation of data and interpretation of results
• Conducts formal training using educational materials and visual aids in the education of students and public
health staff, and assists in the evaluation and recommendation for improvement of such materials
• Participates and works with higher-level nutritionists or consultants in inservice training of health personnel
• Prepares reports, records, and other data related to nutritional services
• Assists in monitoring local health units for compliance with federal or state regulations related to nutrition
programs or grant projects
Key knowledge, skills, and abilities for entry-level public health nutritionists include
• Working knowledge of the principles and practices of nutrition and food, particularly in relation to health and
disease
• Knowledge of current developments in public health nutrition and their application to statewide and/or local
nutrition programs
• Knowledge of social, cultural, and economic problems and their impact on public health nutrition
• Knowledge of the general organization and function of public health agencies
• Ability to effectively use educational materials for the nutrition education of individuals and groups
• Ability to gather, interpret, evaluate, and use statistical data
• Ability to present ideas clearly and concisely
• Ability to establish and maintain working relationships with professional and lay groups, other employees, and
the general public
Minimum qualifications, in terms of experience and training, for entry-level public health nutrition positions may
call for graduation from an accredited 4-year college or university with a bachelor degree, including or supplemented
by at least 15 semester hours in foods and nutrition including at least one course in diet therapy and one course in
community nutrition or nutrition in life cycle; or completion of an undergraduate curriculum accredited or approved by
the American Dietetic Association (ADA). Registration or current eligibility for registration by the Commission on
Dietetic Registration (CDR) may be accepted in lieu of other specified qualifications. A registered dietitian is identified
by the RD credential.
As noted previously, there were 59,500 nutritionists and dietitians employed in the United States in 2013, with
8,700 working for government agencies at the federal, state, or local level. The median salary for nutritionists and
dietitians employed in the governmental sector in 2013 was also $54,000 with the middle 50% earning between
$41,000 and $68,000. Entry-level salaries were in the $33,000–$40,000 range. The Bureau of Labor Statistics projects
there will be 82,000 positions overall, including 9,400 positions in the governmental sector in the year 2022. Because
of job growth, retirements, and other job changes, more than 22,000 positions have been or will be filled between
2012 and 2022, although growth among government agencies will be substantially less.
EMERGENCY MEDICAL TECHNICIANS AND PARAMEDICS
Emergency medical technicians (EMTs) assess injuries, administer emergency medical care, and extricate trapped
individuals. Duties often include transporting injured or sick persons to medical facilities. Paramedics are trained to
provide more complex and sophisticated medical care under the general supervision of physicians.
There were 238,000 EMTs and paramedics in the United States in 2013, with 70,000 working for public sector
agencies. The median salary for public sector EMTs and paramedics in 2013 was $35,000 with the middle 50% earning
between $26,000 and $50,000. Job growth for this occupation is expected to be moderate through 2022, with 121,000
positions to be filled through increased demand and job turnover. Jobs will increase but a lower rate for government
employment.
LABORATORY WORKERS
Public health laboratories require a variety of professional and technical workers, including public health scientists
and laboratory technologists and technicians. Public health scientists are not one of the standard occupational
categories tracked by the Bureau of Labor Statistics, although there are several other standard occupational
categories that work in this capacity (such as microbiologists and biochemists). Technologists and technicians working
in medical and clinical labs, including public health labs, are among the occupations for which national data are
compiled. Public health laboratory workers prevent the spread of disease, protect against environmental hazards, and
ensure the quality of services. Lab workers diagnose and investigate health problems and disasters, evaluate the
effectiveness and quality of services, and research new insights and innovative solutions to health problems. Public
Health Workforce Enumeration 2000 data identified 22,000 public health laboratory workers in governmental public
health agencies in the year 2000. Far fewer laboratory workers (6,100) were identified in more recent surveys of state
and local public health agencies conducted in 2012 and 2013.3,4
Public health laboratory scientists are professionals who plan, design, and implement laboratory procedures to
identify and quantify agents in the environment that may be hazardous to human health; biologic agents believed to be
involved in the etiology of diseases in animals or humans, such as bacteria, viruses, and parasites; or other physical,
chemical, and biologic hazards. Titles include microbiologist, chemist, toxicologist, physicist, and entomologist.
Public health laboratories rely heavily on the work of technologists and technicians in order to perform a variety of
chemical, serologic, viral, or bacteriologic analyses of clinical or environmental specimens according to established
procedures. Work involves performing complex tests under general supervision, ensuring the accuracy of the tests
through quality control procedures, notifying appropriate scientific and supervisory staff when a test system is not
functioning, and, in consultation with appropriate authorities, implementing and documenting appropriate remedial
and corrective actions. Work may also involve communicating with health professionals in other agencies regarding
routine questions concerning specimen requirements and tests offered. Work is performed under general supervision;
however, public health laboratory scientists are expected to exercise independent judgment within the framework of
established procedures and policies.
Public health laboratory scientists include microbiologists, biochemists, and biophysicists. Microbiologists
investigate the growth, structure, development, and other characteristics of microscopic organisms, such as bacteria,
algae, or fungi. Biochemists and biophysicists study the chemical composition and physical principles of living cells
and organisms, their electrical and mechanical energy, and related phenomena. They may conduct research to further
understanding of the complex chemical combinations and reactions involved in metabolism, reproduction, growth, and
heredity. Biochemists may also determine the effects of foods, drugs, serums, hormones, and other substances on
tissues and vital processes of living organisms.
Essential and important duties of a public health laboratory scientist include
• Performs routine serologic tests for the presence of antibodies or antigens to various disease agents
• Performs a variety of bacteriologic examinations for the presence of disease agents or contaminants in clinical or
other specimens, such as feces, urine, sputum, spinal fluid, blood cultures, water specimens, dairy products,
foods, and beverages
• Performs microscopic examinations of animal heads for rabies
• Performs microscopic examinations for tissue and intestinal protozoans, helminths, and nematodes
• Performs cultural and microscopic examinations for gonorrhea, and cultural, biochemical, and serologic
examinations for various species of bacteria
• Performs analytic chemical analysis on clinical and environmental samples using a variety of methodologies and
instrumentation
• Evaluates methods and instruments for determination of blood alcohol content in breath, blood, urine, or saliva;
periodically performs quality assurance checks of field units; testifies in court as required
• Performs screening and confirmatory tests to detect inborn errors of metabolism and sickle cell disease
• Performs, records, and reviews quality control results to determine the validity, accuracy, or precision of tests
performed and to ascertain the quality of reagents, chemicals, or media used for analysis
• Participates in sample accessioning and record keeping to ensure that all specimens are accounted for,
appropriately handled, and properly and completely tested
• Records and reports results in the proper manner for the technical area of analysis; checks reports for accuracy;
maintains confidentiality of reports
• Consults with public health personnel, physicians, other laboratory workers, and healthcare professionals
regarding the interpretation of results, collection of specimens, and the applicability of tests to particular
circumstances
Knowledge, skills, and abilities relevant for public health laboratory scientists include
• Knowledge of the principles and practices of microbiology or analytic chemistry
• Knowledge of accepted analytic techniques
• Knowledge of laboratory methods, materials, techniques, and safety procedures
• Knowledge of the principles, practices, and methods of a public health, medical, or other health-related analytic
laboratory
• Knowledge of common laboratory equipment and apparatus, and when appropriate, some knowledge of the
operation, maintenance, and repair of specific instruments, such as gas chromatographs, atomic absorption units,
fluorescent microscopes, and spectrophotometer readers
• Working knowledge of statistics, the metric system, and mathematics for interpreting data and reporting results
• Ability to perceive colors and, when applicable, eyesight sufficiently strong to permit extended microscopic work
• Ability to perform assigned tasks exactly according to prescribed procedures, to accurately observe and
interpret results, and to make reports
• Ability to communicate effectively
• Ability to establish and maintain working relationships with staff members, public health personnel, physicians,
other laboratories, and the public
• Ability to effectively organize work
Minimum qualifications for public health laboratory scientists often call for 2 years of professional experience as a
chemist, microbiologist, medical technologist, or associate public health laboratory scientist, and graduation from an
accredited 4-year college or university with a bachelor degree with major specialization in a biologic or chemical
science, or medical technology. In some instances, possession of Clinical Laboratory Improvement Amendments of
1988 certification will substitute for the educational requirements. Graduate education in the above areas may
substitute on a year-for-year basis for the stated experience.
Microbiologists investigate the growth, structure, development, and other characteristics of microscopic organisms,
such as bacteria, algae, or fungi. This category includes medical microbiologists who study the relationship between
organisms and disease or the effects of antibiotics on microorganisms. There were 20,000 microbiologists employed in
the United States in 2013, with government agencies employing 4,600. Microbiologists employed by government
agencies had a median salary of $76,000 in 2013, with the middle 50% earning between $56,000 and $101,000. Mean
salaries for microbiologists working for federal agencies are well above the mean salaries at state and local
governmental agencies. Only modest growth is projected for this occupation through 2022, with about 7,100 positions
to be filled through increased demand and job turnover. Little if any growth is anticipated for microbiology positions
employed by government.
Medical and clinical laboratory technologists perform complex medical laboratory tests for the diagnosis, treatment,
and prevention of disease. Duties may include training or supervising staff. Medical and clinical laboratory technicians
perform routine medical laboratory tests for the diagnosis, treatment, and prevention of disease, often under the
supervision of a medical technologist.
Essential and important duties for a public health laboratory technologist include
• Receives, counts, logs, and labels samples submitted by field staff and individuals for testing
• Prepares samples for analysis by racking, centrifuging, filtering, weighing, and so on, and distributes prepared
samples to appropriate testing areas
• Pipettes serum samples onto testing plates and adds antigen or reagents in accordance with standard laboratory
procedures; stirs, rocks, shakes, and incubates mixture for specified time; reads test results in accordance with
established parameters
• Draws blood and collects urine, stool, sputum, and other samples for analysis as ordered by physicians; performs
routine analyses of specimens
• Maintains basic records consistent with assigned responsibilities
• Prepares sample specimen kits and shipping boxes for mailing
• Cleans and maintains sample containers, laboratory equipment, and work areas
Key knowledge, skills, and abilities for public health laboratory technologists include
• Knowledge of basic science terminology, concepts, and principles
• Knowledge of laboratory procedures, techniques, and equipment
• Knowledge of blood-drawing techniques
• Ability to properly operate microscopes, centrifuges, autoclaves, sterilizers, or other laboratory equipment
• Ability to apply proper methods of handling and disposing of chemicals and infectious materials
• Ability to perform assigned tasks according to specific instructions and clearly prescribed procedures
• Ability to read, compare, identify, and record laboratory data accurately, such as names, numbers, sample
descriptions, and so on
• Ability to perform basic mathematics and make accurate measurements
• Ability to make accurate observations and prepare accurate records of laboratory tests
• Ability to work with other employees, laboratory staff, health professionals, and the general public
Minimum qualifications for these positions may call for 1 year of experience in a medical or public health laboratory
performing routine laboratory tests under the direction of a physician or qualified laboratory technician, and
possession of a high school diploma or a general educational development certificate. College coursework with
specialization in the chemical, physical, or biologic sciences may substitute on a year-for-year basis for deficiencies in
the required experience.
Medical and clinical laboratory technologists numbered 163,000 in 2013. The vast majority work for hospitals,
nonhospital-based laboratories, physician offices, and universities. Government agencies employed 7,000 lab
technologists. There were 157,000 medical and clinical laboratory technicians employed by the same types of
organizations as for lab technologists. Government agencies employed only 5,100 of these workers. The Public Health
Workforce Enumeration 2000 report identified 8,000 public health laboratory technicians working in governmental
public health agencies. Despite projections that the number of positions for laboratory technologists and technicians
will grow substantially (156,000 positions to be filled due to increased demand and job turnover) between 2012 and
2022, relatively few of these new positions will be filled in the government sector.
The median salary for laboratory technologists employed by government agencies in 2013 was $62,000, with the
middle 50% earning between $53,000 and $69,000. Public sector laboratory technicians had a median salary of
$40,000 in 2013, with the middle 50% earning between $34,000 and $47,000. Salaries for laboratory technicians
working for federal, state, and local governmental agencies are similar.
OPTOMETRISTS
Optometrists diagnose, manage, and treat conditions and diseases of the human eye and visual system. Duties include
examining eyes and the visual system, diagnosing problems or impairments, prescribing corrective lenses, and
providing treatment. Optometrists may prescribe therapeutic drugs to treat specific eye conditions.
There were 32,000 optometrists in the United States in 2013, with only about 500 working for public sector
agencies. The median salary for public sector optometrists in 2013 was $82,000 with the middle 50% earning between
$34,000 and $93,000. Job growth for this occupation is expected to be very strong through 2022, with 18,000 positions
to be filled through increased demand and job turnover. Jobs will increase very little, if at all, for government agencies.
PHARMACISTS
Pharmacists dispense drugs prescribed by physicians and other health practitioners and provide information to
patients about medications and their use. Pharmacists may advise physicians and other health practitioners on the
selection, dosage, interactions, and side effects of medications.
Public health pharmacists combine pharmacy and public health skills to plan, organize, and perform drug-related
activities with a specific public health focus or within a public health setting. Public health pharmacists may work in
agency-run pharmacies or serve as the liaison between private pharmacies and the public health agency in regard to
standards, procedures, and education. They also dispense drugs prescribed by physicians and other health
practitioners and provide information to patients about medications and their use. Pharmacists advise physicians and
other health practitioners on the selection, dosage, interactions, and side effects of medications and are increasingly
involved in Strategic National Stockpile planning and operations. The Public Health Workforce Enumeration 2000
report identified 2,300 public health pharmacists working in federal, state, and local public health agencies in the year
2000.
There were 287,000 pharmacists in the United States in 2013, with only about 9,000 working for public sector
agencies. The median salary for public sector pharmacists in 2013 was $110,000 with the middle 50% earning
between $97,000 and $119,000. Job growth for this occupation is expected to be moderate through 2022, with
110,000 positions to be filled through increased demand and job turnover. Jobs will increase only slightly for
government agencies.
PHYSICIAN ASSISTANTS
Physician assistants (PAs) provide healthcare services typically performed by a physician, under the supervision of a
physician. PAs may conduct complete physicals, provide treatment, counsel patients and, in some cases, prescribe
medication. Most PAs graduate from an accredited educational program for physician assistants.
There were 88,000 PAs in the United States in 2013, with only about 3,000 working for public sector agencies. The
median salary for public sector PAs in 2013 was $88,000 with the middle 50% earning between $78,000 and $95,000.
Similar to that for general dentists, job growth for this occupation is expected to be strong through 2022, with 49,000
positions to be filled through increased demand and job turnover. Jobs will increase very little, if at all, for government
agencies.
PHYSICIANS
Physicians (general and family practitioners) diagnose, treat, and help prevent diseases and injuries that commonly
occur in the general population. General and family practice physicians may refer patients to specialists when needed
for further diagnosis or treatment.
Public health physicians identify persons or groups at risk of illness or disability, and develop, implement, and
evaluate programs or interventions designed to prevent, treat, or ameliorate such risks. Public health physicians may
provide direct medical services within the context of such programs and include physicians with doctor of medicine
and doctor of osteopathic medicine degrees working as either generalists or specialists. Relatively few active
physicians in the United States work in public health settings, and only a small number of those public health
physicians have training in public health or preventive medicine. For example, the number of physicians who are board
certified in preventive medicine with a specialization in public health actually decreased from 2,300 in 1980 to 1,800
in 2000. Those with specializations in general preventive medicine increased from 800 to 1,700, and those specializing
in occupational medicine increased from 2,400 to 3,000 during that same period. The Public Health Workforce
Enumeration 2000 report identified 9,000 public health physicians working in federal, state, and local public health
agencies. Surveys of local and state health departments conducted in 2012 and 2013 identified only about 3,200 public
health phyisicns.3,4 Many public health physicians may fall under other non-physician SOCs, such as chief executive
officers, medical and health services managers, and epidemiologists, making a precise enumeration of their number
impossible.
There were 121,000 generalist physicians (general and family practitioners) in the United States in 2013, with only
about 3,000 working for public sector agencies. The median salary for public sector general physicians in 2013 was
$149,000 with the middle 50% earning between $117,000 and $184,000. Overall job growth for this occupation is
expected to be strong through 2022, with 49,000 positions to be filled through increased demand and job turnover.
Jobs will also increase moderately for government employment.
VETERINARIANS
Veterinarians diagnose, treat, or research diseases and injuries of animals. Some veterinarians conduct research and
development, inspect livestock, or care for pets and companion animals. Public health veterinarians/animal control
specialists identify and assess health risks to humans from animals; they plan, manage, and evaluate programs to
reduce these risks. The Public Health Workforce Enumeration 2000 study identified more than 3,100 veterinarians and
animal control specialists working in governmental public health agencies, indicating that professionals other than
veterinarians coordinate and manage animal control programs at the local level.
There were 59,000 veterinarians in the United States in 2013, with only about 2,000 working for public sector
agencies. The median salary for public sector veterinarians in 2013 was $85,000 with the middle 50% earning between
$76,000 and $95,000. Job growth for this occupation is expected to be strong through 2022, with 31,000 positions to
be filled through increased demand and job turnover. Jobs will increase very little for government agencies.
OUTSIDE-THE-BOOK THINKING 13-2
What features make one or more of these public health occupations a career worth pursuing?
PUBLIC HEALTH PROGRAM SPECIALISTS
Public health program specialists plan, develop, implement, and evaluate programs or interventions designed to
identify persons at risk of specified health problems and to prevent, treat, or ameliorate such problems. This includes
public health workers reported as public health program specialists without specific designation of a program, as well
as those reported as specialists working in a specific program (e.g., maternal and child health, acquired immune
deficiency syndrome awareness, immunization, retail food inspection programs). Public health program specialists
have a wide range of educational preparation, including many individuals who have preparation in a specific
occupational category or profession (e.g., dental health, environmental health, nutrition, and nursing). The Public
Health Workforce Enumeration 2000 report identified 12,000 public health program specialists.
A large number of public health program specialists work in licensing and regulatory programs performing various
types of inspections. Many different titles are used, such as licensure, inspection, and regulatory specialist. These
positions audit, inspect, and survey programs, institutions, equipment, products, and personnel, using approved
standards for design or performance. This title includes workers who perform regular inspections of a specified class
of sites or facilities, such as restaurants, nursing homes, and hospitals whose personnel and materials present
constant and predictable threats to the public, without specification of educational preparation. This classification also
includes a number of individuals with preparation in environmental health, nursing, and other health fields. The Public
Health Workforce Enumeration 2000 report identified 21,000 licensure/inspection/regulatory specialists working in
federal, state, and local public health agencies.
Public health specialists carry responsibility for planning, performing, or supervising technical and professional
work involving public health and consumer protection services. This includes performing inspections, surveys, and
investigations to identify and eliminate conditions hazardous to life and health, providing consultative services and
assistance in assigned areas of responsibility, ensuring corrective actions are taken to eliminate public health or other
hazards, and ensuring compliance with applicable statutes and regulations.
The functions within this job family vary by level and from program to program, but may include the following:
• Develops, implements, and manages projects and initiatives for an assigned program or unit
• Develops and implements activities to ensure effective operations and compliance with established standards
and/or contracted goals and objectives
• Serves as a team leader on specific projects
• Coordinates program activities that may include fiscal monitoring; grant writing; monitoring of funded programs
or agencies to ensure compliance; report preparation and writing; and assisting with developing and distributing
communications, brochures, and educational materials
• Coordinates/oversees activities that may include health education; training; development and oversight of
requests for proposals and grants; and developing and distributing communications, brochures, and educational
materials
• Collaborates and meets with management staff to -determine program requirements, standards, and goals
• Evaluates projects or initiatives to determine effectiveness and to recommend changes and improvements
• Supervises employees; trains and evaluates staff; and reviews the work of subordinates for completeness,
accuracy, and content
• Assists in overseeing specialized research and evaluation projects
• Delivers services according to established program protocols
• Conducts inspections, surveys, and investigations of food establishments, lodging facilities, barber shops, public
bathing places, schools, day care centers, nursing homes, hospitals, and other regulated facilities to identify
public health hazards or environmental conditions that are detrimental to life and health
• Monitors state food supplies and products; provides training and technical assistance; ensures compliance with
applicable laws, rules, and regulations; and assists in the implementation of Hazard Analysis Critical Control
Point (HACCP) systems in food establishments and in verifying implementation
• Responds to complaints concerning foodborne illnesses, adulterated foods, food tampering, recalls, insect or
rodent infestation, or other issues related to food establishments or the sale of food and food products
• Reviews and acts on various epidemiologic reports and complaints, including animal bites, rabies, and disease
outbreaks; conducts environmental assessments and other surveys related to lodging, public bathing, and barber
services; and performs inspections for lead contamination and other public health hazards or nuisances
• Provides emergency response services for complaints concerning foodborne illnesses, fires in food
establishments, accidents involving the transportation of food, incidents concerning food or water contamination,
and power outages or natural disasters involving food products; conducts inspections or investigations on an as-
needed basis, including on weekends and at night
• Directs the embargo and disposal of food products found unfit for human consumption; conducts evaluations to
determine imminent hazards to life or health that warrant the closure of a facility
• Prepares records, reports, and correspondence concerning regulatory actions as needed; conducts follow-up
inspections and surveys to ensure corrective actions have been taken and that public health hazards are
eliminated; and testifies at hearings and court proceedings concerning regulatory actions as required
The public health specialist series within a personnel system may include three or more levels that are
distinguished by the level of complexity of specific job assignments, the extent of responsibility assigned for specific
tasks, the level of expertise required for completion of the assigned work, and the responsibility assigned for providing
leadership to others.
For public health program specialists working in an inspection or regulatory program, for example, the entry level
of the series involves assigned duties and responsibilities in a training status to build skills in conducting inspections
and investigations, performing basic professional analysis, and interpreting state and federal laws. Entry-level public
health specialists perform tasks involving the evaluation of inspection or survey data and the preparation of technical
records and reports, and assist in making recommendations concerning remedial actions to correct public health
hazards and provide for consumer protection.
Knowledge, skills, and abilities required at the entry level include knowledge of the causes, impact, and prevention
of public health problems in regulated establishments; food microbiology as it applies to preventing foodborne illness;
basic epidemiology and chemistry; mathematical concepts, including basic statistical analysis; food processing
techniques such as modified atmospheric packaging; and rules and regulations governing food establishments, public
bathing places, nursing homes, schools, day care facilities, or other licensed establishments. Abilities required include
the ability to conduct inspections and investigations of regulated facilities; identify the causes of foodborne illnesses
and related health hazards; analyze and evaluate environmental and sanitary conditions; organize work and work
independently; communicate effectively, both orally and in writing; and use computers to organize data and generate
reports.
Experience and education requirements at this level consist of a bachelor degree with at least 30 semester hours in
a biologic, medical, or physical science; food science or technology; and chemistry, nutrition, engineering,
epidemiology, or closely related scientific field.
Midlevel public health specialist positions involve more advanced assigned duties for inspections, surveys, and
investigations related to public health services, consumer protection, and the enforcement of applicable state and
federal laws in the assigned area of responsibility. Midlevel public health specialists evaluate inspection and survey
data, prepare technical records and reports, make recommendations concerning required remedial actions, and
provide technical assistance and training as needed to correct public health or consumer protection problems. Some
responsibility may also be assigned for providing limited guidance and training to entry-level employees in performing
various consumer protection program duties. In addition, midlevel public health specialist positions may involve a
clear specialization in a consumer protection or public health discipline and recognition as an expert in the specialty
along with a high degree of technical and administrative freedom to plan, develop, organize, and conduct all phases of
the work necessary for completion within broad program guidelines.
Knowledge, skills, and abilities required at this middle level include those identified in the entry level plus the
ability to make recommendations concerning the implementation of HACCP systems and verify implementation;
conduct preoperational inspections to determine compliance with approved plans; assist in planning and presenting
education and training programs; plan and conduct field investigations; ensure that corrective action has been
completed to eliminate health hazards; analyze and interpret engineering plans and specifications; and assist in
developing HACCP plans for the regulated food industry.
Experience and education requirements at this level consist of those identified for entry-level positions plus 2 years
professional work experience in public health or consumer protection or a master’s degree in a listed field and
successful completion of training in conducting food establishment inspections plus 2 additional years of qualifying
experience.
Salary scales vary greatly from agency to agency, although entry-level positions may be in the $30,000–$35,000
range, with midlevel positions in the $40,000–$50,000 range. Higher-level public health specialist positions that
oversee several program areas or units can expect salaries equivalent to other midlevel managers in these
organizations. Job growth for public health specialists is expected to be about average for all positions in the health
field.
POLICY ANALYSTS
Public policy is an important public health tool used to promote conditions in which individuals and communities can
be healthy. Public health policy analysts analyze needs and plans for the development of public health and other
programs, facilities and resources, and/or analyze and evaluate the implications of alternative policies relating to
public health and health care for a defined population. Public health analysts determine the questions that such
policies will raise, answer those questions, and help shape policies that make our society a better place to live.
Public health policy analysts function under many different titles, including health planners, researchers, and health
economists. Health economists conduct research, prepare reports, or formulate plans to aid in the solution of
economic problems arising from the production and distribution of goods and services related to public health and
health care. Health economists may collect and process economic and statistical data using econometric and sampling
techniques.
Public health policy analysts must be able to dissect a problem, analyze and interpret data, and evaluate and create
alternative courses of action. They provide information to government officials and the public about which policies will
be most effective in meeting society’s public health goals.
Public health policy analysts work in national, state, and local governments, nonprofit agencies, “think tanks,”
consulting firms, community action groups, and direct service organizations. International health and development
organizations also employ public health policy analysts. The Public Health Workforce Enumeration 2000 report
identified nearly 6,000 public health policy analysts, planners, researchers, and economists. Because of the wide
variation in titles used for this function, it is likely that there are actually many more public health analyst positions in
the public health workforce.
Important and essential duties of a public health policy analyst include
• Conducts site visits to assess the operations and costs of state, federal, and local healthcare programs
• Conducts literature reviews
• Performs quantitative analyses with large databases to determine program outcomes or conduct policy
simulations
• Writes chapters of analytic reports and proposals for new projects
• Tracks financial progress of projects using computerized spreadsheets, prepares reports for monthly project
reviews, and assists with budget revisions and contract proposals
Key knowledge, skills, and abilities for public health policy analyst positions include
• Knowledge of current policy issues in one or more of the following areas: managed care, public health
infrastructure, state health policy, healthcare reimbursement issues, mental health/substance abuse, maternal
and child health, disability, long-term care, or other relevant areas
• Knowledge of healthcare policy issues related to employer-based coverage, managed care, Medicaid, Medicare,
and the uninsured
• Knowledge of how to use data to affect policy and systemic changes
• Ability to establish collaborative working relationships with diverse interest groups and stakeholders
• Excellent writing and verbal skills, particularly in presenting complex information in a clear, comprehensible
format
Minimum qualifications for public health policy analyst positions vary greatly but generally require a master’s
degree in public policy, public health, economics, statistics, or a related field, or equivalent experience in a clinical
field, and extensive knowledge of quantitative and qualitative research methods. In some instances, a bachelor degree
and a minimum of 5 years of experience, preferably in healthcare advocacy or policy analysis, may be acceptable.
Invariably, work experience with state or federal government, a foundation, a policy research organization, or a
healthcare program is desirable.
Salaries for public health analysts vary considerably based on education, experience, and specific duties within an
organization. With little information available on employment trends for these positions, it is difficult to assess future
job prospects, although the number of such positions does not appear to be declining.
PUBLIC HEALTH INFORMATION SPECIALISTS AND ANALYSTS
Public health information systems and data analysts plan, direct, or coordinate activities in areas such as electronic
data processing, information systems, systems analysis, and computer programming. They often work with computer
specialists who manage the specialized technical aspects of computer operation, applications, operating systems, and
hardware. Common titles include computing consultant, applications programmer, computer service technician, data
entry technician, data processing specialist, network technician, information technology specialist, and vital records
support specialist. Not included are titles that operate computers as part of administrative or professional tasks.
Important and essential duties of a public health information specialist include
• Plans and coordinates the collection, analysis, and dissemination of complex disease and other health data and
information
• Performs health risk and community needs appraisals
• Monitors and evaluates programs for effectiveness and quality
• Collaborates with other agencies, organizations, and stakeholders in the identification and monitoring of
community health needs
• Exercises independent judgment in analyzing problems, issues, and situations; develops and implements
recommendations
• Plans and conducts meetings
• Presents information and represents the agency at public and other meetings
• Complies with legal standards and requirements
• Collects, researches, verifies, enters, updates, analyzes, summarizes, and presents complex disease and other
health information and data
• Records information and data accurately following procedures; prepares complete reports on time with
supporting conclusions and recommendations, such as the health status report
• Communicates changes and progress and completes projects on time and within budget
• Formulates recommendations anticipating possible ramifications and appropriately communicates significance of
findings
Public health information specialist positions require a bachelor degree in public health or a related field and 5
years of progressively responsible experience in public health evaluation or a related health field. A master’s degree in
public health is preferred. These positions require knowledge of core public health functions; epidemiologic principles
and practices, including symptoms, causes, means of transmission, and methods of control of communicable, chronic,
and complex disease; principles of disease investigation, control, and prevention; and emergency response principles
and practices. These positions also require familiarity with the operation of computers and a variety of office software
including word processing, spreadsheet, database, geographical information systems, mapping, statistical, and other
applications related to the area of assignment.
The Public Health Workforce Enumeration 2000 study identified 900 health information specialists and 6,000
computer specialists working for governmental public health agencies. Surveys conducted in 2012 and 2013 identified
3,500 health information specialists working in state and local public health agencies.3,4 Salaries for health information
specialists are often in the $40,000–$50,000 range. Health information specialist jobs are projected to be among the
fastest growing in the health sector.
OUTSIDE-THE-BOOK THINKING 13-3
In which organizations and geographic regions will the public health occupations presented in this chapter expand most
rapidly in the next two decades?
ADDITIONAL INFORMATION
Many sources provide additional and more detailed information for the occupational categories addressed in this
chapter.
The American Public Health Association (APHA, www.apha.org) has sections that focus on issues important to each
of these occupational categories, including food and nutrition; social work; mental health; alcohol, tobacco, and other
drugs; medical care; and oral health. APHA also has a laboratory special interest group, veterinary public health
special interest group, and public health law forum.
ASTPHND (www.astphnd.org/) provides information on and resources for public health nutrition professionals.
Another resource for nutritionists is the ADA (www.eat-right.org/Public/), which has 65,000 members and works in
concert with the CDR (www.cdrnet.org/). More than 80,000 dietitians and dietetic technicians across the country and
the world have taken CDR exams over the past several decades. CDR currently awards four separate and distinct
credentials: RD; Dietetic Technician, Registered; Board Certified Specialist in Renal Nutrition; and Board Certified
Specialist in Pediatric Nutrition. The commission’s certification programs are fully accredited by the National
Commission for Certifying Agencies, the accrediting arm of the National Organization for Competency Assurance.
Web sites of the National Association of Social Workers (www.socialworkers.org) and the Council on Social Work
Education (www.cswe.org) provide information on accredited social work programs. The Association of Social Work
Boards (www.aswb.org) is a good source of information on licensing requirements and testing procedures used for
state licensing purposes.
Information on public health laboratory workers is available from the Association for Public Health Laboratories
(www.aphl.org) and the National Center for Public Health Laboratory Leadership
(http://www.aphl.org/mycareer/lablead/pages/default.aspx). The American College of Preventive Medicine
(www.acpm.org) and American Medical Association (www.amaassn.org/) Web sites provide information on public
health physicians.
The Community Health Planning and Policy Development section of the American Public Health Association (APHA)
Web site (www.apha.org) provides useful information for public health policy analysts. Similarly, the American Health
Information Management Association (AHIMA, www.ahima.org) is the premier association of health information
management professionals, with 50,000 members committed to advancing the health information management
profession. AHIMA focuses on advocacy, education, certification, and lifelong learning and works through the
Commission on Accreditation for Health Informatics and Information Management Education (CAHIM) to accredit
degree-granting programs in health informatics and information management. CAHIM establishes quality standards
for the educational preparation of future health information management professionals.
CONCLUSION
Professionals comprise the major share of the public health workforce, although public health professionals are quite
diverse in terms of their professional background and experience. Nutritionists are valuable resources for public
health agencies and the communities they serve, although most nutritionist positions work within the massive
federally funded WIC program. More local public health agencies than state public health agencies provide social,
mental, and behavioral health services, because these programs may be funded by and relate to state agencies other
than the state health agency in many states. Public health laboratory expertise is essential for disease and threat
detection, and one of the major impacts of increased federal spending for terrorism preparedness is resulting in
upgraded lab capabilities for state and local public health agencies. Recruiting and retaining the many levels of
laboratory professionals and technicians necessary for lab operations has emerged as an important priority for public
health as well as national security concerns. Physicians once dominated the field of public health. Today they represent
one of many important professions within the public health workforce, standing beside veterinarians, pharmacists, and
dental health workers. The regulatory and administrative processes within governmental public health agencies now
require a level of legal expertise beyond that called for in the past. These many and varied professional categories
provide public health with the multidisciplinary and interdisciplinary muscle needed to battle modern public health
threats and issues. Public health organizations use many different titles for public health program staff. Indeed, most
public health workers function within a defined program or program-related unit such as environmental health,
maternal and child health, Supplemental Food Program for Women, Infants, and Children, or immunization program.
Program specialists work on all aspects of program planning, implementation, and evaluation in concert with
professionals, technicians, and administrative support personnel. Because the programs in which they work often have
specific goals and objectives, program specialists are at risk of operating in an isolated environment. This contributes
to the critique that programs operate as silos within an agency, often unrelated to the operation of the many other silos
housed within that same agency. Because of their generalist skills, program specialists may move from one program to
another as a means of career and salary advancement. Their crosscutting, core, generalist public health practice skills
are generally acquired through work experiences rather than academic preparation. The size and impact of this corps
of public health program specialists argue that development and enhancement of these crosscutting competencies
should be a central strategy of public health workforce development efforts.
REFERENCES
1. Bureau of Labor Statistics, U.S. Department of Labor. Databases and tables. www.bls.gov/data/. Accessed June 15, 2014.
2. Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Information and Analysis
and Center for Health Policy, Columbia School of Nursing. Public Health Workforce Enumeration 2000. Washington, DC: HRSA; 2000.
3. National Association of County and City Health Officials. 2013 National Profile of Local Health Departments. Washington, DC: NACCHO; 2014.
4. Association of State and Territorial Health Officials. State Health Profile, Volume Three, 2012. Washington, DC: ASTHO; 2014.
CHAPTER 14
Public Health Practice: Future Challenges
LEARNING OBJECTIVES
Given its current mission, functions, and past achievements, describe the public future challenges facing the
public health system and their implications for improving population health status and quality of life. Key
aspects of this competency include being able to:
• Identify and discuss at least three lessons from public health’s achievements in the 20th century
• Identify and discuss at least three current issues, challenges, or limitations facing public health and public health
practitioners in the second decade of the 21st century
This text approaches what public health is and how it works from a unified conceptual framework. Key dimensions of
the public health system are examined, including its purpose, functions, capacity, processes, and outcomes. Although it
is a simple framework, many of the concepts addressed are anything but simple. As a result, much has been left
unsaid, and many important issues and problems facing the public health system have been addressed only in passing.
This may serve to whet the appetite of those eager to move beyond the basics and ready to tackle emerging and more
complex issues in greater depth. The basic concepts included in this text seek to facilitate that process and encourage
outside-the-book thinking. Delving into these other issues without the benefit of a broad understanding of the field and
how it works, however, can be hazardous in any field of endeavor. For public health workers, continuously fighting off
alligators remains the major deterrent to draining the swamp in order to avert the alligator threat in the first place.
The public health achievements of the 20th century demonstrate that the problems facing public health have
changed over the past century and argue that we can expect them to continue to change throughout the current
century. In retrospect, many past problems appear as though they should have been relatively easy to solve in
comparison with those on the public health agenda at the beginning of the 21st century; however, we often forget that
last century’s problems appeared to be quite formidable to public health advocates 100 years ago. Although
formidable, they were eventually deemed unacceptable, initiating the chain of events that resulted in an impressive
catalog of accomplishments ranging from infectious disease threats to oral health.
Each public health achievement provides valuable lessons and insights into the obstacles to achieving even further
gains that lie ahead. Challenges reside at many levels, especially at the level of preparedness for unforeseen and
previously unanticipated threats to the public’s health. Melding the expectations for addressing ongoing health
problems in the community with those for preparing and responding to new threats leads us to the three key questions
addressed in this chapter:
1. What are the lessons learned from the threats and challenges faced by public health in 20th century America?
2. What are the limitations and challenges facing public health in the 21st century?
3. How can these limitations and challenges be overcome?
LESSONS FROM A CENTURY OF PROGRESS IN PUBLIC HEALTH
The remarkable achievements of the 20th century did not completely eradicate the public health problems faced in
1900. Many of these continue to threaten the health of Americans and impede progress toward realizing the life span
projections presented in Figure 14-1. New faces for old enemies have appeared in the form of challenges and
obstacles to be overcome in the early decades of the 21st century. Infectious diseases, tobacco, maternal and infant
mortality, environmental and occupational health, food safety, cardiovascular disease, injuries, and oral health remain
high on the list of leading threats to the public’s health. Each presents special challenges.
FIGURE 14-1 Past and Projected Female and Male Expectancy at Birth, United States, 1900–2050
Reproduced from U.S. Public Health Service. Healthy People 2010: Understanding and Improving Health. Washington, DC: PHS; 2000.
Infectious Diseases
The continuing battle against infectious diseases will be fought on several fronts because of the emergence of new
infectious diseases and the reemergence of old enemies, often in drug-resistant forms. For example, infections caused
by Escherichia coli O157:H7 have emerged as a frequent and frightening risk to the public. Initially identified as the
cause of hemorrhagic conditions in the early 1980s, this pathogen was increasingly associated with foodborne illness
outbreaks in the 1990s, including a major outbreak in the Pacific Northwest related to E. coli-contaminated
hamburgers distributed through a national fast food chain.1 The source of the E. coli was cattle. Other outbreaks of
this pathogen involved swimmers in lake water contaminated by bathers infected with the organism (Figure 14-2).
Because many of the illnesses are minor and both medical and public health practitioners fail to perform the tests
necessary to diagnose E. coli infections properly, current surveillance efforts greatly underreport the extent of this
condition.
Multidrug-resistant pathogens represent another emerging infectious disease problem for the public health system.
The widespread and, at times, indiscriminate use of antibiotics in agricultural and healthcare settings produces strains
of bacteria that are resistant to these drugs. Antimicrobial agents have been increasingly deployed throughout the
second half of the 20th century. Slowly, over this period, the consequences of these miracle drugs have been
experienced in our communities, as well as our health facilities. The emergence of drug-resistant strains has reduced
the effectiveness of treatment for several common infections, including tuberculosis, gonorrhea, pneumococcal
infections, and hospital-acquired staphylococcal and enterococcal infections. For tuberculosis, drug resistance and
demographic trends, including immigration policies, played substantial roles in this disease’s resurgence in the early
1990s. The changing demographics of tuberculosis infections are illustrated in Figure 14-3.
FIGURE 14-2 Emergence of a Public Health Threat: The Escherichia coli 0157: H7 Time Line
Reproduced from Centers for Disease Control and Prevention. Addressing Emerging Infectious Disease Threats: A Prevention Strategy for the
United States. Atlanta, GA: CDC; 1994.
Pathogens, both old and new, have devised ingenious ways of adapting to and thwarting the weapons used to
control them. Many factors in society, the environment, and global interconnectedness continue to increase the risk of
emergence and spread of infectious diseases. An outbreak of monkeypox virus affecting several states in the United
States in 2003 demonstrates how unusual diseases in remote parts of the world can affect Americans virtually
overnight (Figure 14-4). In 2014, Middle East Respiratory Syndrome (MERS) made its first appearance in the United
States, again illustrating this threat.
The potential for global outbreaks and massive pandemics is now on the public health radar screen. An outbreak of
severe acute respiratory syndrome hit more than two dozen countries in North America, South America, Europe, and
Asia in 2003 before it was contained, but not before taking nearly 800 lives. The possibility of a global pandemic of
influenza virus looms as even more frightening because it is impossible to predict when the next influenza pandemic
will occur or how severe it will be. Wherever and whenever a pandemic starts, everyone everywhere in the world is at
risk. Countries might, through measures such as border closures and travel restrictions, delay arrival of the virus, but
cannot stop it.
Health professionals remain concerned that the continued spread of a highly pathogenic avian H5N1 virus across
eastern Asia and other countries represents a significant threat to human health. The H5N1 virus has raised concerns
about a potential human pandemic because:
• It is especially virulent.
• It is being spread by migratory birds.
• It can be transmitted from birds to mammals and in some limited circumstances to humans.
• Like other influenza viruses, it continues to evolve.
FIGURE 14-3 Number and Rate of Tuberculosis Cases Among U.S.-Born and Foreign-Born Persons, by Year
Reported, 2000–2013
Reproduced from Alami NN, Yuen CM, Miramontes R, Pratt R, Price SF, Navin TR. Trends in tuberculosis, United States, 2013. MMWR. 2014;
63(11);229–233.
Since 2003, a growing number of human H5N1 cases have been reported in Asia, Africa, and Europe. More than
half of the people infected with the H5N1 virus have died. Most of these cases are all believed to have been caused by
exposure to infected poultry. There has been no sustained human-to-human transmission of the disease, but the
concern is that H5N1 will evolve into a virus capable of human-to-human transmission.
A massive epidemic of Ebola virus disease, a rare and deadly disease previously known as Ebola hemorrhagic fever,
led to an unprecedented international response in 2014 after the case count in West Africa (Guinea, Liberia, Nigeria,
Sierra Leone) surpassed 10,000 with case fatality rates in the 70% range (see Figure 14-5 and Table 14-1). This
explosion of cases occurred after decades of smaller, intermittent outbreaks affecting a dozen countries in Africa. The
importation of travel-related cases to the United States and elsewhere outside West Africa in late 2014, leading to
cases among several health care workers, further demonstrated the global risks associated with uncontrolled local
outbreaks and the importance of vigilance and preparedness in dealing with unfamiliar pathogens.
Heightened concerns over the risk of acts of bioterrorism add a new twist to the threats posed by infectious
diseases. As noted in our examination of public health emergency preparedness and response, these concerns have
raised expectations for public health to serve both national security and personal safety roles.
The influence of infectious diseases in the development of chronic diseases such as diabetes, heart disease, and
some cancers further argues that infectious diseases will continue as important health risks in the new century. To
battle infectious diseases, the development and deployment of new methods, both in laboratory and epidemiologic
sciences, are needed to better understand the interactions among environmental factors as contributors to the
emergence and reemergence of infectious disease processes. Also, despite the successes realized in the development
and use of vaccines over the past century, substantial gaps persist in the infrastructure of the vaccine delivery system,
including the roles played by parents, providers, information technology, and biotech and pharmaceutical companies.
Improving the coordination of these elements holds the promise of reducing the toll from infectious diseases in the
21st century.
FIGURE 14-4 Movement of Imported African Rodents to Animal Distributors and Distribution of Prairie Dogs
from an Animal Distributor Associated with Human Cases of Monkeypox, 11 States, 2003
Notes:
Illinois (IL), Indiana (IN), Iowa (IA), Kansas (KS), Michigan (MI), Minnesota (MN), Missouri (MO), New Jersey (NJ), South Carolina (SC), Texas (TX),
and Wisconsin (WI). Japan is included among sites having received rodents implicated in the outbreak.
† Date of shipment unknown.
* Identified as distributor C in MMWR 2003;52:561–564.
§ Identified as distributor B in MMWR 2003;52:561–564.
‡ Identified as distributor D in MMWR 2003;52:561–564.
§§ Includes two persons who were employees at IL-1.
Reproduced from Centers for Disease Control and Prevention. Update: multi-state outbreak of monkeypox—Illinois, Indiana, Kansas, Missouri,
Ohio, and Wisconsin, 2003. MMWR. 2003:52(27):642–646.
Tobacco Use
The potential gains to be realized from further reduction of tobacco usage are also apparent. Despite the overall
decline in tobacco use among adults over the second half of the 20th century, an alarmingly high prevalence of tobacco
use among teens persists, and rates among adults are no longer declining, as they did prior to 1980. These trends
suggest that concerns over risks related to exposure to environmental tobacco smoke will continue for many years to
come. Disparities in tobacco use by race and ethnicity, together with the growth of demographic groups with high use
rates, add yet another dimension to the war against tobacco. New approaches and new products will raise new issues
of safety, whereas the increase in tobacco use across the globe will transport old and new challenges around the
world.
FIGURE 14-5 Cases of Ebola Virus Disease in Africa, 1976-2014
Source: Reproduced from Centers for Disease Control and Prevention. Ebola Virus Distribution Map. Available at
http://www.cdc.gov/vhf/ebola/outbreaks/history/distribution-map.html. Accessed November 4, 2014.
TABLE 14-1 Ebola Virus Disease – Known Cases and Outbreaks in Reverse Chronological Order, Various
Countries, 1976-2014 (through 11/3/2014)
Notes: *Numbers reflect laboratory confirmed cases only. 2014 Democratic Republic of Congo outbreak not related to 2014 outbreak involving
multiple countries; Multiple countries in 2014 include Liberia, Sierra Leone, Nigeria, Guinea, United States, Senegal and Spain as of November
4, 2014.
Source: Data from Centers for Disease Control and Prevention. Available at http://www.cdc.gov/vhf/ebola/outbreaks/history/chronology.html.
Accessed November 4, 2014
Maternal and Child Health
Even as maternal and child health outcomes have improved dramatically, there has been little change in the prime
determinants of perinatal outcomes—the rate of low birth weight and preterm deliveries. This situation must be
addressed to even partially replicate the gains realized in the 20th century. Another important risk factor moving in
the wrong direction is the rate of unintended pregnancies. Together, these challenges call for improved understanding
of the biologic, social, cultural, economic, psychological, and environmental factors that influence maternal and infant
health outcomes and in the effectiveness of intervention strategies designed to address these causative factors.
Motor Vehicle Injuries
The impressive gains realized in reducing motor vehicle injuries have uncovered gaps in our understanding of
comprehensive prevention. Challenges include expanding surveillance to monitor nonfatal injuries, detect new
problems, and set priorities. Greater research into emerging and priority problems, as well as intervention
effectiveness, is also needed, as are more effective collaborations and interagency partnerships. Injuries to pedestrians
from vehicles other than automobiles will also challenge public health in the 21st century. The effects of age, alcohol
use, seat belt use, and interventions targeting these risks will require greater attention for progress to continue in the
battle against motor vehicle injuries.
Cardiovascular Disease
An aging population less threatened by infectious disease and injury will place even more people at risk of ill health
related to cardiovascular diseases. Greater attention to research to understand the various social, psychological,
environmental, physiologic, and genetic determinants of cardiovascular diseases is needed in the new century.
Reducing disparities that exist in terms of burden of disease, prevalence of risk factors, and ability to reach high-risk
populations represents another mega challenge. Identifying new and emerging risk factors and their relationships,
including genetic and infectious disease factors, will be necessary in both developed and developing parts of the world.
Food Safety
Our understanding of food safety and nutrition made great strides in the 1900s, but both old and new risks will need to
be addressed in the new century. Iron and folate deficiencies continue, and many of the advantages related to
breastfeeding remain unrealized. The emergence of obesity, often in the midst of food deserts, as an increasingly
prevalent condition throughout the population is one of the most startling developments of the late 20th century.
Persistent challenges include applying new information about nutrition, dietary patterns, and behavior that promote
health and reduce the risk of chronic diseases.
Oral Health
One of the most overlooked achievements of public health in the 20th century was the dramatic decline in dental
caries due to fluoridation of drinking water supplies. Ironically, these advances in oral health have contributed to the
perception that dental caries are no longer a significant public health problem and that fluoridation is no longer
needed. These battles are likely to be fought in political, rather than scientific, arenas, presenting a substantial
challenge to public health in the 21st century.
Workplace Safety
Workplaces are now safer than ever before, yet challenges remain on this front, as well. Improved surveillance of
work-related injuries and illnesses and better methods of conducting field investigations in high-risk occupations and
industries remain formidable challenges. Applying new methods of risk assessment to improve assessment of injury
exposures and intervention outcomes, as well as improved research into intervention effectiveness, surveillance
methods, and organization of work represent additional challenges for public health practice in the 21st century.
Unfinished Agenda
It is clear that much remains to be done. The national Healthy People process articulates this unfinished agenda by
identifying important targets and leading indicators of health status for the United States.2 These health problems
persist on the public health agenda, which has now expanded to include new issues related to alcohol and substance
abuse, mental health, violence, and risky sexual behaviors. These are now categorized as important public health
problems and have taken their rightful place on the public health agenda. Progress toward these leading health
indicators documents the challenges that lie ahead. The public health challenges of the 21st century appear daunting,
but those of the preceding century must have seemed even more so.
Applying the lessons learned from the recent century of progress in public health to both new and persisting health
threats will be necessary to increase the span of healthy life and eliminate the huge disparities in health outcomes that
are the overarching goals of the year 2020 national health objectives. The public health challenges of both centuries
call for the application of sound science in an environment that supports social justice in health. This remains the most
formidable challenge facing public health practice in the 21st century.
OUTSIDE-THE-BOOK THINKING 14-1
What was the most important achievement of public health in the 20th century? Why?
What will likely be the most important achievement of public health in the 21st century? Why?
LIMITATIONS OF 21ST-CENTURY PUBLIC HEALTH
Despite the remarkable achievements of the 20th century, there is much for public health to do in the early decades of
the new century. Continued progress is by no means assured because of a new constellation of problems and important
limitations of conventional public health efforts. Global environmental threats, the disruption of vital ecosystems,
global population overload, persistent and widening social injustice and health inequalities, and lack of access to
effective care add to the list of health problems left over from the 20th century.3 Consider, for example, the
implications of the link between social position and health, and a nation growing more and more diverse, with a
disproportionate burden of poverty falling on children, minorities, and one-parent families. Further gains in health
status may be less related to science than to social policies. For some public health professionals, the limitations of
conventional public health are difficult to accept because, in large part, they represent the supporting pillars of the
public health enterprise. This reluctance to critically self-assess makes future progress less certain. It is useful to
examine these limitations in terms of their relationship to the two major forces shaping public health responses—
science and social values.
Among the limitations affecting the science of public health is an undue emphasis on reductionist thinking that
seeks molecular-level explanations for social and structural phenomena. Identification of risk factors has been useful
for public health efforts, but the emphasis on individual risk factors often obscures patterns that call for multilevel
responses. The persistent identification of the association of social deprivation with many of the important health
problems of the last century is a case in point. Approaches for reducing coronary heart disease provide another
example. Health interventions targeting a reduction in coronary heart disease frequently focus on risk factors at the
physiologic level, such as blood pressure control, cholesterol, and obesity and on lifestyle factors at the individual
level, including smoking, nutrition, physical activity, and psychosocial factors. However, there are also environmental
influences, such as geographic location, housing conditions, occupational risks, and social structure influences, such
as social class, age, gender, and race/ethnicity. In this multilevel view of coronary heart disease, interventions that
focus on primary and secondary prevention (those addressing the physiologic and individual levels) need to be
supplemented by organization-level and community-level interventions (addressing environmental influences) and
healthy public policy (addressing the social structure level).
Another limitation of public health’s scientific heritage is the penchant for dichotomous thinking and the failure to
view health phenomena as continuous. Using coronary heart disease as an example, dichotomous thinking draws
attention to individual and physiologic level factors, whereas viewing this condition as continuous encourages a
population-wide view and development of interventions that reduce overall incidence and prevalence by affecting
frequency distributions in the entire population. A view of health problems as continuous phenomena suggests that
efforts be made throughout the population to move the entire frequency distribution for coronary heart disease “to the
left,” rather than to reduce disease burden only among those groups most heavily impacted. Here it is apparent that
science and social values are not pure and mutually exclusive forces.
Discussion and debate over scientific approaches to public health problems are not, however, purely scientific in
nature. At the heart of collective actions are collective values as to whether issues affecting individuals are more
important than issues affecting communities of individuals and as to the meaning of health itself. Should public health
emphasize the health of individuals or the health of communities? In part, these reflect the different perspectives of
health described in other chapters. On one hand is a mechanistic view of health as the absence of disease, promoting
health interventions that emphasize curative treatment for afflicted individuals. On the other hand is a more holistic
view of health that sees health as a complex equilibrium of forces and factors necessary for optimal functioning of that
individual. This latter view emphasizes health maintenance and health promotion, often through broad social policies
affecting the entire community. Differences in public health systems among societies are largely described by these
differences. Some societies, like the United States, focus on individuals using a largely medical treatment approach.
Others are more heavily influenced by collectivism and a holistic view of health. At the core of what can be
accomplished under either view, however, are basic values and social philosophies that guide the use of the scientific
knowledge available at any point in time. These differences in social values also affect perceptions as to what is
expected of government and, as a result, the form and leadership of public health efforts. To a large extent, these
forces have hastened the development of community public health practice and career opportunities in public health in
the United States, a phenomenon described in previous chapters.
THE FUTURE OF PUBLIC HEALTH IN 1988 AND A QUARTER CENTURY LATER
In many respects, the limitations of modern public health are as apparent as its achievements. Persisting, emerging,
reemerging, and newly assigned problems will forever challenge public health as a social enterprise. Success will
depend on both the structure and the content of the public health response. A continuous, critical, and comprehensive
self-examination of the public health enterprise offers the greatest chance for continued success. A series of such self-
examinations began with the 1988 report of Institute of Medicine (IOM), The Future of Public Health.4 A
comprehensive reexamination, The Future of the Public’s Health in the 21st Century, was completed in 2002.5 A
companion study of issues related to educating public health professionals was also completed by the IOM in 2002.6
These examinations outlined the limitations of public health efforts in the 20th century, but cast these failings as
lessons, challenges, and opportunities for public health in the 21st century.
The Future of Public Health, 1988
The IOM’s landmark report, completed in 1988, found much of value in the nation’s public health efforts, but it also
identified a long list of problems. The most serious problem of all was that Americans were taking their public health
system for granted. The nation had come to believe that epidemics of communicable diseases were a thing of the past
and that food and water would forever be free of infectious and toxic agents. Americans assumed that workplaces,
restaurants, and homes were safe and that everyone had access to the information and skills needed to lead healthy
lives. They also assumed that all of this could occur even while public health agencies were being increasingly called
on to provide health services to nearly 50 million Americans who had no health insurance or were underinsured;
however, across the nation, states and localities were failing to provide the resources that would allow both the
traditional public health and more recent health service roles to be carried out successfully. When future benefits
compete with immediate needs, the results are predictable.
These circumstances fostered the image of a public health system in disarray. Within this system, neither the public
nor those involved in the work of public health appreciated the scope and content of public health in modern America.
There was little consensus as to the specific responsibilities to be expected from the various levels of government and
even less interest in securing such consensus.
Previous chapters document that several formulations in the IOM report have been widely embraced by the public
health community. These include statements of the mission, substance, and core functions of public health. The
mission has been described simply as ensuring conditions in which people can be healthy. The substance consists
largely of organized community efforts to promote health and prevent disease. The IOM report identified an essential
role for government in public health in organizing and ensuring that the mission gets addressed. An expanded view of
the fundamental functions of governmental public health was articulated in the three core functions of assessment,
policy development, and assurance. These represent a more comprehensive view of public health efforts than that
conveyed by earlier views that public health primarily furnished services and enforced statutes. The new public health
differed in its emphasis on problem identification and resolution as the basis of rational interventions and on working
with and through other stakeholders, rather than intervening unilaterally.
Perhaps the most motivating aspect of the IOM report, however, was its characterization of the disarray of public
health and the significance of that disarray. The IOM report painted a picture of disjointed efforts in the 1980s to deal
with immediate crises, such as the epidemic of human immunodeficiency virus infections and an increasing lack of
access to health services and enduring problems with significant social impacts, such as injuries, teen pregnancy,
hypertension, depression, and tobacco and drug use. With impending crises on the horizon in the form of toxic
substances, mental illness, Alzheimer’s disease, and public health capacity, the IOM report found the situation to be
grimmer still.
The report found a wide gap between the capacity of the public health system of the 1980s and those of a public
health system capable of rising to modern challenges. It charted a course to move ever closer to an optimally
functioning system. Several enabling steps were identified:
• Improving the statutory base of public health
• Strengthening the structural and organizational framework
• Improving the capacity for action, including technical, political, management, programmatic, and fiscal
competencies of public health professionals
• Strengthening linkages between academia and practice4
In the end, the report concluded that working through a multitude of society’s institutions, rather than through only
traditional public health organizations, is the key to improving the public health system. It is also a daunting task,
calling for entering into partnerships with sectors such as education, law enforcement, media, faith, corrections, and
business, and fostering change through leadership and influence, rather than through command and control. The
barriers to effecting these collaborations are the major obstacles to achieving the aspirations outlined in the Healthy
People national health objectives. These barriers come in all sizes and shapes and from many different sources. Some
are perceived as external barriers; others appear to be more internal.
The IOM report identified important barriers inhibiting effective public health action:
• Lack of consensus on the content of the public health mission
• Inadequate capacity to carry out the essential public health functions of assessment, policy development, and
assurance of services
• Disjointed decision making without necessary data and knowledge
• Inequities in the distribution of services and the benefits of public health
• Limits on effective leadership, including poor interaction among the technical and political aspects of decisions,
rapid turnover of leaders, and inadequate relationships with the medical profession
• Organizational fragmentation or submersion
• Problems in relationships among the several levels of government
• Inadequate development of necessary knowledge across the full array of public health needs
• Poor public image of public health, inhibiting necessary support
• Special problems that unduly limit the financial resources available to public health4
The Future of Public Health, A Quarter Century Later
The IOM advanced these themes through several other reports published in the 1990s and early years of the new
century. A brief status report on progress in implementing the 1988 report’s major recommendations was completed in
the mid-1990s, and a report promoting community health improvement processes appeared later in the decade. A full
scale reexamination of the public health enterprise, titled The Future of the Public’s Health in the 21st Century, was
undertaken after the turn of the century and completed in late 2002. That report focused more extensively on
multisectoral partnerships with government than had the 1988 report, which mainly emphasized government’s role in
achieving public health goals.
The 2002 IOM report restated the unique responsibility that government has for promoting and protecting the
health of its people. It noted, however, that four factors argue that government alone should not bear full responsibility
for the health of the public:
1. Public resources are limited, and public health spending must compete with other valid causes.
2. Democratic societies expressly limit the powers of government and reserve many activities for private
institutions.
3. Determinants affecting health derive from multiple sources and sectors, including many social determinants
that cannot be addressed by government alone.
4. There is growing evidence that multisectoral collaborations are more powerful and effective than government
acting alone.5
In light of these factors, the 2002 IOM report examined both the governmental contributions to the public’s health
and those from other sectors of American society. Recommendations for the governmental enterprise were
complemented by recommendations for healthcare providers, business, media, the faith community, and academia. The
report proposed six major areas for action:
1. Adopting a population health approach that considers the multiple determinants of health within an ecological
framework
2. Strengthening the governmental public health infrastructure, which forms the backbone of the public health
system
3. Building a new generation of intersectoral partnerships that also draw on the perspectives and resources of
diverse communities and actively engages them in health actions
4. Developing systems of accountability to ensure the quality and availability of public health services
5. Making evidence the foundation of decision making and the measure of success
6. Enhancing and facilitating communication within the public health system (e.g., among all levels of the
governmental public health infrastructure, between public health professionals and community members)5
Barriers to future progress are apparent in both major IOM reports. Foremost has been the lack of a social-
ecological view of health that attempts to understand good and poor health in terms of the multiple factors that
interact with each other at the personal, family, community, and population level. Another set of important barriers
affecting public health is the prevailing values of the American public—in particular, those restricting the ability of
government to identify and address factors that influence health. Social values determine the extent to which
government can regulate human behavior, such as through controlling the production and use of tobacco products or
requiring bicycle or motorcycle helmet use. These values also determine whether and to what extent family planning
or school-based clinic services are provided in a community and determine the content of school health education
curricula. Some of these social values find strange bedfellows. For example, many Americans oppose control of
firearms on the basis of principles of self-protection embodied in the U.S. Constitution; gun companies also oppose
control, although on the basis of more direct economic considerations.
Economic and resource considerations are common themes, as well. One obvious issue is that most public health
activities remain funded from the discretionary budgets of local, state, and federal government. At all levels,
discretionary programs have been squeezed by true entitlement programs, such as Medicaid and Medicare, as well as
by some governmental responsibilities that have become near entitlements, such as public safety, law enforcement,
corrections, and education. The war on terrorism with military campaigns in Iraq and Afghanistan further squeezed
the national budget and any chance of significant health or human service initiatives at home. Funding one set of
health-related services from governmental discretionary funds while other health services are financed through a
competitive marketplace widens the imbalance between treatment and prevention as investment strategies for
improved health status. There are powerful economic interests among health sector industries, as well as among
industries whose products affect health, such as the tobacco, alcohol, pesticide, and firearms industries. One can only
dream that equally powerful lobbies, other than those made up of pharmaceutical companies, might develop for
hepatitis or drug-resistant tuberculosis.
All too often, the complex problems and issues of public health, with causes and contributing factors perceived to
lie outside its boundaries, lead public health professionals to believe that they should not be held accountable for
failure or success; however, many facets of public health practice itself could be further improved. These include
relationships with the private sector and medical practice and some internal reengineering of public health processes.
Fear and suspicion of the private sector can lead to many missed opportunities. Just as the three most important
factors determining real estate values are location, location, and location, it can be argued that the three most
important factors for health are jobs, jobs, and jobs. If this is anywhere near true, suspicions of the private sector need
to be put to rest. There is little question that employment is a powerful preventive health intervention, in terms of both
individual and community health status. Community development activities that bring new businesses and jobs to a
community can affect health status more positively than a public health clinic on every corner. Furthermore,
businesses have been major forces behind the growth of managed care systems in the United States. Their partnership
with public health interests will be essential to secure new resources or to shift the balance between treatment and
prevention strategies. Increased partnerships with medical care interests will also be necessary. Unfortunately, there
is widespread ignorance of the medical care sector among public health workers.
Among barriers internal to public health agencies is one that often goes unnoticed—the persistent and widespread
use of categorical approaches to the deployment of interventions, which often fragments and isolates individual
programs, one from another. In addition to the unnecessary proliferation of information, management, and other
administrative processes, each program tends to develop its own assortment of interest and constituency groups,
including those involving program staff members, who often work to oppose meaningful consolidation and integration
of programs.
Another limiting factor is the generalized inability to prioritize and focus public health efforts, despite the wealth of
information as to which factors most affect health at the national, state, and even local levels. Time and time again,
tobacco, alcohol, diet, and violence have been shown to lie at the root of most preventable mortality and years of
potential life lost. Ideally, resource allocation decisions would be made on the basis of the most important attributable
risks, rather than being spread around to address, ineffectively, risks both large and small. With scores of priorities,
there are really none, and without clear priorities, accountability is seldom expected. Public health has always
operated at the interface of science and politics; political issues and compromises are natural. Still, inconsistencies
between stated public health priorities and actual program priorities, as demonstrated through funding, are
themselves barriers to public understanding and support for public health work. Comprehensive and systematic
approaches must replace current silo strategies.
Other factors that influence public understanding and support for public health relate to the transition from
conditions caused by microorganisms to those caused by human behaviors. It is more difficult for the public to
appreciate the scientific basis for public health interventions when social, rather than physical sciences, guide
strategies. This occurs at a time when government is increasingly portrayed as both incompetent and overly intrusive.
Largely because governmental processes are considered by the public to be intensely political, the public view of
public health processes, including programs and regulations, is that of highly politicized and partly scientific exercises.
There has been considerable debate as to whether the 1988 IOM report accurately captured the problems and
needs of the American public health system. In many respects, the report restated the fundamental values and
concepts underlying public health in terms of its emphasis on prevention, professional diversity, collaborative nature,
community problem solving, loosely attached constituencies, assurance functions, need to draw other sectors into the
solution of public health problems, and lack of an identifiable constituency. Taken together, these features appear to
represent disarray; however, the cause of this disarray may not lie with public health but rather with our social and
governmental institutions, more generally. Posing solutions that restructure the public health system’s components
may do little more than rearranging the deck chairs on the Titanic would have done.
It may be necessary to more broadly restructure the tasks and functions of public health to deal with modern public
health problems. The larger work of public health is to get the threat protection, disease prevention, and health
promotion job done right, rather than to get it done through a traditional structuring of roles and responsibilities.
Preventing disease and promoting health must be embraced throughout society and its health institutions, rather than
existing in a parallel subsystem. There is no evidence to support the contention that public health activities are best
organized through public health agencies of government. Other nations have emphasized social policies that have
brought them better overall health outcomes for their populations at much lower cost. It is the mission and the effort
that are important and not necessarily the organization from which those efforts are generated.
OUTSIDE-THE-BOOK THINKING 14-2
Using an academic grading scale from A to F, how effective is the public health system in the United States? How did you
arrive at this rating?
CONCLUSION: THE NEED FOR A MORE EFFECTIVE PUBLIC HEALTH SYSTEM
The perpetual frustration for public health is the gap between what has been achieved and what could have been
achieved. The unfulfilled promise of public health should not be viewed as some unfortunate accident but as a direct
result of a series of past decisions and actions undertaken quite purposefully. Sadly, they reflect both a history of
disregard and the consequences of battles over the legitimacy, scope, professional authority, and political reach of
public health.7 A recent example is the use of tobacco settlement funds.
The various settlements in 1998 with a group of the major tobacco companies will provide $250 billion to the states
over a 25-year period. These settlements were initially viewed as a colossal success for public health over one of its
most important enemies. Although still in the middle years of this possible quarter-century windfall, state legislative
and executive branch leaders have opted to use this money for a variety of purposes, some for health purposes but
much for other ends. It was expected that approaches would vary from state to state, with most using some portion of
the money to support tobacco cessation and prevention interventions. Early indications, however, are that as little as
one third of the settlement funds were earmarked for health programs and that the health share declined rapidly in
the face of state budget deficits throughout the first and second decades of the century.
The tobacco company settlement can be viewed as a success story or as part of a full accounting of the massive
failure of public health efforts in the battle against tobacco use. Why did it take 3 decades to change public
perceptions and values to the point that settlement became inevitable? Without attention to the lessons of this saga
and to strengthening the public health system, tobacco will be the first of many health hazards that are inadequately
addressed and for which a negotiated settlement will eventually occur. If we look at the tobacco settlement as a signal
of the failure of public health and evidence of a weak public health infrastructure, this windfall becomes, at best, a
bittersweet victory. Perhaps the tobacco settlement windfall would best be directed toward averting the next tobacco-
like settlement. Difficult questions arise, even in otherwise good times!
In any event, the settlement offered the possibility of a sustained increase in public health resources to the tune of
about $10 billion annually for 25 years. Considering that only approximately $43 billion was expended for
governmental public health activities in 2000, the tobacco funds represented a possible 25% increase. Additional
funding to governmental public health agencies for bioterrorism preparedness on top of the tobacco settlement funds
provided for a possible doubling of governmental public health activities in the early years of the 21st century. As we
have seen, however, this was an illusion that never materialized.
These circumstances and other key issues and challenges facing the future of public health defy simple
summarization. This chapter has examined several, including those offered by the achievements and limitations of
public health practice in the 20th century and others offered by the IOM reports; other chapters presented many
more. Which of these are most important remains a point of contention. It would be useful to have an official list that
represents the consensus of policy makers and the public alike; however, because an official list is lacking, several
general conclusions as to the critical challenges and obstacles facing the future of public health in the United States
are offered here. They summarize some of the important themes of this text in describing why we need more effective
public health efforts.
The Easy Problems Have Already Been Solved
Major successes have been achieved through public health efforts over the past 150 years, largely related to massive
reductions in infectious diseases but also involving substantial declines in death rates for injuries and several major
chronic diseases since about 1960. The list of current problems for public health includes the more difficult chronic
diseases, new and emerging conditions, including bioterrorism, and broader social problems with health effects (teen
pregnancy and violence are good examples) that have identifiable risk and contributing factors that can be addressed
only through collective action. The days of command-and-control approaches to relatively simple infectious risks are
behind us. In the past, environmental sanitation and engineering could collaborate with communicable disease control
expertise to address important public health problems. The collaborations needed for violence prevention or
bioterrorism preparedness require very different skills and relationships.
To a Hammer, the Entire World Looks Like a Nail
Behind the aphorism that to a hammer, the entire world looks like a nail is the perception that common education and
work experiences foster common professional perspectives. The danger lies in believing that one’s own professional
tools are adequate to the task of dealing with all of the problems and needs that are served by the profession. Each
profession has its own scientific base and jargon. Problems are given labels or diagnoses, using the profession’s
specialized language, so that the tools of the profession can be brought to bear on those problems. All too often,
however, the problems come to be considered as the domain of that profession, and the potential contributions of other
professions and disciplines are underappreciated. Although public health professionals are remarkably diverse in
terms of their educational and experiential backgrounds, we can also fall into this trap. When we do, bridges to other
partners are not built, and collaborations do not take place. As a result, problems that can be addressed only through
collaborative, intersectoral approaches flourish unabated.
A Friend in Need Is a Friend Indeed
Finding the means to build such bridges can be difficult, but some key collaborations appear to be absolutely essential
for the work of public health to succeed. Certainly, links between public health and medical care must be improved for
both to prosper in a reforming health system. Links with businesses also represent another avenue for mutually
successful collaborations. The key is to find major areas of common purpose. For medical care interests, the common
denominator is that prevention saves money and rewards those who use it as an investment strategy. For business
interests, the bottom line has to be improved, and businesses must accept the premise that improving health status in
the community serves their bottom lines through healthier, more productive workers and healthier and wealthier
consumers.
You Get What You Pay For
There is good cause to question the current national investment strategy as it relates to health. The excess capacity
that has been established in the American health system is becoming increasingly unaffordable, and the results are
nothing about which to write home. Still, the competition for additional dollars is intense among the major interests
that dominate the health industry, and there is only minimal movement to alter the current balance between treatment
and prevention strategies. With less than 5% of all health expenditures supporting public health’s core functions and
essential services and only about 1% supporting population-based prevention, even small shifts could reap substantial
rewards. The argument that resources are limited and that there simply are not adequate resources to meet
treatment, as well as prevention purposes, is uniquely American and quite inimical to the public’s health. More
disconcerting yet are the lost opportunities in securing and using recent tobacco settlement and bioterrorism
preparedness funding to shore up a sagging public health infrastructure.
It’s Not My Job?
The job description of public health has never been clear. As a result, public health has become quite proficient in
delivering specific services, with less attention paid to mobilizing action toward those factors that most seriously affect
community health status. Among traditional health-related factors, tobacco, alcohol, and diet are factors responsible
for much of modern America’s mortality (or lack thereof) and morbidity. Nonetheless, the resources supporting
interventions directed toward these factors are minuscule. Similarly, the primary cause of America’s relatively poor
health outcomes, in comparison with other developed nations, as well as the most likely source for further health gains
in the United States, resides in the huge and increasing gaps among racial and ethnic groups. The public health
system, from national to state and local levels, must recognize these circumstances and move beyond them to advocate
and build constituencies aggressively for efforts that target the most important of the traditional health risk factors
and that promote social policies that will both minimize and equalize risks throughout the population. The task is as
simple as following the golden rule and doing for others what we want done for ourselves because efforts to improve
the health of others make everyone healthier. This does not constitute a new job description for public health in the
United States, but rather a recommitment to an old, reasonably successful, and absolutely necessary one.
REFERENCES
1. Centers for Disease Control and Prevention. Addressing Emerging Infectious Disease Threats: A Prevention Strategy for the United States.
Atlanta, GA: U.S. Public Health Service; 1994.
2. U.S. Department of Health and Human Services. Healthy People 2020. Accessible at www.healthypeople.gov. Accessed June 15, 2014.
3. McKinlay JB, Marceau LD. To boldly go …. Am J Public Health. 2000; 90: 25–33.
4. Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press; 1988.
5. Institute of Medicine. The Future of the Public’s Health in the 21st Century. Washington, DC: National Academy Press; 2003.
6. Institute of Medicine. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. Washington, DC: National
Academy Press; 2003.
7. Fee E, Brown TM. The unfulfilled promise of public health: déjà vu all over again. Health Aff. 2002; 21: 31–43.
Glossary
TERM DEFINITION (NOTE: Some definitions are quoted from other sources; refer to text for citations.)
Access—The potential for or actual entry of a population into the health system. Entry is dependent on the wants,
resources, and needs that individuals bring to the care-seeking process. Ability to obtain wanted or needed services
may be influenced by many factors, including travel distance, waiting time, available financial resources, and
availability of a regular source of care.
Accreditation—For public health agencies, accreditation is a process that measures the performance of the
organization against a set of nationally recognized, practice-focused and evidence-based standards. The Public Health
Accreditation Board recognizes (i.e., accredits) public health agencies that meet these standards.
Actual Cause of Death—A primary determinant or risk factor associated with a pathologic or diagnosed cause of
death. For example, tobacco use would be the actual cause for deaths from many lung cancers.
Adjusted Rate—The adjustment or standardization of rates is a statistical procedure that removes the effect of
differences in the composition of populations. Because of its marked effect on mortality and morbidity, age is the
variable for adjustment used most commonly. For example, an age-adjusted death rate for any cause permits a better
comparison between different populations and at different times because it accounts for differences in the distribution
of age.
Administrative Law—Rules and regulations promulgated by administrative agencies within the executive branch of
government that carry the force of law. Administrative law represents a unique situation in which legislative,
executive, and judicial powers are carried out by one agency in the development, implementation, and enforcement of
rules and regulations.
Age-Adjusted Mortality Rate—The expected number of deaths that would occur if a population had the same age
distribution as a standard population, expressed in terms of deaths per 1,000 or 100,000 persons.
Affordable Care Act—The common name for the Patient Protection and Affordable Care Act of 2010 (Public Law 111-
148), which is the federal statute incorporating many health reform provisions affecting health insurance policies,
coverage, cost, and quality of care. This legislation is also known as “Obamacare,” as it was proposed by the Obama
Administration and signed into law by the President.
Appropriateness—Health interventions for which the expected health benefit exceeds the expected negative
consequences by a wide enough margin to justify the intervention.
Assessment—One of public health’s three core functions. Assessment calls for regularly and systematically collecting,
analyzing, and making available information on the health of a community, including statistics on health status,
community health needs, and epidemiologic and other studies of health problems.
Assets—Resources available to achieve a specific end, such as community resources that can contribute to community
health improvement efforts or emergency response resources, including human, to respond to a public health
emergency.
Association—The relationship between two or more events or variables. Events are said to be associated when they
occur more frequently together than one would expect by chance. Association does not necessarily imply a causal
relationship.
Assurance—One of public health’s three core functions. It involves assuring constituents that services necessary to
achieve agreed-upon goals are provided by encouraging actions on the part of others, by requiring action through
regulation, or by providing services directly.
Attributable Risk—The theoretical reduction in the rate or number of cases of an adverse outcome that can be
achieved by elimination of a risk factor. For example, if tobacco use is responsible for 75% of all lung cancers, the
elimination of tobacco use will reduce lung cancer mortality rates by 75% in a population over time.
Behavioral Risk Factors Surveillance System—A national data collection system funded by the Centers for Disease
Control and Prevention (CDC) to assess the prevalence of behaviors that affect health status. Through individual state
efforts, CDC staff coordinate the collection, analysis, and distribution of survey data on seat belt use, hypertension,
physical activity, smoking, weight control, alcohol use, mammography screening, cervical cancer screening, and AIDS,
as well as other health-related information.
Biosurveillance—The process of gathering, integrating, interpreting, and communicating essential information that
might relate to disease activity and threats to human, animal, or plant health. For public health workers,
biosurveillance activities range from standard epidemiological practices to advanced technological systems, utilizing
complex algorithms.
Bioterrorism—The threatened or intentional release of biologic agents (viruses, bacteria, or their toxins) for the
purpose of influencing the conduct of government or intimidating or coercing a civilian population to further political
or social objectives. These agents can be released by way of the air (as aerosols), food, water, or insects.
Capacity—The capability to carry out the core functions of public health. Also see infrastructure.
Capitation—A method of payment for health services in which a provider is paid a fixed amount for each person
served, without regard to the actual number or nature of services provided to each person in a set period of time.
Capitation is the characteristic payment method in health maintenance organizations.
Case Definition—Standardized criteria for determining whether a person has a particular disease or health-related
condition. Criteria often include clinical and laboratory findings, as well as personal characteristics (e.g., age, sex,
location, time period). Case definitions are often used in investigations and for comparing potential cases.
Case Management—The monitoring and coordinating of services rendered to individuals with specific problems or
who require high-cost or extensive services.
Casualty—Any person suffering physical and/or psychological damage that leads to death, injury, or material loss.
Causality—The relationship of causes to the effects they produce; several types of causes can be distinguished. A
cause is termed necessary when a particular variable must always precede an effect. This effect need not be the sole
result of the one variable. A cause is termed sufficient when a particular variable inevitably initiates or produces an
effect. Any given cause may be necessary, sufficient, neither, or both.
Cause of Death—For the purpose of national mortality statistics, every death is attributed to one underlying
condition, based on the information reported on the death certificate and utilizing the international rules for selecting
the underlying cause of death from the reported conditions.
Centers for Disease Control and Prevention (CDC)—The Centers for Disease Control and Prevention, based in
Atlanta, Georgia, is the federal agency charged with protecting the nation’s public health by providing direction in the
prevention and control of communicable and other diseases and responding to public health emergencies. CDC’s
responsibilities as the nation’s prevention agency have expanded over the years and will continue to evolve as the
agency addresses contemporary threats to health, such as injury, environmental and occupational hazards, behavioral
risks, and chronic diseases; and emerging communicable diseases, such as the Ebola virus.
Certification—A process by which an agency or association grants recognition to another party who has met certain
predetermined qualifications specified by the agency or association.
Chronic Disease—A disease that has one or more of the following characteristics: (1) it is permanent, (2) it leaves
residual disability, (3) it is caused by a nonreversible pathologic alteration, (4) it requires special training of the patient
for rehabilitation, or (5) it may be expected to require a long period of supervision, observation, or care.
Clinical Practice Guidelines—Systematically developed statements that assist practitioner and patient decisions
about appropriate health services for specific clinical conditions.
Clinical Preventive Services—Clinical services provided to patients to reduce or prevent disease, injury, or disability.
These are preventive measures (including screening tests, immunizations, counseling, and periodic physical
examinations) provided by a health professional to an individual patient.
Community—A group of people who have common characteristics; communities can be defined by location, race,
ethnicity, age, occupation, interest in particular problems or outcomes, or other common bonds. Ideally, there should
be available assets and resources, as well as collective discussion, decision making, and action.
Community Health Improvement Process—A systematic effort that assesses community needs and assets,
prioritizes health-related problems and issues, analyzes problems for their causative factors, develops evidence-based
intervention strategies based on those analyses, links stakeholders to implementation efforts through performance
monitoring, and evaluates the effect of interventions in the community.
Community Health Needs Assessment—A formal approach to identifying health needs and health problems in the
community. A variety of tools or instruments may be used; the essential ingredient is community engagement and
collaborative participation.
Community Preventive Services—Population-based interventions to reduce or prevent disease, injury, or disability.
These are preventive interventions targeting the entire population rather than individuals.
Comprehensive Emergency Management—A broad style of emergency management, encompassing prevention,
preparedness, response, and recovery.
Condition—A health condition is a departure from a state of physical or mental well-being. An impairment is a health
condition that includes chronic or permanent health defects resulting from disease, injury, or congenital
malformations. All health conditions except impairments are coded according to an international classification system.
Based on duration, there are two types of conditions—acute and chronic.
Consequence Management—An emergency management function that includes measures to protect public health
and safety, restore essential government services, and provide emergency relief to governments in the event of
terrorism.
Contamination—An accidental release of hazardous chemicals or nuclear materials that pollute the environment and
place humans at risk.
Contributing Factor—A risk factor (causative factor) that is associated with the level of a determinant. Direct
contributing factors are linked with the level of determinants; indirect contributing factors are linked with the level of
direct contributing factors.
Core Functions—Three basic roles for public health for assuring conditions in which people can be healthy. As
identified in the Institute of Medicine’s landmark report, The Future of Public Health, these are assessment, policy
development, and assurance.
Cost-Benefit Analysis—An economic analysis in which all costs and benefits are converted into monetary (dollar)
values, and results are expressed as dollars of benefit per dollars expended.
Cost-Effectiveness Analysis—An economic analysis assessed as a health outcome per cost expended.
Cost-Utility Analysis—An economic analysis assessed as a quality-adjusted outcome per net cost expended.
Countermeasures—A measure or action that is taken to counter or offset another measure. Countermeasures are
designed or selected for their precision and specificity in preventing undesired outcomes from occurring.
Covert Releases—For biologic agents, an unannounced release of a biologic agent that causes illness or other effects.
If undetected, a covert release has the potential to spread widely before it is detected.
Crisis Management—Administrative measures that identify, acquire, and plan the use of resources needed to
anticipate, prevent, and/or resolve a threat to public safety (such as terrorism).
Crude Mortality Rate—The total number of deaths per unit of population reported during a given time interval, often
expressed as the number of deaths per 1,000 or 100,000 persons.
Cultural Competence—The ability to communicate with and provide services to an individual or a group with full
respect for the culturally associated values, preferences, language, and experiences of the group.
Decision Analysis—An analytic technique in which probability theory is used to obtain a quantitative approach to
decision making.
Decontamination—The removal of hazardous chemicals or nuclear substances from the skin and/or mucous
membranes by showering or washing the affected area with water or by rinsing with a sterile solution.
Demographics—Characteristic data, such as size, growth, density, distribution, and vital statistics, which are used to
study human populations.
Demonstration Settings—A population-based or clinic-based environment in which prevention strategies are field-
tested.
Determinant—A primary risk factor (causative factor) associated with the level of health problem (i.e., the level of the
determinant influences the level of the health problem).
Disability Limitation—An intervention strategy that seeks to arrest or eradicate disease and/or limit disability and
prevent death.
Disaster—Any event, typically occurring suddenly, that causes damage, ecologic disruption, loss of human life, or
deterioration of health and health services and that exceeds the capacity of the affected community on a scale
sufficient to require outside assistance.
Disaster Severity Scale—A scale that classifies disasters by the following parameters: (1) the radius of the disaster
site, (2) the number of dead, (3) the number of wounded, (4) the average severity of the injuries sustained, (5) the
impact time, and (6) the rescue time. By attributing a numeric score to each of the variables from 0 to 2, with 0 being
the least severe and 2 the most severe, a scale with a range of 0 to 18 can be created.
Discounting—A method for adjusting the value of future costs and benefits. Expressed as a present dollar value,
discounting is based on the time value of money (i.e., a dollar today is worth more than it will be a year from now, even
if inflation is not considered).
Distributional Effects—The manner in which the costs and benefits of a strategy affect different groups of people in
terms of demographics, geographic location, and other descriptive factors.
Early Case Finding and Treatment—An intervention strategy that seeks to identify disease or illness at an early
stage so that prompt treatment will reduce the effects of the process.
Effectiveness—The improvement in health outcome that a strategy can produce in typical community-based settings.
Also, the degree to which objectives are achieved.
Efficacy—The improvement in health outcome effect that a strategy can produce in expert hands under ideal
circumstances.
Emergency—Any natural or human-made situation that results in severe injury, harm, or loss to humans or property.
Emergency Management Agency—The agency, under the authority of the governor’s office, that coordinates the
efforts of the state’s health department, housing and social service agencies, and public safety agencies (such as state
police) during an emergency or disaster. The emergency management agency also coordinates federal resources made
available to the states, such as the National Guard, Centers for Disease Control and Prevention, and the Public Health
Service.
Emergency Medical Services (EMS) System—The coordination of the prehospital system (including public access,
911 dispatch, paramedics, and ambulance services) and the in-hospital system (including emergency departments,
hospitals, and other definitive care facilities and personnel) to provide emergency medical care.
Emergency Operations Center (EOC)—The site from which civil governmental officials (such as municipal, county,
state, or federal) direct emergency operations in a disaster.
Epidemic—The occurrence of a disease or condition at higher than normal levels in a population.
Epidemiology—The study of the distribution of determinants and antecedents of health and disease in human
populations, the ultimate goal of which is to identify the underlying causes of a disease, then apply findings to disease
prevention and health promotion.
Escherichia coli (E. coli) O57:H7—A bacterial pathogen that can infect humans and cause severe bloody diarrhea
(hemorrhagic colitis) and serious renal disease (hemolytic uremic syndrome).
Essential Public Health Services—A formulation of the processes used in public health to prevent epidemics and
injuries, protect against environmental hazards, promote healthy behaviors, respond to disasters, and ensure quality
and accessibility of health services. Ten essential services have been identified:
1. Monitoring health status to identify community health problems
2. Diagnosing and investigating health problems and health hazards in the community
3. Informing, educating, and empowering people about health issues
4. Mobilizing community partnerships to identify and solve health problems
5. Developing policies and plans that support individual and community health efforts
6. Enforcing laws and regulations that protect health and ensure safety
7. Linking people to needed personal health services and ensuring the provision of health care when otherwise
unavailable
8. Ensuring a competent public health and personal healthcare workforce
9. Evaluating effectiveness, accessibility, and quality of personal and population-based health services
10. Conducting research for new insights and innovative solutions to health problems
Evacuation—The organized removal of civilians from a dangerous or potentially dangerous area.
Evidence-Based Public Health—Key components of evidence-based public health include making decisions on the
basis of the best available scientific evidence, using data and information systems systematically, applying program-
planning frameworks, engaging the community in decision making, conducting sound evaluation, and disseminating
what is learned. Three types of evidence have been presented on the causes of diseases and the magnitude of risk
factors, the relative impact of specific interventions, and how and under which contextual conditions interventions
were implemented.
Federal Response Plan—The plan that coordinates federal resources in disaster and emergency situations in order to
address the consequences when there is need for federal assistance under the authorities of the Stafford Disaster
Relief and Emergency Assistance Act.
Federally Funded Community Health Center—An ambulatory healthcare program (defined under Section 330 of
the Public Health Service Act), usually serving a catchment area that has scarce or nonexistent health services or a
population with special health needs; sometimes known as a neighborhood health center. Community health centers
attempt to coordinate federal, state, and local resources in a single organization capable of delivering both health and
related social services to a defined population. Although such a center may not directly provide all types of health
care, it usually takes responsibility to arrange all medical services for its patient population.
Field Model—A framework for identifying factors that influence health status in populations. Initially, four fields were
identified: (1) biology, (2) lifestyle, (3) environment, and (4) health services. Extensions of this approach have also
identified genetic, social, and cultural factors and have related these factors to a variety of outcomes, including
disease, normal functioning, well-being, and prosperity.
Foodborne Illness—Illness caused by the transfer of disease organisms or toxins from food to humans.
General Welfare Provisions—Specific language in the Constitution of the United States that empowers the federal
government to provide for the general welfare of the population. Over time, these provisions have been used as a basis
for federal health policies and programs.
Goals—For public health programs, general statements expressing a program’s aspirations or intended effect on one
or more health problems, often stated without time limits.
Governmental Presence at the Local Level—A concept that calls for the assurance that necessary services and
minimum standards are provided to address priority community health problems. This responsibility ultimately falls to
local government, which may utilize local public health agencies or other means for its execution.
Harm Reduction—A set of practical strategies reflecting individual and community needs that meet individuals with
risk behaviors where they are to help them reduce any harms associated with their risk behaviors.
Hazard—A possible source of harm or injury.
Hazard Vulnerability Analysis—A systematic approach to recognizing hazards that may affect a population,
community, or organization. The risks associated with each hazard are analyzed to prioritize planning, mitigation,
response, and recovery activities. A hazard vulnerability analysis serves as a needs assessment for emergency
preparedness and response activities.
Health—The state of complete physical, mental, and social well-being and not merely the absence of disease or
infirmity. It is recognized, however, that health has many dimensions (anatomic, physiologic, and mental) and is largely
culturally defined. The relative importance of various disabilities will differ, depending on the cultural milieu and on
the role of the affected individual in that culture. Most attempts at measurement have been assessed in terms of
morbidity and mortality.
Health Disparity—Difference in health status between two groups, such as the health disparity in mortality between
men and women, or the health disparity in infant mortality between African American and white infants.
Health Education—Any combination of learning opportunities designed to facilitate voluntary adaptations of
behavior (in individuals, groups, or communities) conducive to good health. Health education encourages positive
health behavior.
Health Impact Assessment—A systematic process that uses an array of data sources and analytic methods, and
considers input from stakeholders to determine the potential effects of a proposed policy, plan, program, or project on
the health of a population and the distribution of those effects within the population. Health impact assessments
provide recommendations on monitoring and managing those effects.
Health Maintenance Organizations—Entities that manage both the financing and provision of health services to
enrolled members. Fees are generally based on capitation, and health providers are managed to reduce costs through
controls on utilization of covered services.
Health Planning—Planning concerned with improving health, whether undertaken comprehensively for an entire
community or for a particular population, type of health services, institution, or health program. The components of
health planning include data assembly and analysis, goal determination, action recommendation, and implementation
strategy.
Health Policy—Social policy concerned with the process whereby public health agencies evaluate and determine
health needs and the best ways to address them, including the identification of appropriate resources and funding
mechanisms.
Health Problem—A situation or condition of people (expressed in health outcome measures such as mortality,
morbidity, or disability) that is considered undesirable and is likely to exist in the future.
Health Problem Analysis—A framework for analyzing health problems to identify their determinants and
contributing factors so that interventions can be targeted rationally toward those factors most likely to reduce the
level of the health problem.
Health Promotion—An intervention strategy that seeks to eliminate or reduce exposures to harmful factors by
modifying human behaviors. Any combination of health education and related organizational, political, and economic
interventions designed to facilitate behavioral and environmental adaptations that will improve or protect health. This
process enables individuals and communities to control and improve their own health. Health promotion approaches
provide opportunities for people to identify problems, develop solutions, and work in partnerships that build on
existing skills and strengths.
Health Protection—An intervention strategy that seeks to provide individuals with resistance to harmful factors,
often by modifying the environment to decrease potentially harmful interactions. Those population-based services and
programs control and reduce the exposure of the population to environmental or personal hazards, conditions, or
factors that may cause disease, disability, injury, or death. Health protection also includes programs that ensure that
public health services are available on a 24-hour basis to respond to public health emergencies and coordinate
responses of local, state, and federal organizations.
Health Regulation—Monitoring and maintaining the quality of public health services through licensing and discipline
of health professionals, licensing of health facilities, and enforcement of standards and regulations.
Health Status Indicators—Measurements of the state of health of a specified individual, group, or population.
Health status may be measured by proxies such as people’s subjective assessments of their health; by one or more
indicators of mortality and morbidity in the population, such as longevity or maternal and infant mortality; or by the
incidence or prevalence of major diseases (communicable, chronic, or nutritional). Conceptually, health status is the
proper outcome measure for the effectiveness of a specific population’s health system, although attempts to relate
effects of available medical care to variations in health status have proved difficult.
Health System—As used in this text, the sum total of the strategies designed to prevent or treat disease, injury, and
other health problems. The health system includes population-based preventive services, clinical preventive and other
primary medical care services, and all levels of more sophisticated treatment and chronic care services.
Healthy Communities—A framework for developing and tailoring community health objectives so that these can be
tracked as part of the initiative to achieve the national health objectives included in Healthy People 2020.
Healthy People 2020—The national disease prevention and health promotion agenda that includes the national
health objectives to be achieved by the year 2020, addressing improved health status, risk reduction, and utilization of
preventive health services.
Incidence—A measure of the disease or injury in the population, generally the number of new cases occurring during
a specified time period.
Incident Command System (ICS)—The model for command, control, and coordination of a response to an
emergency providing the means to coordinate the efforts of multiple agencies and organizations.
Indicator—A measure of health status or a health outcome.
Infant Mortality Rate—The number of live-born infants who die before their first birthday per 1,000 live births; often
broken into two components, neonatal mortality (deaths before 28 days per 1,000 live births) and postneonatal
mortality (deaths from 28 days through the rest of the first year of life per 1,000 live births).
Infectious Disease—A disease caused by the entrance into the body of organisms (such as bacteria, protozoans,
fungi, or viruses) that then grow and multiply there (often used synonymously with communicable disease).
Infrastructure—The systems, competencies, relationships, and resources that enable performance of public health’s
core functions and essential services in every community. Categories include human, organizational, informational,
and fiscal resources.
Inputs—Human resources, fiscal and physical resources, information resources, and system organizational resources
necessary to carry out the core functions of public health (sometimes referred to as capacities).
Intervention—A generic term used in public health to describe a program or policy designed to have an impact on a
health problem. For example, a mandatory seat belt law is an intervention designed to reduce the incidence of
automobile-related fatalities. Five categories of heath interventions are: (1) health promotion, (2) specific protection,
(3) early case finding and prompt treatment, (4) disability limitation, and (5) rehabilitation.
Leading Causes of Death—Those diagnostic classifications of disease that are most frequently responsible for deaths
(often used in conjunction with the top 10 causes of death).
Leading Health Indicators—A panel of health-related measures that reflect the major public health concerns in the
United States. They were selected to track progress toward achievement of Healthy People goals and objectives. They
address 10 public health concerns: (1) physical activity, (2) overweight and obesity, (3) tobacco use, (4) substance
abuse, (5) responsible sexual behavior, (6) mental health, (7) injury and violence, (8) environmental quality, (9)
immunizations, and (10) access to health care.
Life Expectancy—The number of additional years of life expected at a specified point in time, such as at birth or at
age 45.
Local Health Department (LHD)—Functionally, a local (county, multicounty, municipal, town, other) health agency,
operated by local government, often with oversight and direction from a local board of health, that carries out public
health’s core functions throughout a defined geographic area. A more traditional definition is an agency serving less
than an entire state that carries some responsibility for health and has at least one full-time employee and a specific
budget.
Local Health Jurisdiction (LHJ)—A unit of local government (county, multicounty, municipal, town, other), often
with oversight and direction from a local board of health and with an identifiable local health department, that carries
out public health’s core functions throughout a defined geographic area.
Local Public Health Authority—The agency charged with responsibility for meeting the health needs of the
community. Usually this is the policy/governing body and its administrative arm, the local health department. The
authority may rest with the policy/governing body, may be a city/county/regional authority, or may consist of a
legislative mandate from the state. Some local public health authorities have independence from all other
governmental entities, whereas others do not.
Local Public Health System—The collection of public and private organizations having a stake in and contributing to
public health at the local level. It involves far more than the local public health agency.
Managed Care—A system of administrative controls intended to reduce costs through managing the utilization of
services. Managed care can also mean an integrated system of health insurance, financing, and service delivery that
focuses on the appropriate and cost-effective use of health services delivered through defined networks of providers
and with allocation of financial risk.
Measure—An indicator of health status or a health outcome, used synonymously with indicator in this text.
Medicaid—A federally aided, state-operated and administered program that provides basic medical services to
eligible low-income populations, established through amendments as Title XIX of the Social Security Act in 1965. It
does not cover all of the poor, however, but only persons who meet specified eligibility criteria. Subject to broad
federal guidelines, states determine the benefits covered, program eligibility, rates of payment for providers, and
methods of administering the program.
Medical Reserve Corps—Locally based teams of health professionals and other personnel who provide surge
capacity for emergencies.
Medicare—A national health insurance program for elderly persons established through amendments to the Social
Security Act in 1965 that were included in Title XVIII of that act.
Midlevel Practitioners—Non-physician healthcare providers, such as nurse practitioners and physician assistants.
Mission—For public health, ensuring conditions in which people can be healthy.
Mitigation—Measures taken to reduce the harmful effects of a disaster or emergency by attempting to limit the
impact on human health and economic infrastructure.
Mobilizing for Action through Planning and Partnerships (MAPP)—A voluntary process for organizational and
community self-assessment, planned improvements, and continuing evaluation and reassessment. The process focuses
on community-wide public health practice, including a health department’s role in its community and the community’s
actual and perceived problems. It provides for a community health improvement process to assess health needs, sets
priorities, develops policy, and ensures that health needs are met.
Morbidity—A measure of disease incidence or prevalence in a given population, location, or other grouping of
interest.
Mortality—Expresses the number of deaths in a population within a prescribed time. Mortality rates may be
expressed as crude death rates (total deaths in relation to total population during a year) or as death rates specific for
diseases and sometimes for age, sex, or other attributes (e.g., the number of deaths from cancer in white males in
relation to the white male population during a given year).
National Health Expenditures—The amount spent for all health services and supplies and health-related research
and construction activities in the United States during the calendar year.
Obamacare—See Affordable Care Act.
Objectives—Targets for achievement through interventions. Objectives are time-limited and measurable in all cases.
Various levels of objectives for an intervention include outcome, impact, and process objectives.
Outcomes—Indicators of health status, risk reduction, and quality-of-life enhancement (sometimes referred to as
results of the health system). Outcomes are long-term objectives that define optimal, measurable future levels of
health status; maximum acceptable levels of disease, injury, or dysfunction; or prevalence of risk factors.
Outputs—Health programs and services intended to prevent death, disease, and disability, and to promote quality of
life.
Personal Health Services—Diagnosis and treatment of disease or provision of clinical preventive services to
individuals or families in order to improve individual health status.
Police Power—A basic power of government that allows for restriction of individual rights to protect the safety and
interests of the entire population.
Policy Development—One of public health’s three core functions. Policy development involves serving the public
interest by leading in developing comprehensive public health policy and promoting the use of the scientific knowledge
base in decision making.
Population-Based Public Health Services—Interventions aimed at disease prevention and health promotion that
affect an entire population and extend beyond medical treatment by targeting underlying risks, such as tobacco, drug,
and alcohol use; diet and sedentary lifestyles; and environmental factors.
Postponement—A form of prevention in which the time of onset of a disease or injury is delayed to reduce the
prevalence of a condition in the population.
Preparedness—All measures and policies taken before an event occurs that allow for prevention, mitigation, and
readiness.
Prevalence—A measure of the burden of disease or injury in a population, generally the number of cases of a disease
or injury at a particular point in time or during a specified time period. Prevalence is affected by both the incidence
and the duration of disease in a population.
Prevented Fraction—The proportion of an adverse health outcome that has been eliminated as a result of a
prevention strategy.
Prevention—Anticipatory action taken to prevent the occurrence of an event or to minimize its effects after it has
occurred. Prevention aims to minimize the occurrence of disease or its consequences. It includes actions that reduce
susceptibility or exposure to health threats (primary prevention), detect and treat disease in early stages (secondary
prevention), and alleviate the effects of disease and injury (tertiary prevention). Examples of prevention include
immunizations, emergency response to epidemics, health education, modification of risk-prone behavior and physical
hazards, safety training, workplace hazard elimination, and industrial process change.
Preventive Strategies—Frameworks for categorizing prevention programs, based on how the prevention technology
is delivered—provider to patient (clinical preventive services), individual responsibility (behavioral prevention), or
alteration in an individual’s surroundings (environmental prevention)—or on the stage of the natural history of a
disease or injury (primary, secondary, tertiary).
Primary Medical Care—Clinical preventive services, first-contact treatment services, and ongoing care for commonly
encountered medical conditions. Basic or general health care focuses on the point at which a patient ideally seeks
assistance from the medical care system. Primary care is considered comprehensive when the primary provider takes
responsibility for the overall coordination of the care of the patient’s health problems, whether these are medical,
behavioral, or social. The appropriate use of consultants and community resources is an important part of effective
primary health care. Such care is generally provided by physicians but can also be provided by other personnel, such
as nurse practitioners or physician assistants.
Primary Prevention—Prevention strategies that seek to prevent the occurrence of disease or injury, generally
through reducing exposure or risk factor levels. These strategies can reduce or eliminate causative risk factors (risk
reduction).
Public Health—Activities that society undertakes to ensure the conditions in which people can be healthy. These
include organized community efforts to prevent, identify, and counter threats to the health of the public.
Public Health Accreditation Board—The organization that establishes performance standards for public health
agencies and coordinates the process of measuring those standards and recognizing (i.e., accrediting) those agencies
that meet these standards. Also see accreditation.
Public Health Agency—A unit of government (federal, state, local, or regional) charged with preserving, protecting,
and promoting the health of the population through ensuring delivery of essential public health services.
Public Health in America—A document developed by the Core Functions Project that characterizes the vision,
mission, outcome aspirations, and essential services of public health. Also see essential public health services.
Public Health Organization—A nongovernmental entity (e.g., not-for-profit agency, association, corporation)
participating in activities designed to improve the health status of a community or population.
Public Health Practice—The development and application of preventive strategies and interventions to promote and
protect the health of populations.
Public Health Practice Guidelines—Systematically developed statements that assist public health practitioner
decisions about interventions at the community level.
Public Health Processes—Those collective practices or processes that are necessary and sufficient to ensure that
the core functions and essential services of public health are being carried out effectively, including the key processes
that identify and address health problems and their causative factors and the interventions intended to prevent death,
disease, and disability, and to promote quality of life.
Public Health Service—U.S. Public Health Service, as reorganized in 1996, which now includes the Office of Public
Health and Science (which is headed by the Assistant Secretary for Health and includes the Office of the Surgeon
General), eight operating agencies (Health Resources and Services Administration; Indian Health Service; Centers for
Disease Control and Prevention; National Institutes of Health; Food and Drug Administration; Substance Abuse and
Mental Health Services Administration; Agency for Toxic Substances and Disease Registry; and Agency for Healthcare
Research and Quality); and the Regional Health Administrators for the 10 federal regions of the country.
Public Health System—That part of the larger health system that seeks to ensure conditions in which people can be
healthy by carrying out public health’s three core functions. The system can be further described by its inputs,
practices, outputs, and outcomes.
Public Health Workforce—The public health workforce includes individuals
• Employed by an organization engaged in an organized effort to promote, protect, and preserve the health of a
defined population group. The group may be public or private, and the effort may be secondary or subsidiary to
the principal objectives of the organization
• Performing work made up of one or more specific public health services or activities
• Occupying positions that conventionally require at least 1 year of postsecondary specialized public health
training and that are (or can be) assigned a professional occupational title
Quality-Adjusted Life Years (QALYs)—A measure of health status that assigns to each period of time a weight,
ranging from 0 to 1, corresponding to the health-related quality of life during that period. These are then summed
across time periods to calculate QALYs. For each period, a weight of 1 corresponds to optimal health, and a weight of 0
corresponds to a health state equivalent to death.
Quality of Care—The degree to which health services for individuals increase the likelihood of desired health
outcomes and are consistent with established professional standards and judgments of value to the consumer. Quality
also may be seen as the degree to which actions taken or not taken maximize the probability of beneficial health
outcomes and minimize risk and other undesired outcomes, given the existing state of medical science and art.
Rapid Needs Assessment—A variety of epidemiologic, statistic, anthropologic techniques designed to provide
information about an affected community’s needs following a disaster or other public health emergency.
Rate—A mathematical expression for the relation between the numerator (e.g., number of deaths, diseases,
disabilities, services) and denominator (population at risk), together with specification of time. Rates make possible a
comparison of the number of events between populations and at different times. Rates may be crude, specific, or
adjusted.
Recovery—Actions of responders, government, and victims that help return an affected community to normal by
stimulating community cohesiveness and governmental involvement. The recovery period falls between the onset of an
emergency and the reconstruction period.
Rehabilitation—An intervention strategy that seeks to return individuals to the maximum level of functioning
possible.
Response—The phase in a disaster or public health emergency when relief, recovery, and rehabilitation occur.
Risk—The probability that exposure to a hazard will lead to a negative consequence.
Risk Assessment—A determination of the likelihood of adverse health effects to a population after exposure to a
hazard.
Risk Factor—A behavior or condition that, on the basis of scientific evidence or theory, is thought to influence
susceptibility to a specific health problem.
Risk Ratio/Relative Risk—The ratio of the risk or likelihood of the occurrence of specific health outcomes or events
in one group to that of another. Risk ratios provide a measure of the relative difference in risk between the two groups.
Relative risk is an example of a risk ratio in which the incidence of disease in the exposed group is divided by the
incidence of disease in an unexposed group.
Screening—The use of technology and procedures to differentiate those individuals with signs or symptoms of disease
from those less likely to have the disease. Then, if necessary, further diagnosis and, if indicated, early intervention and
treatment can be provided.
Secondary Medical Care—Specialized attention and ongoing management for common and less frequently
encountered medical conditions, including support services for people with special challenges because of chronic or
long-term conditions. Services are provided by medical specialists who generally do not have their first contact with
patients (e.g., cardiologists, urologists, dermatologists). In the United States, however, there has been a trend toward
self-referral by patients for these services rather than referral by primary care providers.
Secondary Prevention—Prevention strategies that seek to identify and control disease processes in their early stages
before signs and symptoms develop (screening and treatment).
Span of Healthy Life—A measure of health status that combines life expectancy with self-reported health status and
functional disabilities to calculate the number of years in which an individual is likely to function normally.
Specific Rate—Rates vary greatly by race, sex, and age. A rate can be made specific for sex, age, race, cause of
death, or a combination of these.
State Health Agency—The unit of state government that has leading responsibility for identifying and meeting the
health needs of the state’s citizens. State health agencies can be freestanding or units of multipurpose health and
human service agencies.
Strategic National Stockpile—A collection of pharmaceuticals, medical supplies, and equipment that can be
immediately deployed to meet state and local needs during a public health emergency (formerly known as the National
Pharmaceutical Stockpile).
Strategic Planning—A disciplined process aimed at producing fundamental decisions and actions that will shape and
guide what an organization is, what it does, and why it does what it does. The process involves assessing a changing
environment to create a vision of the future; determining how the organization fits into the anticipated environment,
based on its mission, strengths, and weaknesses; and then setting in motion a plan of action to position the
organization.
Surveillance—Systematic monitoring of the health status of a population through collection, analysis, and
interpretation of health data in order to plan, implement, and evaluate public health programs, including determining
the need for public health action.
Tertiary Medical Care—Subspecialty referral care requiring highly specialized personnel and facilities. Services are
provided by highly specialized providers (e.g., neurologists, neurosurgeons, thoracic surgeons, intensive care units).
Such services frequently require highly sophisticated equipment and support facilities. The development of these
services has largely been a function of diagnostic and therapeutic advances attained through basic and clinical
biomedical research.
Tertiary Prevention—Prevention strategies that prevent disability by restoring individuals to their optimal level of
functioning after a disease or injury is established and damage is done.
Triage—The selection and categorization of victims of a disaster or other public health emergency as to their need for
medical treatment according to the degree of severity of illness or injury as well as the availability of medical and
transport facilities.
Vulnerability—The susceptibility of a population to a specific type of event, generally associated with the degree of
possible or potential loss from a risk that results from a hazard at a given intensity. Vulnerability can be influenced by
demographics, the age and resilience of the environment, technology, social differentiation and diversity, as well as
regional and global economics and politics.
Weapons of Mass Destruction—Any device, material, or substance used in a manner, in a quantity or type, or under
circumstances evidencing intent to cause death or serious injury to persons or significant damage of property.
Years of Potential Life Lost (YPLL)—A measure of the impact of disease or injury in a population that calculates
years of life lost before a specific age (often age 65 or age 75). This approach places additional value on deaths that
occur at earlier ages.
Index
The index that appeared in the print version of this title was intentionally removed from the eBook. Please use the search
function on your eReading device to search for terms of interest. For your reference, the terms that appear in the print index
are listed below.
A
a governmental presence at the local level (AGPALL)
access to health care
accidents as leading cause of death, 1900 vs. 2000
accreditation, LHD engagement with PHAB
Accrediting Commission on Education for Health Services Administration (ACHESA)
acquired immune deficiency syndrome (AIDS)
action cycle, in MAPP model
ADA. See American Dietetic Association
administration costs, expenditures for, U.S.
administrative business professionals, training for
administrative business support staff
administrative law
administrative law judges/hearing officers
number of and salary profiles for federal and state/local workers
number of in 2013 and projected for 2022 and number of positions to be filled, 2012–2022, for all industries and government
administrative occupations, characteristics of
administrative support occupations, characteristics of
administrative workers, percentage of, in public health workforce, U.S., 2000
administrators, percentage of, in public health workforce, U.S., 2000
Affordable Care Act
health reform provisions
Afghanistan war
African Americans in U.S., growing population of
Age of Reason
age-specific mortality rates
Agency for Health Care Research and Quality (AHRQ)
Agency for Toxic Substances and Disease Registry (ATSDR)
aging population
diseases of
retirement and career prospects for public health workers
in U.S.
AGPALL. See a governmental presence at the local level
agricultural producers, public health emergency preparedness and
AHRQ. See Agency for Health Care Research and Quality
AIDS. See acquired immune deficiency syndrome
alcohol abuse
All-Hazards Preparedness Act
Alzheimer’s disease
age-adjusted death rates for
as leading cause of death, 2000
ambulatory surgery centers, proliferation of, in U.S.
American Academy of Environmental Engineers, web site
American Board of Industrial Hygiene
American College Health Association
American College of Epidemiology
American College of Healthcare Executives
American College of Preventive Medicine
American Dietetic Association (ADA)
American Epidemiology Society
American government, public health and
American Medical Association
American Nurses Association (ANA)
Scope and Standards of Public Health Nursing Practice
American Public Health Association (APHA)
epidemiology and statistics section of
Health Administration Section of
public health nursing section of
web site
American School Health Association
ANA. See American Nurses Association
animal control workers
anthrax attacks
bioterrorism fears and
cases of anthrax associated with mailed paths of implicated envelopes and intended target sites, U.S., 2001
epidemic curve for 22 cases of bioterrorism-related anthrax, U.S., 2001
anthropology
APEXPH. See Assessment Protocol for Excellence in Public Health
APHA. See American Public Health Association
ASPR. See Office of the Assistant Secretary for Preparedness and Response
assessment, as core public health function
Assessment Protocol for Excellence in Public Health (APEXPH)
Association for Professionals in Infection Control and Epidemiology
Association for Public Health Laboratories
Association of Community Health Nurse Educators
Association of Schools and Programs of Public Health
Association of Schools of Public Health
Association of Social Work Boards
Association of State and Territorial Directors of Health Promotion and Public Health Education
Association of State and Territorial Directors of Nursing
Association of State and Territorial Health Officials (ASTHO)
Association of State and Territorial Public Health Nutrition Directors (ASTPHND)
Association of University Programs in Health Administration (AUPHA) web site
assurance, as core public health function
ASTHO. See Association of State and Territorial Health Officials
ASTPHND. See Association of State and Territorial Public Health Nutrition Directors
ATSDR. See Agency for Toxic Substances and Disease Registry
audiologists
B
baby boom generation, public policy decision making and
behavioral and mental health workers
salaries of
behavioral sciences
benefits, justice and
Bentham, Jeremy
bicycle helmet use
biological agents
Category A
Category B
Category C
biostatics competency expectations, for graduates of master’s in public health degree programs
biostatisticians
additional sources of information about
important and essential duties for
role of
salaries for
typical minimum qualifications for
biostatistics
bioterrorism
activities, coordination of
biological agents with
defined
emergencies, unique aspects of
infectious diseases and
preparedness and response
epidemiologists, and increased funding for
state health agencies and
preparedness funds, size of public health, workforce and
bioterrorism threats
cases of anthrax associated with mailed paths of implicated envelopes and intended target sites, U.S., 2001
epidemic curve for 22 cases of bioterrorism-related anthrax, U.S., 2001
epidemiology and
Black Death (plague)
block grants
BLS. See Bureau of Labor Statistics
blue collar occupations, for public health workers
Board Certified Specialist in Pediatric Nutrition
Board Certified Specialist in Renal Nutrition
Board of Certified Safety Professionals (BCSP)
budgets, local health departments
burdens, justice and
Bureau of Labor Statistics (BLS)
C
CAIH credential. See Certified Associate Industrial Hygienist credential
Canada, health expenditures in
cancer
infectious diseases and some types of
as leading cause of death, 1900 vs. 2000
capacity-building plan, Model Standards, healthy communities and development of
cardiovascular disease, future challenges related to
career prospects
for epidemiology and disease control professionals
for public health administrators
for public health education and information professionals
for public health nurses
for public health workers
case-finding efforts, for infectious and noninfectious conditions
case management
categorical approaches to program management
causative factors, analyzing health problems for
CDC. See Centers for Disease Control and Prevention
CDR. See Commission on Dietetic Registration
CEHT. See certified environmental health technician
Centers for Disease Control and Prevention (CDC)
federal funding for antiterrorism activities of
funding for public health workforce through
laboratory investigation and analysis by
public health preparedness and response coordination by
state and local emergency preparedness
certification
for community health nurses
for environmental and occupational professionals
for public health education and information professionals
for public health workforce
Certified Associate Industrial Hygienist (CAIH) credential
certified environmental health technician (CEHT)
certified food safety professional (CFSP)
certified health education specialists (CHES)
certified industrial hygienists (CIH)
CFSP. See certified food safety professional
Chadwick, Edwin
chemical mass casualty threats
CHES. See certified health education specialists
Child and Adult Care Food Program (food stamps)
child mortality rates, over course of 20th century
children, in poverty
CHIP model. See community health improvement planning model
Cholera outbreak (1854), John Snow’s investigations of
chronic diseases
aging population and
comprehensive model of prevention/control of
chronic obstructive lung disease, as leading cause of death, 2000
CIH. See certified industrial hygienists
cities, home rule powers and
city health departments
Clean Air Act
Clean Water Act
clerical occupations, characteristics of
Clinical Laboratory Improvement Amendments of 1988
clinical laboratory technologists and technicians
clinical services
counties and
expenditures for, U.S.
Coalition of National Health Education Organizations
collaboration
collective values, future challenges in public health and
command-and-control approach, government and
Commission on Accreditation of Healthcare Management Education
Commission on Dietetic Registration (CDR)
common law
communicable diseases
investigators
important and essential duties for
typical minimum qualifications for
state statutes and legal frameworks relative to
community assets, identifying
community-based health policy development
community, defining
community engagement
community health assessments
local health department participation in
local health jurisdictions and
percentage distribution of local health departments, by roles in, U.S., 2013
community health centers
community health improvement planning (CHIP) model
enabling widespread adoption of
local health department participation in
operationalizing community health concept through
community health needs, Model Standards, healthy communities and assessment of
community health profile, indicators for
community health, public health nurses involved in
community health status assessment, MAPP model
community health strategies, examples of
community hospitals, decline in number of
community mental health services
community organizational structure, Model Standards, healthy communities and assessment of
community-oriented primary care
community partnerships, mobilizing, policy development for public health and
community prevention services, counties and
community process, APEXPH and
community public health practice, in 21st century
community public health systems, MAPP as road map for
community themes assessment, MAPP model
Community Tool Box (University of Kansas)
community-wide response, emergency preparedness and
competencies
in epidemiology and disease control
for health educators
for public health nurses
for public health workforce
Comprehensive Environmental Response, Competition, and Liability Act
confidentiality, public health laws and
Connecticut, local public health agencies in
Constitution of the United States
federal health powers enumerated in
purposes of public health law and
statutory-based laws and
constitutional law
containment of healthcare costs
continuing education for healthcare workforce
continuing education for public health workers
continuing education units (CEUs)
core competencies
in epidemiology and disease control
for public health workforce
for students receiving master’s of public health degree
workforce development and
core functions, public health workforce and
coronary heart disease
projected health expenditures and
reducing, future challenges in
cost-benefit analyses
cost-effectiveness analyses
cost of health care
containment measures
escalating, federal budget deficit and
cost-utility analyses
Council of State and Territorial Epidemiologists (CSTE)
Council on Certification of Health, Environmental, and Safety Technologists
Council on Linkages between Academia and Public Health
Practice
Council on Social Work Education
counties, health roles of
county administrators
county commissioners
county health departments, establishment of
credentials
for environmental and occupational professionals
for nutritionists and dietitians
for public health workforce
crude mortality rates
CSTE. See Council of State and Territorial Epidemiologists
cultural competence, defined
cycle completion, APEXPH and
D
DALY. See disability-adjusted life-year
deaths
causes of
disparities for major causes of
leading cause of, 1900 vs. 2000
demographic trends
public health field and
in U.S. health system
dental health professionals
dental hygienists
number of and salary profiles for federal and state/local workers
number of in 2013 and projected for 2022 and number of positions to be filled, 2012–2022, for all industries and government
in public health
dentists
number of and salary profiles for federal and state/local workers
number of in 2013 and projected for 2022 and number of positions to be filled, 2012–2022, for all industries and government
number of, in public health workforce
Department of Agriculture, U.S.
Department of Commerce, public health emergency preparedness and
Department of Defense
Department of Education
Department of Energy, public health emergency preparedness and
Department of Health and Human Services (DHHS)
operating divisions within
organization chart, 2014
organization of federal health responsibilities within
public health preparedness and response coordination
Department of Homeland Security (DHS)
“all-hazards” approach to disasters/homeland security issues
directorates within
public health preparedness and response coordination by
Department of Justice
Department of Transportation
public health emergency preparedness and
Department of Veterans Affairs
DHHS. See Department of Health and Human Services
DHS. See Department of Homeland Security
diabetes
infectious diseases and
as leading cause of death, 2000
dichotomous thinking, public health’s scientific heritage and
diet
Dietetic Technician, Registered
diphtheria
as leading cause of death, 1900
disability-adjusted life-year (DALY)
disability, declining levels of, aged 55–70
disability limitation, rehabilitation and
Disaster Medical Assistance Teams (DMATs)
Disaster Mortuary Teams (DMORTs)
discharge planning, managed care and
disease agents, in bioterrorism attacks
disease investigators
additional sources of information about
role of
disease management, focus of
disparities, for major causes of death
DMATs. See Disaster Medical Assistance Teams
DMORTs. See Disaster Mortuary Teams
DNA fingerprinting
doctor of public health (DrPH) degree
doctoral degrees, for epidemiology and disease control professionals
domains, of public health
drinking water, fluoridation of, oral health and
DrPH degree. See doctor of public health degree
drug-resistant pathogens, as emerging infectious disease problem
durable medical products, expenditures for, U.S.
duties
for environmental engineers
for environmental specialists, entry level
for environmental specialists, midlevel
for environmental specialists, senior level
for epidemiology and disease control
for health officers
for health services managers
for local health department directors
for medical and public health nutritionists
for nutritionists and dietitians
for occupational health and safety specialists
for public health administrators
for public health emergency preparedness
for public health laboratory specialists
for public health laboratory technologists
for public health nurses
for public health occupations
for public health workers
for response coordinators
E
early case finding, disability limitation, rehabilitation and
Ebola hemorrhagic fever
Ebola virus disease
cases of
massive epidemic of
ecological view of health, lack of
economic dimensions of health outcomes
education path
for environmental engineers
for environmental specialists
for occupational health and safety specialist
for public health nursing
for public health workers
core competencies and
EIS. See Epidemiologic Intelligence Service
Elizabethan Poor Laws
EMAC. See Emergency Management Assistance Compact
emergency centers, proliferation of, in U.S.
emergency exercises, types of
Emergency Management Assistance Compact (EMAC)
emergency medical technicians (EMTs)
emergency operations center (EOC), in incident command systems
emergency preparedness and response
percentage of states reporting stronger infrastructure and programs for
public health roles in
community-wide response
epidemiologic investigation and analysis
intervention
laboratory investigation and analysis
preparedness planning
public health surveillance
risk communication
unique aspects of bioterrorism emergencies
workplace preparedness
public perceptions of
reported change in, LHD functions
state and local preparedness grants of
Emergency Preparedness and Response Directorate, DHS
emergency preparedness core competencies, for all public health workers
emergency preparedness, typical minimum qualifications for
emergency response coordinators
Emerson Report
employees, full-time equivalent, in LHDs
employment, as powerful preventive health intervention
EMTs. See emergency medical technicians
environmental and occupational health
additional information sources on
important and essential duties in
number of workers in field of
occupational classification
positions, salaries, and career prospects in
public health practice profile
qualifications for
workplace considerations
environmental engineering technicians
characteristics of
salaries for
environmental engineers
characteristics of
important and essential duties for
salaries for
typical minimum qualifications for
environmental hazards
intervention and
environmental health
activities
public health practice profile
environmental health scientists and specialists, salaries for
environmental pollution
Environmental Protection Agency
environmental science
and protection technicians
characteristics of
environmental specialists
entry level
important and essential duties for
typical minimum requirements for
midlevel
important and essential duties for
typical minimum requirements for
senior level
important and essential duties for
typical minimum requirements for
environmental statutes, federal
EOC. See emergency operations center
EPHS. See essential public health services
epidemics
of diseases
public health surveillance and
Epidemiologic Intelligence Service (EIS), web site
epidemiologic investigation and analysis, emergency, preparedness and response in
epidemiologists
additional sources of information about
entry level
important and essential duties for
typical minimum qualifications for
funding of
number and salary profile for federal and state/local workers
number of, in 2013, and projected for 2022 and number of positions to be filled, 2012–2022 for all industries and government
role of
salaries for
senior level
important and essential duties for
typical minimum qualifications for
shortage of
typical day for
epidemiology
and disease control
additional information sources on
important and essential duties in
occupational classification
positions, salaries, and career prospects
public health practice profile
qualifications in
workplace considerations
as mother science of public health practice
epidemiology competency expectations, for graduates of master’s in public health degree programs
equity in health care
Escherichia coli O157:H7
emergence of a public health threat: time line
infections caused by
essential public health services (EPHS)
expenditures for
by government level, U.S., 1980–2012
as percent of total health spending, U.S., 1980–2012
U.S., 1980–2012
public health workforce and
ethics and skills, for public health workers
ethnic composition, current and projected, U.S. population
ethnicity, disparities in tobacco usage and
evaluation strategy, Model Standards, healthy communities and development of
expenditures
by federal government for health-related services
funding sources for, U.S., 2012
for public health workers
questioning national investment strategy relative to
for state health programs
total national, federal, state/local government, for health-related purposes, U.S., 1980–2021
in U.S. health system
percentage of GDP spending for health-related purposes, 1980–2012
selected years, 1980–2012
F
fair compensation, public health law and
family planning
family structure changes, in U.S.
Farr, William
FDA. See Food and Drug Administration
federal budget, balancing, healthcare costs and
Federal Bureau of Investigation
Federal Emergency Management Agency (FEMA)
federal emergency medical assets
federal environmental statutes
federal government
intergovernmental relationships and
as largest purchaser of health care
public health and
federal government health agencies, full-time equivalent (FTE) workers in, U.S., 1995–2012
federal grants-in-aid
federal grants, state health agencies and
federal health agencies
Federal Insecticide, Fungicide, and Rodenticide Act
federal legal system
Federal Mine Safety and Health Act
federal powers, evolution of, into health arena
federal public health activities, in United States
Federal Security Agency
Federal Stafford Act
federalism, health sector in U.S. and
FEMA. See Federal Emergency Management Agency
females life expectancy at birth for, past and projected, U.S., 1900–2050
firearm-related injuries, projected health expenditures and
firearms, control of
fluoridation of drinking water
Food and Drug Administration (FDA)
Food, Drug, and Cosmetic Act
food industry, public health emergency preparedness and
food safety, addressing new and old risks related to
foodborne illnesses
Escherichia coli 0157:H7 and
public health surveillance and
forces of change assessment, MAPP model
formula grants
Framingham Heart Study
full-time equivalent (FTE) employees
in LHDs
in state health departments
full-time equivalent (FTE) health workers
mean salary for, in state and local health agencies, 1998–2012, U.S.
in state and local health agencies per 10,000 populations, 1995–2012, U.S.
steady increase in number of, in governmental health agencies
functional disability
funding sources
for local health departments
for national health expenditures, U.S., 2012
for public health protection programs
future challenges in public health practice
future of public health in 1988 and two decades later
limitations of 21st century public health
need for more effective public health system
Future of Public Health, The (IOM)
conclusions drawn in
G
GDP. See gross domestic product
Gebbie, Kristine
gender, health status and
General Board of Health (England)
germ theory
Germany, health expenditures in
global warming
government
command-and-control approach and
public health’s link to
three levels of, health roles and
2002 IOM report on contributions to public health by
government public health expenditures
as percent of total health spending, U.S., 1980–2012
in U.S., 1980–2012
governmental public health
federal health agencies
local health departments
state health agencies
graduate degrees
for environmental and occupational health
for epidemiology and disease control professionals
for public health workers
graduate education
in epidemiology and disease control
for public health laboratory specialists
grantmaking, federal, approaches to
Great Depression
gross domestic product (GDP) percentage of health expenditures, U.S.
group medical practices, proliferation of, in U.S.
growth prospects, for public health workforce
gun control
H
hantavirus
health
culture effects on
determinants of
economic value placed on
holistic vs. mechanistic views of
illness and disease
influences on
global health influences
risk factors
social and cultural influences
multidimensional view of
in United States
health alerts
health educators
competencies for
number of and salary profile for federal and state/local workers
number of, in 2013 and projected for 2022 and number of positions to be filled, 2012–2022 for all industries and government
health field, consolidation within
health impact pyramid
health indicators, gains, gaps, and outcomes in, U.S.
health insurance
Americans without
cost of health care and
health maintenance organizations, proliferation of, in U.S.
health measures
morbidity, disability, and quality measures
mortality-based measures
health officers
important and essential duties for
local health departments, tenure of
typical minimum qualifications for
health outcomes
economic dimensions of
health measures and
poverty
health policy, increased politicization of
health problems
analyzing for causative factors
defined
health promotion, specific protection and
health reform
failure of, in 1994
provisions, timeline for
Health Resources and Services Administration (HRSA)
training in public health
health sector, growth in, career prospects and
health service strategies, targets of
health services administrators
health services managers
important and essential duties for
typical minimum qualifications for
health status, race and
health system
changing roles, themes, and paradigms in
demographic and utilization trends for
healthcare resources and
Health United States
healthcare delivery models, changing, in U.S.
healthcare pyramid levels
healthcare resources, in U.S. health system
healthcare social workers
Healthy Communities
Healthy People 2020
community health profile indicators
goals of
leading health indicators
model
progress measures towards
Tool Kit
vision, mission, goals, and focus areas
Healthy People 2000, assessments of
heart disease
infectious diseases and
leading cause of, 1900 vs. 2000
hemorrhagic health conditions, Escherichia coli 0157:H7 and
Hill-Burton Act
Hippocratic oath
Hispanics growth of population, in U.S.
HIV. See human immunodeficiency virus
H1N1 influenza
holistic view of health
home health care, expenditures for, U.S.
home rule options
home rule powers
Homeland Security Act of 2002, provisions of
Homeland Security Presidential Directive 5
homicide rates
hospital bioterrorism planning, HRSA funding for
hospital outpatient visits, increase in
Hospital Services and Construction Act (Hill-Burton Act)
hospitalizations, managed care and review/certification of
hospitals, collaborations between public health and
housing
HRSA. See Health Resources and Services Administration
human H5N1 cases, growing number of
human immunodeficiency virus (HIV)
antibody testing, conflicts between public health and medical practice over
state statutes and legal frameworks relative to
human service agencies, state
Hurricane Katrina
coordinated response to
EMAC personnel deployed during
Hurricane Rita, EMAC personnel deployed during
I
ICS. See incident command systems
IHS. See Indian Health Service
illness
culture effects on
and disease, health
imperialism
incidence
incident command systems (ICS), key components of
incrementalism, health sector in U.S. and
Indian Health Service (IHS)
indigent health care, counties and
industrialism
infant mortality rate
age-specific mortality rates and
over course of 20th century
infectious diseases
crude death rate for, U.S., 1900–1996
massive reductions in
20th century achievements related to
influenza
leading cause of, 1900 vs. 2000
new potential for global pandemic of
Information technology, size of public health workforce and
initial mission statement
injuries
injustices
innovation, health problems and
inputs, of public health system
Institute of Medicine (IOM)
landmark reports by
intergovernmental relationships
International Epidemiological Association
intervention strategies
emergency preparedness/response and
Model Standards, healthy communities and development of
IOM. See Institute of Medicine
Iraq war
J
Japan, health expenditures in
Jenner, Edward
job descriptions for public health practitioners, core competencies in
job opportunities, in public health field
jobs, private sector and
Journal of the American Medical Association
judicial law
justice
K
Kellogg Foundation
kidney disease, as leading cause of death, 2000
Koch’s postulates
L
laboratory investigation and analysis, emergency preparedness and response
laboratory specialists, number of and salary profiles for federal and state/local workers
law
assurance of public’s health through
public health
purposes of
types of
leadership development, for public health
legislatively based law
leprosy
LHDs. See local health departments
licensed practical/vocational nurses (LPNs/LVNs)
important and essential duties for
number of
employed in U.S.
in U.S.
salaries for
typical minimum qualifications for
licensing
for public health workforce
for registered nurses
for social workers
life expectancy
at birth and health spending
at birth past and projected, female and male, U.S., 1900–2050
computations for
increases in
postponement of morbidity and
in U.S.
percentage improvement in selected measures of
local agencies and assets, public health emergency preparedness
local boards of health, responsibilities of
local government health agencies, full-time equivalent (FTE) workers in, U.S., 1995–2012
local governments, state constitutions and statutes and
local health department directors
important and essential duties for
typical minimum qualifications for
local health departments (LHDs)
APEXPH, utilization and
estimated size and composition of workforce for, U.S., 2013
evolution of public health services and
functions of
funding sources
MAPP process and
percentage distribution of, by roles in community health assessments, U.S., 20013
percentage of
percentage of, selected public health professional occupations
percentage of, with completed community health assessment and community health improvement plans, U.S., 2012 and 2013
public health emergency preparedness and
salary scales in
small, medium, and large; percentage of all LHDs and percentage of population served, in U.S., 2013
staffing patterns in
state areas served by
top priority areas for
total expenditures of
vital statistics for
widely used definitions for
local health jurisdictions (LHJ)
community health assessments conducted by
public health emergency preparedness and
local level, a governmental presence at
local priorities and community health resources, Model Standards, healthy communities and determination of
local public health
activities, in U.S., growth of
basic six services of
local public health system assessment, MAPP model
long-term care
low birth weight deliveries
low-birth-weight infants, projected health expenditures and
low-income population, inequalities in healthcare access for
M
males life expectancy at birth for, past and projected, U.S., 1900–2050
managed care
growth of
in U.S.
management sciences
MAPP. See Mobilizing for Action through Planning and Partnerships
Marine Hospital Service
market justice, social justice vs.
mass casualty threats
Massachusetts, local public health agencies in
Master’s of Public Health (MPH) degree
core environmental health competencies for students receiving
for epidemiology and disease control professionals
program graduates epidemiology and biostatistics competency expectations for
social and behavioral science competency expectations for
maternal and child health
block grant
improvements in
programs, public health nurses involved in
McKeown, T.
measles
mechanistic view of health
Medicaid
controlling costs within
DHHS budget and
establishment of
national health expenditures, U.S., 2012
medical errors
medical practice
public health and
public health interface with
Medical Reserve Corps, emergency deployment of
medical social workers
number of and salary profiles for federal and state/local workers
number of in 2013 and projected for 2022 and number of positions to be filled, 2012–2022, for all industries and government
number of, in U.S.
medical specialties, in U.S.
Medicare
controlling costs within
DHHS budget and
national health expenditures, U.S., 2012
Medicine/Public Health Initiative
mental health
mental health counselors, salaries for
mental health services
mental health social workers
mental illness
metropolitan areas, job opportunities for healthcare workers in
metropolitan local health departments
Metropolitan Medical Response System (MMRS)
microbiologists
essential and important duties of
number of and salary profiles for federal and state/local workers
number of in 2013 and projected for 2022 and number of positions to be filled, 2012–2022, for all industries and government
salaries of
minorities, poverty and
MMRS. See Metropolitan Medical Response System
Mobilizing for Action through Planning and Partnerships (MAPP)
community participants in
distinguishing features of
model
as road map for community public health systems
model cities
Model Public Health Emergency Powers Act
Model Standards, healthy communities, implementation of, steps in
monkeypox virus
movement of imported African rodents to animal distributors and distribution of prairie dogs from animal distributor
associated with human cases of, 2003
morbidity
cost-utility analyses
disability, and quality measure of health
mortality
cost-utility analyses
preventable and common causes of
mortality-based measures
mortality rates
crude
crude and age-adjusted, U.S., 1960–2004
in U.S., throughout 20th century
mortuaries, temporary, mass casualty situations and
motor vehicle injuries
projected health expenditures and
reducing, gains in
motorcycle helmet use
MPH degree. See Master’s of Public Health degree
multidrug-resistant pathogens, as emerging infectious disease problem
municipal governments, public health and role of
N
NACCHO. See National Association of County and City Health Officials
National Association of County and City Health Officials (NACCHO)
National Association of Social Workers
National Center for Health Statistics
National Center for Public Health Laboratory Leadership
National Commission for Certifying Agencies
national deficit, healthcare costs and
National Disaster Medical System (NDMS)
National Environmental Health Association (NEHA)
National Guard
National Health Accounts
National Health Interview Survey
National Health Security Strategy (NHSS)
National Incident Management System (NIMS)
National Institutes of Health (NIH)
public health preparedness and response coordination
National Onsite Wastewater Recycling Association Model Code
National Organization for Competency Assurance
National Preparedness Guidelines
National Public Health Leadership Institute
National Public Health Performance Standards Program
national public health preparedness and response coordination
federal agencies and assets
federal emergency medical assets
federal funding for public health infrastructure
national public health workforce
National Response Plan (NRP), purpose of
National Turning Point Initiative, strategies in
National Vaccination Board (England)
NDMS. See National Disaster Medical System
NEHA. See National Environmental Health Association
NHSS. See National Health Security Strategy
NIH. See National Institutes of Health
NIMS. See National Incident Management System
nonmetropolitan area local health departments, top priority areas for
NRP. See National Response Plan nurses
number
of, in public health workforce
as professional core of public health workforce
nursing home care, expenditures for, U.S.
nutritionists and dietitians
additional information sources about
essential and important duties for
government employed
number of and salary profiles for federal and state/local workers
number of in 2013 and projected for 2022 and number of positions to be filled, 2012–2022, for all industries and government
number of, in public health workforce
role of
salaries for
typical minimum qualifications for
O
obesity, emergence of, as prevalent condition
occupational classifications
description of
percentage of public health workers in selected occupational categories, U.S., 2013
for public health workers
occupational health and safety specialists
characteristics of
important and essential duties for
salaries for
typical minimum requirements for
Occupational Health and Safety Technologist (OHST) certification
Occupational Safety and Health Act
occupationally related injuries, projected health expenditures and
Office of Emergency Preparedness and Response, DHHS
Office of Public Health and Science (OPHS)
Office of Public Health Emergency Preparedness and Response
Office of the Assistant Secretary for Preparedness and Response (ASPR)
officials in public health workforce, percentage of, U.S., 2013
Oklahoma City bombing
one-parent families
O’Neil, Tip
onsite wastewater system installers
OPHS. See Office of Public Health and Science
opportunity costs
optometrists
oral health
expenditures for, U.S.
improvements in
oral health professionals
organization of community, Model Standards, healthy communities and assessment of
organizational assets, types of
organizational capacity
APEXPH and assessment of
Model Standards, healthy communities and assessment of
organizational role, Model Standards, healthy communities and assessment of
outcome displacement
outcome objectives, Model Standards, healthy communities and assessment of
outcomes of public health system
over-the-counter medicine, expenditures for, U.S.
P
PAHPA. See Pandemic and All Hazards Preparedness Act
Pandemic and All Hazards Preparedness Act (PAHPA)
pandemics
Pasteur, Louis
PATCH. See Planned Approach to Community Health
pentagon, terrorist attacks on (2001)
per capita public health expenditures, in U.S.
performance measurement, community health objectives and
personal healthcare services, expenditures for, U.S.
personal healthcare workforce, competent, assuring
Pew Health Professions Commission, on 21st century health system, U.S.
PHAB. See Public Health Accreditation Board
pharmaceutical manufacturers, public health emergency preparedness and
pharmacists
number of in 2013 and projected for 2022 and number of positions to be filled, 2012–2022, for all industries and government
in public health workforce, number of
working in U.S., number of
Philadelphia, yellow fever epidemic in
physician population, specialty composition of, U.S.
physicians
board certified
expenditures for, U.S.
number of and salary profiles for federal and state/local workers
number of in 2013 and projected for 2022 and number of positions to be filled, 2012–2022, for all industries and government
in public health workforce, number of
working in U.S., number of
Planned Approach to Community Health (PATCH)
pluralism, health sector in U.S. and
pneumonia, leading cause of, 1900 vs. 2000
police powers of states
policy development, as core public health function
policy making, community-based health policy development and
polio
political nature of public health
political process, public health system and
Poor Laws (Elizabethan)
population-based activities, public health services and
population-based public health activity expenditures
as percent of total health spending, U.S., 1980–2012
in U.S.
population-based public health services
population health, defined
positions
growth of, for public health administrators
number of, for environmental and occupational workers
post-IOM report initiatives
APEXPH mobilizing for action through planning and partnerships
PATCH, model processes
poverty
preferred provider organizations, proliferation of, in U.S.
prenatal care, utilization by low-income population and
preparedness planning
preparedness, response inextricably linked to
prescription drugs, expenditures for, U.S.
preterm deliveries
prevalence
categorization of
prevention
health services and
early case finding and prompt treatment, disability limitation, and rehabilitation
levels of, with effects
links with prevention
links with public health and medical practice
medicine and public health collaborations
public health and medical practice interfaces
specific protection and health promotion
targets of
public health activities and
public health and focus on
prevention-related expenditures, in United States
primary building blocks
primary care physicians, managed care and
primary medical care
primary prevention
comprehensive model of chronic disease prevention and control
defined
effects of
health services pyramid
Principles of Community Engagement, CDC
privacy provisions, public health laws and
private healthcare providers, public health emergency preparedness
private insurance, national health expenditures, U.S., 2012
private property issues, public health law and
private sector healthcare providers, public health emergency preparedness and
private sector jobs
professional occupations, characteristics of
professional public health workers in U.S., 2000, percentage of
project grants
prompt treatment, disability limitation, rehabilitation and
psychology
public health
accomplishments in
American, early influences on
American government and
assessment in
assurance and
core functions of
critiques of statutory basis of
dimensions of
disarray in
economic and resource considerations and
federal public health activities in U.S.
function
growth of local and state public health activities in U.S.
images and definitions of
intergovernmental relationships
IOM identification of important barriers inhibiting effective action by
logic model representation of
medical practice interface with
mission and functions of
mission of
needed collaborations in
policy development for
practice and function before
practice and functions after
recommitment to successful job description for
as system
2002 IOM report on governmental contributions to
unique features of
expanding agenda
focus on prevention
grounded in science
inherently political nature
link with government
social justice philosophy
uncommon culture
United States
achievements
death rate
value of
Winslow’s definition of
Public Health Accreditation Board (PHAB)
Public health activity (PHA) expenditures, by government level, U.S., 1980–2012
public health administration
important and essential duties
for health officers
for health services managers
for local health department directors
for public health emergency preparedness and response coordinator
minimum qualifications in
for emergency preparedness and response coordinators
for health officers
for health services manager
for local health department directors
occupational classification
positions, salaries, and career prospects
public health practice profile for
sources of information about
workplace considerations
public health administrators
career prospects for
public health practice profile for
qualifications for
responsibilities of
work settings for
public health agencies, community-wide response to emergencies and role of
public health codes, improving, recommendations for
public health community
public health education and information
additional information about
important and essential duties for professionals
occupational classification
positions, salaries, and career prospects
public health practice profile for
qualifications for
workplace considerations
public health educators
entry level
important and essential duties for
typical minimum qualifications for
role of
senior level
important and essential duties for
typical minimum qualifications for
typical day for
public health emergency
preparedness, important and essential duties for
risk communication
Public Health Foundation
Public Health in America statement
relationship of, to public health practice
public health infrastructure
emergency preparedness and federal funding for
public health laboratory specialists
essential and important duties of
qualifications for
public health laboratory technologists and technicians
additional information sources about
essential and important duties of
salaries for
typical minimum qualifications for
public health law
purposes of
state powers and authority through
types of
Public Health Leadership Society
public health network, historical evolution of
public health nurses
additional information sources on
entry level
important and essential duties for
typical minimum qualifications for
senior level
important and essential duties for
typical minimum qualifications for
shortage of
workplace considerations
public health nursing
defined as
important and essential duties for
job titles in
minimum qualifications for
occupational classification for
positions, salaries, and career prospects
public health practice profile for
Public Health Nursing section, of APHA web site
public health nutritionists
essential and important duties of
qualifications for
salaries for
public health occupations
categories
characteristics of
additional information
career prospects
important and essential duties
minimum qualifications
occupational classifications
public health practice profile
salary estimates
workplace considerations
and titles, composite public health practice profile for
public health organizations, strategic plans for
public health practice
relationship of Public Health in America statement to
public health practice profile
for environmental health
for epidemiology and disease control
or public health education and information professionals
for public health administrators
for public health nursing
for selected public health professional occupations
Public Health Practitioner Certification Board
public health practitioners
common aspirations among
competencies for
increased demand for
public health profile example
public health preparedness capabilities
Public Health Service Act
public health service agencies
program-level budgets
roles of
public health services framework, assessment, policy development, and assurance in
public health social workers
number of and salary profiles for federal and state/local workers
number of in 2013 and projected for 2022 and number of positions to be filled, 2012–2022, for all industries and government
number of, in U.S.
public health surveillance
public health system, need for effective
public health work, importance of
public health workforce
competent, assuring
composition of
distribution of
emergency preparedness core competencies for
ethics and education for
growth
low priority given to
number of, in selected occupational categories and titles, U.S., 2000
public health work and
shrinking
size and distribution of
Public Health Workforce Enumeration 2000
public information specialists/coordinators
important and essential duties for
number of and salary profile for federal and state/local workers
number of, in 2013 and projected for 2022 and number of positions to be filled, 2012–2022 for all industries and government
typical minimum qualifications for
public relations/public information specialists
number of and salary profile for federal and state/local workers
number of, in 2013 and projected for 2022 and number of positions to be filled, 2012–2022 for all industries and government
Q
QALYs. See quality-adjusted life-years
Quad Council of Public Health Nursing Organization
qualifications
for biostatisticians
for environmental and occupational health
for environmental engineers
for environmental specialists
entry level
midlevel
senior level
for epidemiologists
entry level
senior level
for epidemiology and disease control professionals
for medical and public health nutrition
for nutritionists and dietitians
for public health administration
for public health education and information professionals
for public health laboratory specialists
for public health laboratory technologists
for public health nursing
for public health occupations
for public health workers
quality-adjusted life-years (QALYs)
quality-of-life years lost
quarantines
R
race
disparities in tobacco usage and
health status and
racial composition, current and projected, U.S. population
racial discrimination
radiation mass casualty threats
RD. See registered dietitian
Receipt, Store, and Storage sites, SNS stockpile and
recession of 2009
layoffs and hiring suspensions during
number of governmental health agency workers and
referendum health agencies
registered dietitian (RD)
registered environmental health specialist/registered sanitarian (REHS/RS)
registered environmental technician (RET)
registered hazardous substances professional (RHSP)
registered hazardous substances specialist (RHSS)
registered nurses (RNs)
employed in U.S., number of
as largest professional category within public health workforce
licensing for
national shortage of
number of training and education programs for
salaries for
in U.S., number of
rehabilitation, early case finding, prompt treatment, disability limitation and
REHS/RS. See registered environmental health specialist/registered sanitarian
Reinvention of Government Initiative
Report of the Sanitary Commission of Massachusetts
resolution health agencies
Resource Conservation and Recovery Act
response coordinators
important and essential duties for
typical minimum qualifications for
response, preparedness inextricably linked to
RET. See registered environmental technician
revenue-sharing grants
RHSP. See registered hazardous substances professional
RHSS. See registered hazardous substances specialist
risk communication, emergency preparedness/response and
risk sharing, managed care and
RNs. See registered nurses
Robert T. Stafford Disaster Relief and Emergency Assistance Act
Robert Wood Johnson Foundation
rural areas, job opportunities for healthcare workers in
S
Safe Drinking Water Act
safety in the workplace, improvements and remaining challenges with
salaries
for behavioral and mental health workers
for environmental and occupational workers
for epidemiology and disease control professionals
mean, for full-time equivalent workers of state and local health agencies, 1998–2012, U.S.
for medical and health administrators
for nutritionists and dietitians
for public health education and information professionals
for public health laboratory specialists
for public health laboratory technologists
for public health nurses
for public health workers
Salk vaccine, against polio
SAMHSA. See Substance Abuse and Mental Health Services Administration
sanitary movement
Satcher, David
school lunch programs
schools of public health, training activities for public health workers and
science, public health grounded in
scope, of public health
screenings, health care and
seat belt use
secondary building blocks
secondary medical care
secondary prevention
comprehensive model of chronic disease prevention and control
defined
effects of
health services pyramid
Secretary of Homeland Security, responsibilities of
September 11, 2001 terrorist attacks
septicemia, as leading cause of death, 2000
severe acute respiratory syndrome
sexual behaviors, risky
sexually transmitted diseases (STDs), state statutes and legal frameworks relative to
SHAs. See state health agencies
Shattuck, Lemuel
Sixteenth Amendment
Snow, John
cholera outbreak (1854) investigated by
SNS. See Strategic National Stockpile
social enterprise, public health as
social justice philosophy, in public health
societal benefits
Society for Epidemiologic Research
Society of Public Health Educators
sociology
special emergency powers
stakeholders, in health system
standard occupational categories (SOCs)
state agencies
health responsibilities of
key activities performed by
for public emergency preparedness and services
state constitutions/statutes
local governments and
role of
state government health agencies, full-time equivalent (FTE) workers in, U.S., 1995–2012
state governments, environmental health programs and
state health agencies (SHAs)
selected characteristics, 2012
selected organizational responsibilities of, 2005
vital statistics for
state health departments
state health expenditures
state legal systems
state legislatures
state public health activities, in U.S., growth of
statisticians
number and salary profile for federal and state/local workers, 2013
number of, in 2013, and projected for 2022 and number of positions to be filled, 2012–2022 for all industries and government
salaries for
statutory-based laws, governmental policy choices and
STDs. See sexually transmitted diseases
Strategic National Stockpile (SNS)
strategic planning
process
stroke, projected health expenditures and
substance abuse
counselors, salaries for
social workers
Substance Abuse and Mental Health Services Administration (SAMHSA)
Sudden Acute Respiratory Syndrome
Superfund Amendments and Reauthorization Act
Supplemental Food Program for Women, Infants, and Children
Supreme Court
surveillance
public health
syndromic
T
Target Capabilities List
technical occupations in public health, characteristics of
technicians, percentage of, in public health workforce, U.S., 2000
teen pregnancy
terrorism
terrorist attacks of September 11, 2001
tertiary medical care
tertiary prevention
comprehensive model of chronic disease prevention and control
defined
effects of
health services pyramid
“3 Ps” of global health
Tier 1 Core Competencies, PHNs
Tier 2 Core Competencies, PHNs
Tier 3 Core Competencies, PHNs
tobacco-related illnesses
tobacco settlement funds, use of
tobacco use
gains, losses, and trends in
Toxic Substance Control Act
training
for administrative business professionals
for healthcare workforce
for public health workers
Treasury Department
triage, federal emergency medical assets and
tuberculosis
as leading cause of death, 1900
number and rate of cases among U.S.-born and foreign-born persons, by year reported, 1993–2008
resurgence of, in 1990s
20th century achievements in public health
cardiovascular disease
food safety
infectious diseases
maternal and child health
motor vehicle injuries
oral health
tobacco use
unfinished agenda relative to
workplace safety
21st century public health, limitations of
typhoid
U
uncommon culture, of public health
unemployment
United Kingdom, health expenditures in
United States
health in
health system in
demographic and utilization trends
economic dimensions
healthcare resources
universal access to health care
University of North Carolina School of Public Health
urban areas, job opportunities for healthcare workers in
U.S. Department of Labor
U.S. Environmental Protection Agency
U.S. Office of Personnel Management
U.S. Preventive Health Services Task Force
U.S. Public Health Service
key agencies within
U.S. Public Health Service Agency, fiscal year 2011 program level budgets
utilitarian movement
utilization trends, in U.S. health system
V
vaccines and vaccinations, polio
Veterans Administration
veterinarians
number of and salary profiles for federal and state/local workers
number of in 2013 and projected for 2022 and number of positions to be filled, 2012–2022, for all industries and government
number of, working in U.S.
Vickers, Geoffrey
violence
viruses, potential global pandemics and
vision statement
visioning, MAPP process
W
war on terror
wellness, multidimensional view of
West Nile virus
white collar occupations, for public health workers
WHO. See World Health Organization
whooping cough
Winslow, C. E. A.
women, labor force participation for, in U.S.
work content, for public health workers
workforce development, for public health workers
workplace considerations, for public health workers
workplace preparedness, emergency response and
workplace safety
workplace settings
for environmental and occupational workers
for epidemiology and disease control professionals
for medical and health administrators
for public health education and information professionals
for public health nurses
for public health workers
World Health Organization (WHO)
World Trade Center, terrorist attacks
Y
years of healthy life
years of potential life lost (YPLL)
mortality-based indicator
yellow fever
YPLL. See years of potential life lost