Search

The landmark 1988 Institute of Medicine report The Future of Public Health served the public health community well by pointing to what needed to be done, fostering a sense of urgency, and offering concrete directions to be pursued. In this article, the impact of the 1988 report, and of the subsequent 2003 report on the Centers for Disease Control and Prevention (CDC), is considered by tracing the course of the ideas that influenced the consciousness of the public health community and subsequently catalyzed concrete action. Among these ideas was that "public health is in disarray." This assessment led to an awareness that something needed to be done. Further, by stating that the public health enterprise had 3 core functions (assessment, policy development, and assurance), the 1988 report set in motion policy development to address the "disarray." At a more fundamental level, both reports championed the need for governmental public health (particularly at the CDC) to take action to strengthen the capacity of local and state public health agencies to address a growing range of public health threats and emergencies. ( Am J Public Health . 2024;114(5):489-494. https://doi.org/10.2105/AJPH.2024.307598).

Competing Interests: The authors declare no conflicts of interest.

Background: The authors conducted a cluster randomized study to determine the effect of an exportable educational intervention for young women with breast cancer (YWI) on improving care., Methods: Sites were randomized 1:1 to the YWI or a contact time control physical activity intervention (PAI) stratified by academic or community site. Up to 15 women aged ≤45 years with newly diagnosed breast cancer were enrolled at each of 14 academic sites and 10 were enrolled at each of 40 community sites. The primary endpoint, attention to fertility, was ascertained by medical record review. Statistical inferences concerning the effect of the intervention used general estimating equations for clustered data., Results: A total of 467 patients across 54 sites were enrolled between July 2012 and December 2013. The median age of the patients at the time of diagnosis was 40 years (range, 22-45 years). Attention to fertility by 3 months was observed in 55% of patients in the YWI and 58% of patients in the PAI (P = .88). Rates were found to be strongly correlated with age (P < .0001), and were highest in patients aged <30 years. Attention to genetics was similar (80% in the YWI and 81% in the PAI), whereas attention to emotional health was higher in patients in the YWI (87% vs 76%; estimated odds ratio, 2.63 [95% confidence interval, 1.20-5.76; P = .016]). Patients rated both interventions as valuable in providing education (64% in the YWI and 63% in the PAI)., Conclusions: The current study failed to demonstrate differences in attention to fertility with an intervention to improve care for women with breast cancer, although attention to fertility was found to be higher than expected in both groups and emotional health was improved in the YWI group. Greater attention to young women with breast cancer in general may promote more comprehensive care for this population., (© 2019 American Cancer Society.)

Context: The year-long National Public Health Leadership Institute's (PHLI) goals are to develop the capacity of individual leaders and networks of leaders so that both can lead improvements in public health systems, infrastructure, and population health., Objective: To evaluate PHLI's impact on networks, systems, and infrastructure., Participants: Senior leaders from government, health care, associations, and other organizations who graduated from PHLI between 1992 and 2006., Intervention: Retreats; readings, conference calls, and webinars; personal assessments, feedback, and coaching; and action learning projects., Methods: A cross-sectional survey sent in 2007 to all leaders from the program's first 15 cohorts. Between 1992 and 2006, PHLI graduated 806 leaders. Of the 646 graduates located, 393 (61%) responded, for an overall response rate of 49% (393/806). Telephone interviews of 35 key informants were also conducted., Results: Graduates fostered changes in systems, policies, organizations, and programs and frequently described these changes as resulting from their work as or with networks. Many graduates formed an informal national network of "thought leaders" and volunteered with professional associations to help in creating methods for improving systems and infrastructure. At the state level, graduates worked as informal networks and with associations to restructure services, reorganize agencies, catalyze new laws, and develop programs. Locally, graduates developed coalitions, fostered new laws, and improved programs, among other changes., Conclusion: The Centers for Disease Control and Prevention's multiyear sponsorship of a national program fostered national networks among "thought leaders" who helped to lead the development and diffusion of numerous innovations. Public health leadership development program sponsors should foster collaborative leadership by engaging leaders in systems thinking, team leadership, dialogue, conflict resolution, and negotiation, recommend using networks for sustained personal and system development, and link leaders to networks and associations. Networks provide the collective creativity and broad support needed to enact system and infrastructure changes.

Context: Public health leadership development programs are widely employed to strengthen leaders and leadership networks and ultimately agencies and systems. The year-long National Public Health Leadership Institute's (PHLI) goals are to develop the capacity of individual leaders and networks of leaders so that both can lead improvement in public health systems, infrastructure, and population health., Objective: To evaluate the impact of PHLI on individual graduates using data collected from the first 15 cohorts., Participants: Between 1992 and 2006, PHLI graduated 806 senior leaders from governmental agencies, academia, health care, associations, nonprofit organizations, foundations, and other organizations. Of 646 graduates located, 393 (61%) responded to a survey, for an overall response rate of 49% (393/806)., Intervention: PHLI has included retreats; readings, conference calls, and webinars; assessments, feedback, and coaching; and action learning projects, in which graduates apply concepts to a work challenge aided by peers and a coach., Methods: A survey of all graduates and interviews of 34 graduates and one other key informant., Results: PHLI improved graduates' understanding, skills, and self-awareness, strengthened many graduates' connections to a network of leaders, and significantly increased graduates' voluntary leadership activities at local, state, and national levels (P < .001). Deeper and wider network connections shaped graduates' sense of "belonging" to the national cadre of public health leaders, provided access to supportive peers and ideas, and bolstered confidence and interest in taking on leadership work. Nearly all graduates remained in public health. Some partially attributed to PHLI their promotions into more senior positions., Conclusion: Leadership development programs can strengthen and sustain their impact by cultivating sustained "communities of practice" that provide ongoing support for skill development and innovative practice. Sponsors can fruitfully view leadership development as a long-term investment in individuals and networks within organizations or fields of practice.

Objectives: We sought to identify the incentives most likely to encourage voluntary participation in the national public health accreditation model., Methods: We reviewed existing incentives, held meetings with key informants, and conducted a survey of state and local public health agency representatives. The survey was sent to all state health departments and a sample of local health departments. Group-specific differences in survey responses were examined., Results: Survey response rates were 51% among state health department representatives and 49% among local health department representatives. Both state health department and local health department respondents rated financial incentives for accredited agencies, financial incentives for agencies considering accreditation, and infrastructure and quality improvement as important incentives. State health department respondents also indicated that grant administration and grant application would encourage their participation in the national accreditation model, and local health department respondents also noted that technical assistance and training would encourage their participation., Conclusions: Incentives to encourage participation of state and local agencies in the national voluntary accreditation model should include financial support as well as support for agency infrastructure and quality improvements. Several initiatives are already under way to support agency infrastructure and quality improvement, but financial support incentives have yet to be developed.

True collaboration among large federal agencies is rare, as is that among large and influential national foundations. The collaboration between two major government health agencies (The Centers for Disease Control and Prevention and the Health Resources and Services Administration) and three major health foundations (the W.K. Kellogg Foundation, the Robert Wood Johnson Foundation, and the CDC Foundation) to create the Management Academy for Public Health is unprecedented in public health over the past quarter century. We attribute this success to the unique combination of a strong foundation of relationships between the partners and a commitment to generative dialogue throughout the design and implementation of the program. The success and sustainability of the Academy derive directly from these critical success factors, serving as an exemplary model for future collaborative endeavors.

The Management Moment" is a regular column within the Journal of Public Health Management and Practice. Janet Porter, PhD, and Edward Baker, MD, MPH, MSc, are serving as The Management Moment Editors. Dr Porter is Associate Dean for Executive Education, The North Carolina Institute for Public Health, School of Public Health, at the University of North Carolina at Chapel Hill, and Dr Baker is Director of The North Carolina Institute for Public Health, School of Public Health, at the University of North Carolina at Chapel Hill. This column provides commentary and guidance on timely management issues commonly encountered in public health practice.

The political disintegration of former Yugoslavia inaugurated in 1991 resulted in the decentralization of health systems in the federation's successor nation-states. Efforts by the Open Society Institute improved public health planning and management needs consequent to health sector changes. Beginning in Croatia in 2001, the Institute developed ongoing collaborations between Andrija Stampar School of Public Health and the US Centers for Disease Control and Prevention. In 2003 and 2004, it expanded its project to include the republics of Macedonia and of Serbia and Montenegro.

"The Management Moment" is a regular column within the Journal of Public Health Management and Practice. Janet Porter, PhD, and Edward Baker, MD, MPH, MSc, are serving as The Management Moment Editors. Dr. Porter is Associate Dean for Executive Education, The North Carolina Institute for Public Health, School of Public Health, at the University of North Carolina at Chapel Hill, and Dr. Baker is Director of the North Carolina Institute for Public Health, School of Public Health, at the University of North Carolina at Chapel Hill. This column provides commentary and guidance on timely management issues commonly encountered in public health practice.

Threats to Americans' health-including chronic disease, emerging infectious disease, and bioterrorism-are present and growing, and the public health system is responsible for addressing these challenges. Public health systems in the United States are built on an infrastructure of workforce, information systems, and organizational capacity; in each of these areas, however, serious deficits have been well documented. Here we draw on two 2003 Institute of Medicine reports and present evidence for current threats and the weakness of our public health infrastructure. We describe major initiatives to systematically assess, invest in, rebuild, and evaluate workforce competency, information systems, and organizational capacity through public policy making, practical initiatives, and practice-oriented research. These initiatives are based on applied science and a shared federal-state approach to public accountability. We conclude that a newly strengthened public health infrastructure must be sustained in the future through a balancing of the values inherent in the federal system.

Objectives: We examined the availability and perceived effectiveness of 20 basic public health activities in the communities where most Americans reside., Methods: A self-administered questionnaire was mailed to the 497 directors of US local health departments serving at least 100 000 residents., Results: On average, two thirds of the 20 public health activities were performed in the local jurisdictions surveyed, and the perceived effectiveness rating averaged 35% of the maximum possible. In multivariate models, availability of public health activities varied significantly according to population size, socioeconomic measures, local health department spending, and presence of local boards of health., Conclusions: Local public health capacity varies widely across the nation's most populous communities, highlighting the need for targeted improvement efforts.

The nation's attention has been focused on the vital need for a strong public health infrastructure to protect community health. In this paper we provide an overview of progress during the past decade and point to immediate challenges and opportunities that resulted from recent events. Further, we highlight the need for continued vigilance and broad partnership development if we are to maintain public support for public health. Finally, we point to the need for better language, compelling case reports, and quantitative capacity assessment to guide policymakers and program leaders and to ensure long-term support.

Work has been underway nationally since the mid-1990s to equip state and community public health systems with the infrastructure needed to perform essential public health services. Key components of that infrastructure are a competent workforce, information and communication systems, health department and laboratory capacity, and legal authorities. As part of this transformative work, standards and assessment tools have been developed to measure the capacity and actual performance of public health systems. In addition, a number of states have examined the legal foundation for public health services and have revised and updated those authorities to improve their system's capacity in the context of evolving health challenges. Among those states are Nebraska, New Jersey, and Texas, all of which, beginning in 1999, have adopted dynamic new approaches to aligning public health's legal authorities with new missions and expectations for performance and accountability. This article describes the approaches that these three states have taken to strengthen their legal foundation for public health practice, to illuminate the perspectives legislators and health officials bring to the process, and to give decision makers in other states practical insight into the potential benefits of reviewing and restructuring public health's legal authorities. The underlying stimuli for the states' initiatives differed significantly, yet shared an important, common core. What they held in common was concern that outdated elements of the public health system and infrastructure hindrered delivery of essential public health services at the community level. Where they differed was in the type of tools they found most suitable for the job of rejuvenating those structures. The approaches taken, and the policy tools selected, reflect the unique health needs of each state, establish relationships among state and community health authorities and agencies, and provide guidance by elected and appointed policy makers. Each state continues to refine its approach as it gains experience with the new authorities.

Despite more than a decade of dialogue on the critical needs and challenges in public health workforce development, progress remains slow in implementing recommended actions. A life-long learning system for public health remains elusive. The Centers for Disease Control and Prevention and the Agency for Toxic Substances and Disease Registry in collaboration with other partners in federal, state, local agencies, associations and academia is preparing a national action agenda to address front-line preparedness. Four areas of convergence have emerged regarding: (1) the use of basic and crosscutting public health competencies to develop practice-focused curricula; (2) a framework for certification and credentialing; (3) the need to establish a strong science base for workforce issues; and (4) the acceleration of the use of technology-supported learning in public health.

The scope and purpose of public health injury and disease surveillance systems will expand in response to the increasing information needs of communities and health organizations. Public health leaders must focus on the entire information infrastructure. Surveillance and information systems need to evolve to include targeting and evaluating community-wide prevention programs. Standards governing exchange as well as data content will become central to these new systems and the emerging health information infrastructure. Future surveillance systems will face challenges in forming partnerships with managed care organizations, in developing new information tools, and in training the public health workforce.

This review presents historical and cost-effectiveness perspectives of prevention in health care; discusses the nature, extent, and determinants of health system change, particularly the transition to managed care with large integrated health care corporations; and identifies implications for public health agencies and opportunities for prevention within the reforming health system.

To strengthen the public health infrastructure, the Centers for Disease Control and Prevention (CDC) initiated the Information Network for Public Health Officials (INPHO). CDC INPHO has three goals: (1) to make communication among public health practitioners throughout the United States easy, (2) to make information accessible, and (3) to make secure data exchange as swift and smooth as contemporary technology will allow. Based on a systems approach to supporting the core functions of public health, CDC INPHO achieves its goals by creating a flexible and user-responsive infrastructure of open communications and information exchange.

Although the American public health system has made major contributions to life expectancy for residents of this country over the past century, the system now faces more complex health problems that require comprehensive approaches and increased capacity, particularly in local and State public health agencies. To strengthen the public health system, concerted action is needed to meet these five critical needs: First, the knowledge base of public health workers needs to be supplemented through on-the-job training and continuing education programs. To this end, self-study courses will be expanded, and a network of regional training centers will be established throughout the country. Second, communities need dynamic leadership from public health officials and their agencies. To enhance leadership skills and expand the leadership role of public health agencies, focused personal leadership development activities, including a Public Health Leadership Institute, and national conferences will provide a vision of the future role of public health agencies. Third, local and State public health agencies need access to data on the current health status of the people in their communities and guidance from the nation's public health experts. To improve access to information resources, state-of-the-art technologies will be deployed to create integrated information and communication systems linking all components of the public health system. Fourth, local and State agencies need disease prevention and health promotion plans that target problems and develop strategies and the capacity to address them. To provide communities with structured approaches to this process, planning tools have been developed and distributed, and technical assistance will be provided to local and State health agencies to involve each community in planning,priority setting, and constituency building.Finally, public health agencies need adequate resources to fund prevention programs. To improve the use of existing Federal support and enhance the availability of new community resources, grant programs will be modified, and innovative approaches to local resource enhancement will be developed and shared.Activities in these five key areas are designed to improve the infrastructure of the public health system and its capacity to carry out effectively the core functions of public health assessment, policy development, and assurance of the availability of the benefits of public health. If the nation is to achieve the health objectives for the year 2000, the public health system-the individuals and institutions that, when working effectively together, promote and protect the health of the people-must be strengthened.

Some occupational medical screening programs are designed to detect adverse health effects of workplace hazards and to complement environmental control programs. Often, programs are developed using the approach of clinical practice, and procedures are not adequately standardized. The logic that guides this decision making is not well developed, thus limiting the ability of occupational health practitioners to make defensible decisions regarding the management of individual workers at risk. Although the programs are, in theory, constructed to benefit the worker, little thought has been given to standardization of data collection and to using the medical information that is obtained. Currently, the National Institute for Occupational Safety and Health (NIOSH) is developing recommendations to present to the Occupational Safety and Health Administration to be used in the development of a "generic approach" to screening. These recommendations will include guidelines for threshold exposure levels for screening, rosters of screenable health effects to be targeted, algorithms linking exposure and effects, criteria for test result evaluation, plans for courses of action after testing, and procedures to ensure confidentiality. NIOSH's comprehensive approach to developing occupational screening programs should benefit employees, employers, the scientific community, and the community at large.

Following reports of ten cases of possible organophosphate pesticide poisoning in florists exposed to pesticide residues on cut flowers, we conducted a prospective random-sample survey to determine residual pesticide levels on flowers imported into the United States via Miami, Florida. A sample of all flowers imported into Miami on three days in January 1977 showed that 18 (17.7 per cent) of 105 lots contained pesticide residue levels greater than 5 ppm, and that three lots had levels greater than 400 ppm. Azodrin (monocrotophos) was the most important contaminant with levels of 7.7--4,750 ppm detected in nine lots. We examined 20 quarantine workers in Miami and 12 commercial florists exposed to contaminated flowers. Occasional nonspecific symptoms compatible with possible organophosphate exposure were noted, but we found no abnormalities in plasma or red blood cell cholinesterase levels. This study documents a previously unrecognized potential source of occupational pesticide exposure and suggests that safety standards should be set for residue levels on cut flowers.

Mandates for provider reporting systems have existed in a number of states for many years, but due to various shortcomings the potential for targeted surveillance of occupational illness and injury has not been realized. To achieve a more uniform, active approach to provider reporting, SENSOR will be created as a cooperative state-federal effort designed to develop local capability for the recognition, reporting, follow-up, and prevention of selected occupational disorders. To demonstrate the feasibility of this approach, NIOSH funded a small number of SENSOR projects in 1987. Ultimately, joint state-federal support will be essential to maintain SENSOR activity within a state. SENSOR should not be viewed as the sole approach to the surveillance of occupational illness and injury. Other approaches to the identification of cases of occupational illness or injury and to monitoring the trends of occurrence of these disorders have been developed by NIOSH and various states, and they will continue to function.

Instruments that measure quantitatively sensory threshold to vibration and temperature difference were used to test 93 construction trade painters and a reference group of 105 healthy construction and industrial workers who were not painters. A "forced-choice" testing procedure, and an algorithm for threshold estimation (the "Best PEST"), was used for the Temperature Sensitivity Tester and the Vibratron. The method of limits procedure was used for the Biothesiometer. When measured with the Vibratron, painters in the older age stratum were found to have significantly higher vibration thresholds than the reference group. Painters had significantly more temperature sensitivity thresholds classified as "high" than the reference group. Among painters, exposure intensity and cumulative exposure over the past year was positively associated with vibration thresholds estimated using the Vibratron. Lifetime cumulative exposure, cumulative exposure over the previous month, and exposure intensity were positively associated with vibration thresholds estimated using the Biothesiometer.

Dose-response relationships between blood lead levels and toxic effects have been evaluated in 160 lead workers in two smelters and a chemicals plant. Blood lead levels ranged from 0.77 to 13.51 mumol/litre (16-280 microgram/dl). Clinical evidence of toxic exposure was found in 70 workers (44%), including colic in 33, wrist or ankle extensor muscle weakness in 12, anaemia (Hgb less than 8.69 mumol/litre (Hb/4) or 14.0 gm/dl) in 27, elevated blood urea nitrogen (greater than or equal to 7.14 mmol/litre or 20 mg/dl) in 28, and possible encephalopathy in two. No toxicity was detected at blood lead levels below 1.93 mumol/litre (40 microgram/dl). However, 13% of workers with blood lead levels of 1.93 to 3.81 mumol/litre (40-79 microgram/dl) had extensor muscle weakness or gastrointestinal symptoms. Anaemia was found in 5% of workers with lead levels of 1.93-2.85 mumol/litre (40-59 microgram/dl), in 14% with levels of 2.90 to 3.81 mumol/litre (60-79 microgram/dl), and in 36% with levels greater than or equal to 3.86 mumol/litre (80 microgram/dl). Elevated blood urea nitrogen occurred in long-term lead workers. All but three workers with increased blood urea nitrogen had at least four years occupational lead exposure, and nine had received oral chelation; eight of this group had reduced creatinine clearance, and eight had decreased renal concentrating ability. These data support the establishment of a permissible biological limit for blood lead at a level between 1.93 and 2.90 mumol/litre (40-60 microgram/dl).

Arsenic, lead, and cadmium absorption levels were determined in 1774 children 1-5 years old living in 19 USA towns with primary nonferrous metal smelters. Results were compared with data on 258 children of the same age in three communities without smelters. Increased systemic absorption of arsenic, as reflected by urine arsenic content, was noted in children near 10 of 11 copper smelters. Blood lead levels were also modestly elevated near two copper smelters. Near lead and zinc smelters, elevated levels of lead and cadmium in hair provided evidence of external exposure to these elements. Levels of lead in blood were not, however, elevated near any of three lead smelters and were elevated near only two of five zinc smelters. Blood cadmium levels were high near one lead and two zinc smelters. The apparent sources of exposure (except in one community with elevated levels of arsenic in drinking water) were air, soil, and dust contaminated by smelting operations. While the full biologic significance of these findings is not known exposure of children to toxic heavy metals emitted by smelters should be reduced to a minimum.