The Transformation of Public Health. (Health & Medicine)

Article excerpt

LEST WE FORGET, NOT ALL OF THE TERRORIST attacks launched against the United States last fall came on September 11. In the weeks following the airliner-turned-missile strikes on New York and Washington, a number of Americans became infected, some fatally, with anthrax that apparently was spread purposely by some malevolent agent. Whether that agent is associated with the terrorists of September 11 is unknown at the time of this writing. But what is known is that bioterrorism represents a new challenge for the U.S. public health system.

The U.S. public health system is unique in all the world. It is responsible for a number of remarkable accomplishments, including the elimination or near-elimination of several deadly diseases that ravaged the nineteenth century. But, as politicians and other public officials try to respond to the bioterrorism crisis, the system is in danger of undergoing a radical change in design and purpose that could make it ineffective in meeting its traditional obligations and new responsibilities.

U.S. PUBLIC HEALTH

The business of public health is the prevention of disease and injury, especially by "health protection" -- protection from environmental hazards such as impure water, contaminated foods, and infectious or "quarantinable" diseases. In many nations, responsibility for the promotion of public health is vested in the national government. But in the United States, the Constitution does not grant any such duties to the federal government; those duties instead belong to the states.

They, in turn have developed state and local health departments that hold responsibilites relating to public health. Each health department is directed by a "health officer" who holds broad authority and, at his or her discretion, can perform acts (such as the mandatory quarantining of persons with contagious diseases) that are possible for no other U.S. government agent. It is in the pursuit of health protection that the broad and sometimes coercive powers of state and local health officers have been brought to bear.

Federal role In the U.S. public health system, the traditional role of the federal government has been to assist the state and local health departments with guidance, laboratory support, people, and money from the U.S. Public Health System (USPHS) to assure that national priorities are considered. When a public health problem could affect more than one state, the federal government has used such constitutional authority as "protecting interstate commerce" to take a more direct, active role.

However, in recent decades, Congress has mandated a number of large programs that have created major perturbations for the loose federalism originally characteristic of public health. For example, the Environmental Protection Agency (EPA) and the Occupational Safety and Health Administration (OSHA) gave the federal government vast new authorities to operate directly in the states and perform functions formerly reserved for state and local health departments. Huge federal programs of medical care and nutrition -- Medicare for the elderly, Medicaid for the indigent, and W.I.C. for dependent women, infants, and children -- have implications for health departments and have further blurred the lines of authority for the public's health.

However, in the area of disease control, the federal Centers for Disease Control and Prevention (CDC) have continued to respect the primacy of states. As an operating philosophy to this day, the CDC engages in epidemic investigations in a state Only on request of the state health officer.

Acute care In emergencies, health officers often exercise their "convener" role in the community to stimulate and coordinate the provision of emergency medical services by hospitals, clinics, and medical societies. However, acute medical care -- especially acute emergency medicine -- is far afield from the preventive function for which public health has unique expertise. …