Governmental Public Health

Rita Velikina

University of California Los Angeles, School of Public Health, Department of Epidemiology, Los Angeles, California

Virginia Dato

Division of Infectious Disease Epidemiology, Pennsylvania Department of Health, Harrisburg, Pennsylvania

Michael M.Wagner

RODS Laboratory, Center for Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania


In the report The Future of Public Health, the Institute of Medicine defines public health as "what we, as a society, do collectively to assure the conditions for people to be healthy'' (Committee for the Study of the Future of Public Health, 1988). Government at the federal, state, and local level plays an important role in keeping people healthy (Gostin, 2000). More than 3,000 governmental organizations at all three levels collect information about the health of populations for the purposes of public health surveillance, which, as discussed in Chapter 1, is both broader (includes chronic diseases) and narrower than is biosurveillance as we define the term in this book. In this chapter, we explore the organization of governmental public health, the types of data collected, and the information systems used to manage these data.


On May 22,1869, a committee of the Massachusetts legislature asserted that "all governments since the time of Moses [Leviticus chapters 11-16] are established to protect the life and health of their people''; thus, the first state board of health and vital statistics in the United States was born (Rosenkrantz, 1972; Kaniecki and Asrti, 2004). But even before the United States of America formally existed, the 13 colonies fulfilled the recognized obligations of a sovereign state to take the necessary actions for the promotion and protection of the health and well-being of its inhabitants (Richards and Rathbun, 1993).

2.1. Notifiable Disease Reporting

Notifiable disease reporting (henceforth referred to simply as disease reporting) refers to a form of biosurveillance in which clinicians and laboratories report designated diseases (known as notifiable diseases) to governmental public health (henceforth referred to as health departments) at the time of diagnosis.1

Disease reporting in the United States dates to colonial America, when in 1741 the colony of Rhode Island required tavern keepers to report patrons with smallpox, yellow fever, and cholera to local authorities (Birkhead and Maylahn,2000). In 1874, the Massachusetts Board of Health asked 168 physicians to notify them each week by postcard of the prevalence of 14 infectious diseases in their vicinity. Michigan instituted a similar voluntary system in 1876 and, in 1883, passed a law requiring immediate notification to the board of health of "smallpox, cholera, diphtheria, scarlet fever, or any other disease dangerous to the public health by householders, hotel keepers, tenants and physicians'' (Birkhead and Maylahn, 2000). Massachusetts passed a similar law one year later and imposed a fine on those who failed to report.

From 1949 to 1970, disease reporting evolved into its modern form partly owing to the charismatic influence of Alexander Langmuir, chief of the Bureau of Epidemiology at the CDC2 (Fumento, 2001). At the 1950 Association of State and Territorial Health Officials meeting, Langmuir was the driving force behind the revised specifications of the diseases to be

1 Although 'health department' is less precise than 'governmental public health organization,' it is more readable and understandable. We use the term 'health department' to refer to state and local health departments as well as to the CDC. We realize that the CDC is not considered a health department, but many of the points we make apply to all of these organizations. When information applies only to a local or state health department, we make the distinction clear in the text.

2 In 1946, the Communicable Disease Center was created from the Office of Malaria Control in War Areas, an agency that had been established in 1942 to limit the impact of malaria and other mosquito-borne disease on U.S. military personnel. In 1970, the CDC was renamed the Center for Disease Control to reflect responsibilities for noncommunicable disease problems. In 1992, CDC's name was changed to the Centers for Disease Control and Prevention. This change was enacted by Congress, as part of the Preventive Health Amendments of 1992, to recognize the CDC's leadership role in the prevention of disease, injury, and disability (MMWR Morb Mortal Wkly Rep, 1992).

Handbook of Biosurveillance ISBN 0-12-369378-0

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reported and the frequency of reporting (Committee on Health Promotion and Disease Prevention, 2003). In 1961, responsibility for the collection and publication of data on nationally notifiable diseases was transferred from the National Office of Vital Statistics to the CDC, which began publishing notifiable disease data in the Morbidity and Mortality Weekly Report (Committee on Health Promotion and Disease Prevention, 2003).

Since its early beginnings, disease reporting has expanded in the numbers of diseases reported, the entities responsible for reporting, and the methods by which health departments analyze and disseminate the results of the analyses.

2.2. Other Surveillance Systems

Although systematic disease reporting remains a mainstay of governmental public health, health departments have developed many systems to address specific needs.

The history of surveillance can be traced back to William Farr, the superintendent of the statistical department of the Registrar's General Office of England and Wales from 1839 to 1879. Farr focused on collecting vital statistics, on assembling and evaluating those data, and on reporting both to responsible health authorities and to the general public (Thacker, 2000).

In 1850, Lemuel Shattuck issued a report that linked infant and maternal mortality to communicable disease. He recommended a decennial (every 10 years) census, standardization of disease and death terminology, and collection of health data by demographics. He also applied his recommendations to program activities, such as immunization, school health, and smoking and alcohol abuse (Thacker, 2000).

In 1968, Alexander Langmuir presented a working paper at the 21st World Health Assembly on the concepts and practices of national and global surveillance of communicable disease.The paper was endorsed at the assembly by the 100 delegates present and identified three principal tenets of surveillance: "(1) the systematic collection of pertinent data, (2) the orderly consolidation and evaluation of these data, and (3) the prompt dissemination of results to those who need to know'' (Thacker, 2000).

The 1968 World Health Assembly discussions reflect the broadened concept of surveillance and addressed the application to public health issues other than communicable disease. Since that time, health departments have expanded their focus, placing pediatric lead poisoning, congenital malformations, and injuries under surveillance (Thacker, 2000).

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