U.S. Public Health Infrastructure

1. Milestones in Public Health: Chapter 11 U.S. Public Health Infrastructure One Set of Lectures for All Three – Undergraduate, Graduate Public Health, and Medical and Clinical Education – Levels January 2011

2. Learning Objectives • Define public health • Describe the 10 essential public health services of the U.S. public health system • Describe the U.S. public health infrastructure and its key elements: • Workforce • Information and knowledge systems • Organizational capacity

3. Lecture Outline • Definitions of Public Health • The U.S. Public Health System • The Centers for Disease Control and Prevention • The Public Health Workforce • Information and Knowledge Systems: Surveillance • Organizational Capacity • Looking Ahead

4. U.S. Public Health Infrastructure Definitions of Public Health

5. Definitions of Public Health “What we do collectively as a society to assure the conditions in which people can stay healthy.” Institute of Medicine 1988 “The science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals.” C. E. A. Winslow, 1920

7. U.S. Public Health Infrastructure The U.S. Public Health System

8. U.S. Public Health System The U.S. public health system is distinct from other parts of the health care system in two key respects: • Its primary emphasis is preventing disease, injury and disability • It focuses on population health rather than individual health

9. Background: 10 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 problems

10. Background: 10 Essential Public Health Services (Cont.) • Develop policies and plans that support individual and community health efforts • Enforce laws and regulations that protect health and ensure safety • Link people to needed personal health services and assure the provision of health care when it is otherwise unavailable

11. Background: 10 Essential Public Health Services (Cont.) • Assure a competent public and personal health care workforce • Evaluate the effectiveness, accessibility, and quality of personal and population-based health • Research new insights and innovative solutions to health problems From the Public Health Functions Project (1994-1999), directed by a Steering Committee chaired by the Assistant Secretary of Health and Surgeon General with participation of CDC and a host of public health organizations, foundations, and organizations.

12. Players in the U.S. Public Health System • Both the public and private sectors play an important role in public health • There are more than 3,000 county and city health departments, 3,000 local boards of health and more than 160,000 public and private laboratories

13. Players in the U.S. Public Health System (Cont.) • A series of federal health and environmental agencies set national standards and provide funding, training, scientific guidance, and technical support • Hospitals, clinics, managed care organizations, civic and volunteer groups, and national associations support the work of local, state, and federal public health agencies

14. Schools Civic Groups Nursing Homes Neighborhood Organizations Elected Officials EMS Community Centers Non-Profit Organizations Drug Treatment Home Health Hospitals Public Health Agency Mental Health Law Enforcement Doctors Laboratories Faith Institutions Fire Transit Tribal Health CHCs Employers Corrections Local U.S. Public Health System Camden County, NJ (n.d.) Local Public Health System Illustration, CDC [Online image]. Retrieved from http://www.camdencounty.com/images/mapp002.gif

15. Health care delivery system Community Assuring the Conditions for Population Health Public Health Infrastructure Employers and Business Academia The Media The Public Health SystemNational Academies of Science, Institute of Medicine, 2002

16. U.S. Public Health Infrastructure The Centers for Disease Control and Prevention

17. “When people ask me what’s the biggest challenge in public health, I have an easy answer. For large scale disasters and more routine threats to health, the major problem we face is complacency. We’ve made a lot of progress in our preparedness efforts, but we’re not done yet. We need long term investment to get us where we want to be.” Dr. Julie L. Gerberding CDC Director 2002-2008 Introducing the Centers for Disease Control and Prevention (CDC), a Pillar of the US Public Health Infrastructure

18. Location of the CDC Within the U.S. Department of Health and Human Services

19. The Mission of the CDC “Collaborating to create the expertise, information, and tools that people and communities need to protect their health – through health promotion, prevention of disease, injury and disability, and preparedness for new health threats.” See http://www.cdc.gov/about/organization/mission.htm

20. CDC Accomplishments • Helped with worldwide eradication of smallpox by the late 1970’s • Has tracked emerging infections • Legionnaire’s disease • Hantavirus • Toxic-shock syndrome

21. CDC Accomplishments (Cont.) • Has published the Morbidity and Mortality Weekly Report (MMWR) since 1961, an essential public health tool that tracks data on deaths and certain diseases from every state week to week

22. The CDC National Notifiable Diseases Surveillance System • Public health officials at state health departments and CDC determine which diseases should be nationally notifiable • The Council of State and Territorial Epidemiologists, with input from CDC, makes recommendations annually for additions and deletions to the list of nationally notifiable diseases • Reporting is currently mandated (i.e. by state legislation or regulation) only at the state level. The list of diseases that are considered notifiable, therefore, varies slightly by state. All states generally report the internationally quarantinable diseases (i.e. cholera, plague, and yellow fever) in compliance with the World Health Organization's International Health Regulations

23. Assessment of the U.S. Public Health Infrastructure The US public health infrastructure suffers from “vulnerable and outdated health information systems and technologies, an insufficient and inadequately trained public health workforce, antiquated laboratory capacity, a lack of real time surveillance and epidemiological systems, ineffective and fragmented communications networks, incomplete domestic preparedness and emergency response capabilities, and communities without access to essential public health services.” • Institute of Medicine (Eds). (2002). The Future of the Public’s Health in the 21st Century. Washington, D.C.:National Academies Press.

24. Systems in the Public Health Infrastructure Public health systems in the U.S. infrastructure are built on: • The workforce • Information and knowledge systems • Organizational capacity • Baker, EL et al. The public health infrastructure and our nation’s health. (2005) Annu. Rev. Public Health 2005. 26:303-18

25. Infrastructure for Executing the 10 Essential Public Health Services • Baker, EL et al. The public health infrastructure and our nation’s health. (2005) Annu. Rev. Public Health 2005. 26:303-18

26. U.S. Public Health Infrastructure The Public Health Workforce

27. Public Health Workforce • A public health professional is a person educated in public health or a related discipline who is employed to improve health through a population focus “Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21’st Century” (2003), IOM • About 450,000 individuals make up the public health workforce (local, state, and federal levels, and private) Council on Linkages Between Academia and Public Health Practice (2002). Competencies Project. Retrieved from http://www.trainingfinder.org/competencies/

28. Public Health Workforce (Cont.) The most common professions include: • Nurses • Physicians • Environmental specialists • Laboratorians • Health educators • Epidemiologists • Outreach workers • Managers

29. Public Health Professionals: Epidemiologists • Epidemiologists, or “disease detectives,” detect and investigate health threats and disease patterns, and work to minimize the negative effects of a health threat in a community • They might identify contaminated food causing illness, assess the number of people injured and types of injuries resulting from a disaster Centers for Disease Control and Prevention. (2008). Key Findings from Public Health Preparedness: Mobilizing State by State A CDC Report on the Public Health Emergency Preparedness Cooperative Agreement. Retrieved from http://www.bt.cdc.gov/publications/feb08phprep/pdf/feb08phpkeyfindings.pdf

30. Public Health Professionals: Physicians Physicians in public health include those “…whose training, practice, and world view are based in large part on a population focus rather than individual practice, that is, on assuring the availability of essential public health services to populations using skills, such as leadership, management, and education as well as clinical interventions.” Gebbie, K. , & Hwang, I. (1998). Preparing currently employed public health professionals for changes in the public health system. New York: Center for Health Policy and Health Sciences Research, Columbia University School of Nursing

31. The CDC: The Epidemic Intelligence Service (EIS) • Established in 1951 following the start of the Korean War as an early warning system against biological warfare and man-made epidemics • EIS is composed of medical doctors, researchers, and scientists who serve in two-year assignments. Has expanded into a surveillance and response unit for all types of epidemics, including chronic disease and injuries Centers for Disease Control and Prevention. (n.d.) Epidemic Intelligence Service (EIS). Retrieved from http://cdc.gov/eis/

32. Challenges for the Public Health Workforce • Worker shortages • Lack of formal graduate training among the vast majority of public health workers • Lack of coordinated, competency-based education and training • Lack of certification standards in public health

33. Challenges for the Public Health Workforce: Worker Shortages In a 2002 national survey, health departments were identified as the state agencies most affected by a worker shortage. Counc. State Territ. Epidemiol. (2003). National Assessment of Epidemiologic Capacity in Public Health: Findings and Recommendations. Washington, D.C.: Counc. State Territ. Epidemiol.

34. Challenges for the Public Health Workforce: Worker Shortages (Cont.) • According to the Association of Schools of Public Health, by 2020 the US will face a shortfall of more than 250,000 public health workers • Professions affected by this shortfall include: administrators, health care educators, public health physicians, and public health nurses • Associations of Schools of Public Health, (2008). ASPH • Policy Brief, Confronting the Public Health Workforce Crisis. • Washington, D.C.: Associations of Schools of Public Health.

35. Challenges for the Public Health Workforce: Lack of Formal Graduate Training • A small portion of public health workers receive any formal public health education • According to one national study, 42% of the current epidemiology workforce lack formal training in this field • Counc. State Territ. Epidemiol. (2003). National Assessment of Epidemiologic Capacity in • Public Health: Findings and Recommendations. Washington, D.C.: Counc. State Territ. Epidemiol.

36. Challenges for the Public Health Workforce: Lack of Coordinated, Competency-based Education and Training • Most traditional educational practices lack assurance that students can demonstrate acquisition of knowledge, skills, and attitudes • Many organizations have called for evidence-driven, outcome-based workforce development efforts, including competency-driven approaches to instructional design

37. Challenges for the Public Health Workforce: Lack of Certification Standards in Public Health While certification is common for the professions feeding into the public health workforce (physicians, nurses, etc.), until recently the public health field lacked national standards for educational attainment, continuing competency, and career achievement. Sommer, A., & Akhter, M. N. (2000). It's time we became a profession. American Journal of Public Health, 90(6), 845-846.

38. Historic Goals of Credentialing in Public Health • Increase recognition of the public health professions • Raise the visibility of public health • Measure and improve the competency and consistency of public health workers nationwide NBPHE, 2005 (http://www.nbphe.org/about.cfm)

39. Certificate of Public Health The National Board of Public Health Examiners (NBPHE) was established in September 2005 as an independent organization, the purpose of which is to ensure that students and graduates from schools and programs of public health accredited by the Council on Education for Public Health (CEPH) have mastered the knowledge and skills relevant to contemporary public health. NBPHE, 2005 (http://www.nbphe.org/about.cfm) )

40. Overcoming Public Health Workforce Challenges: Federal Training Initiatives Centers for Disease Control and Prevention • The Public Health Training Network (PHTN) • The National Public Health Leadership Institute • Preparedness and Emergency Response Learning Centers (PERLC) Health Resources and Services Administration • Public Health Training Centers (PHTC)

41. U.S. Public Health Infrastructure Information and Knowledge Systems : Surveillance

42. Information and Knowledge Systems: Surveillance The ongoing systemic collection, analysis and interpretation of health-related data is called surveillance.

43. Surveillance Systems • Help to monitor disease and enable efficient communication among public and private health organizations, the media and the public • Provide data on illness, disability and death from acute and chronic conditions; on injuries; on personal environment and occupational risk factors; and program costs

44. Surveillance Systems (Cont.) • Since 9/11, public health departments have increased their ability to detect diseases due to improvements in surveillance and information systems • Presently all state public health departments can receive and evaluate urgent reports of potential health threats 24/7/365, whereas in 1999 only 12 state public health departments could do so • US Department of Health and Human Services. (2008). Key Findings from Public Health Preparedness: • Mobilizing State by State A CDC Report on the Public Health Emergency Preparedness Cooperative • Agreement. Washington, D.C.; Centers for Disease Control Prevention. p. 2.

45. Surveillance Systems (Cont.) “By 2010, each health department will be able to electronically access and distribute up-to-date public health information and emergency health alerts, monitor the health of communities and assist in the detection of emerging public health problems” U.S. Department of Health and Human Services. (2001). Public Health’s Infrastructure: A Status Report. Washington, D.C.: Centers for Disease Control and Prevention.

46. Surveillance Systems: Challenges Present infrastructure for surveillance systems varies significantly by jurisdiction, from barely existent in some, to state of the art in others.

47. Overcoming Surveillance Systems Challenges: US Department of Health and Human Services Initiatives Centers for Disease Control and Prevention • Health Alert Network (HAN) • National Electronic Disease Surveillance System (NEDSS)

48. Overcoming Surveillance Systems Challenges: US Department of Health and Human Services Initiatives (Cont.) Centers for Disease Control and Prevention • Epidemic Information Exchange (Epi-X) • PulseNet

49. U.S. Public Health Infrastructure Organizational Capacity

50. Organizational Capacity The ability of organizations to activate relationships, workers, information, and equipment to accomplish their stated purposes within the public health system  ASPH, 2010 (http://www.asph.org/document.cfm?page=1115#Q15)