Governmental Public Health

In the United States, there are more than 3,000 health departments, 60 state (or tribal or territorial) health departments, and the CDC at the federal level (Trust for America's Health, 2004).These health departments engage in a variety of activities to protect the public's health. The activities include monitoring the burden of injury and disease in the population through disease surveillance; identifying individuals and groups that have conditions of public health importance through testing, reporting, and partner notification; providing a broad array of prevention services, such as counseling and education; and helping ensure access to healthcare services for poor and vulnerable populations.

The structure of a health department is similar whether the organization is positioned at the federal, state, or local level. A secretary or director leads the organization and oversees numerous programs in addition to biosurveillance, which include such functions as communications, environmental health, laboratory, communicable diseases, and chronic diseases. Figure 5.1 is the structure of a representative health department.

The division of responsibility and authority between state and local health departments varies substantially by state. Some states have a centralized model (e.g.,Arkansas, Florida, Georgia, and Missouri), meaning that the state health department has direct control and authority for supervision of local health departments. In other states (e.g., California, Illinois, and Ohio), local health departments function more independently; they are run by counties (rather than the state) and report directly to local boards of health or health commissioners. Still other states (e.g., Iowa and North Dakota) have no local health department, and the state health department provides all public health services directly (Committee on Health Promotion and Disease Prevention, 2003). In the following sections, we describe the typical division of responsibility between state and local health departments.

For biosurveillance, local and state health departments have primary responsibility for data collection and analysis. Although the CDC publishes goals and standards, local and state health departments implement biosurveillance systems (such as syn-dromic surveillance, discussed below) and develop analytical tools (Heffernan et al., 2004).

FIGURE 5.1 Illustration of the typical organization of a local, state, or federal health department. The subdivisions involved in biosurveillance directly are highlighted with bold outlines. (From the Pennsylvania Department of Health.)

4.1. State Health Departments

Every state has a health department with responsibility for public health activities. That health department may be a stand-alone department or a component of a department with broader responsibilities, such as a health and human services program.

In addition to operating infectious disease reporting systems, state health departments typically have divisions or units with responsibility for disease control, immunization, health education, and health statistics services. State health departments also license and regulate the healthcare system, for both institutions and individual providers that deliver healthcare services. States vary, however, in whether the state health department or some other governmental department has responsibility for programs such as mental health and substance abuse, environmental health, and Medicaid.

4.2. Local Health Departments

Local health departments are also responsible for a variety of activities. In addition to operating infectious disease reporting systems, responsibilities of local health departments include communicable disease control, community assessment, community outreach and education, environmental health services, epidemiology, food safety, health education, restaurant inspections, and tuberculosis testing. A smaller percentage of local health departments offer treatment for chronic disease, behavioral and mental health services, programs for the homeless, substance abuse services, and veterinary public health (National Association of County and City Health Officials, 2001).

4.3. Centers for Disease Control and Prevention

At the federal level, the lead agency related to biosurveillance is the CDC, a nonregulatory agency that is part of the

Department of Health and Human Services (DHHS).The CDC is responsible for collecting, analyzing, and disseminating national disease occurrence and mortality data to the public and to state and local health departments. Any request for CDC assistance must be accompanied by an invitation by a state health department.

The CDC promulgates goals and standards for biosurveillance systems and encourages their adoption by making them requirements for CDC-controlled federal funding to state and local health departments. The CDC also develops software for its own use and for health departments. Table 5.1 lists some agencies with biosurveillance responsibilities within the DHHS (Committee on Health Promotion and Disease Prevention, 2003).

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