Transcription
In this section, we will visit the governance of public health in the United States. Let's take a step back from an individual's ability to complete the core competencies to think instead about how public health is governed in the United States.
In the United States, state and local health departments retain primary responsibility for carrying out public health functions under the U.S. Constitution. There are 51 state health departments, as well as one in the District of Columbia, 175 tribal health departments, over 2,500 local health departments, and eight territorial health departments. The hierarchy of public health infrastructure in the United States is depicted here. At the base is the population being served. Directly serving them are primarily the local health departments, which are overseen or governed by state health departments, which are then overseen by federal health agencies. We see in the arrows here how each level interacts with each other level. Federal health agencies primarily interact with the state health departments, both in terms of the provision of funding or resources, but also in the establishing of guidelines or policies. They also have some interaction directly with local health departments and, to a lesser extent, directly with the population being served.
Now, the state-level health departments are who primarily interact with the local health departments. These county or city health departments receive funding, resources, and support from state health departments. Now, in terms of interaction with the population, in most cases, it's directly through the local health departments, but in certain situations, the state health departments interact directly with their catchment areas.
So let's think a little bit about the core functions at each of the government levels. Each of these levels is responsible for assessment, policy development, and assurance. As you remember, these are the three primary domains under the 10 essential public health services. Let's look at a specific example of tobacco control and how each level of government provides each of these services. The federal government, in terms of assessment, is responsible for national-level public health surveillance of tobacco use and use in subpopulations. They are responsible for policy development in areas under their jurisdiction, such as having a smoking ban on commercial flights. Assurance is done through research that occurs at the federal level and also through grants that are provided to state and local health departments, as well as academic and research institutions.
At a state level, the monitoring of that level is under the jurisdiction of the state; so both monitoring and surveilling tobacco use in the overall population and in sub-populations. In terms of policy development, states have jurisdiction to put forth increases in tobacco taxes, for example. Assurance that they do would also be through the provision of resources or funding. At a local level, reports are issued on tobacco use at as granular a level as possible, thinking about specific neighborhoods or specific city-level information. Local jurisdictions also put forth county-level laws or regulations, such as prohibiting smoking in bars. Assurance work is done, such as providing specific resources to help individuals quit smoking, in say multiple languages if that is relevant for the local population.
This map depicts that it's somewhat complex in the United States whether an area is governed primarily by local health departments, state health departments, or some sort of mixture. You can see in the lighter tan colors states in which the local-level health departments carry out primary responsibility to govern public health. In the yellow states, there's a mixed responsibility; that is, for example, in the state of Maryland, the state health department is primarily overseeing the county health departments across the state, such that individuals who work at county health departments in Maryland are actually employees of the state. In contrast, the Baltimore City Health Department is independent and is providing services for the city specifically. The city health department reports directly to the mayor of Baltimore City and not to the state health department of Maryland. And finally, you see in the light blue states in which it is entirely the state health department's responsibility to provide health services for that state.
So, as you can see, the governance of public health in the United States is complex but does function in a way that provides direct access for all individuals, to the extent possible, through state and local health departments. Therefore, it is essential for us to think about whether the individuals that comprise the core governance of public health in our communities have the necessary skills and resources to carry out the essential public health services.