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Chapter 12 - Public Health

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NOTE: Charts and graphs for this chapter are listed in the right column of the page.

Content Last Updated: 3/29/2011 10:00:13 AM
Graphics Last Updated: 10/12/2012 1:12:15 PM
Note: Terms in green will show glossary definitions when clicked.

Originally written by Deanna Okrent, Alliance for Health Reform. Updated April 2010 by Dr. Susan Polan, Dr. Georges Benjamin and colleagues at the American Public Health Association. This chapter was made possible by the Robert Wood Johnson Foundation.

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  • More than $2.3 trillion is spent nationally on health care. Of that, only $69.4 billion or 3 percent is spent on government public health activities.1
  • An estimated 250,000 more public health workers will be needed by 2020.2
  • The U.S. public health system is not a single entity. It is a network that encompasses several federal agencies, local, state, and territorial health departments, community-based organizations, health delivery settings and much more.
  • American children may now live shorter lives than their parents. 3
  • Climate change could have dramatic public health consequences, causing heat waves, drought and flooding, and spreading infectious diseases. 4
  • The new health reform laws (the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010) provide important support for public health in the U.S.

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What is public health?

"Health care is vital to all of us some of the time, but public health is vital to all of us all of the time."
– C. Everett Koop

Public health is about keeping populations healthy. It is about disease and injury prevention, health promotion and health protection. (Health care, by contrast, involves helping people recover from illness or injury.) From scientific research to health education, the field of public health focuses on the social conditions and systems that affect everyone within a given community.

In the previous century, vast improvements in morbidity and mortality were gained through a focus on preventing the spread of communicable diseases. Immunization, disease screening, especially tuberculosis (TB) screening, clean water, hand washing, and other sanitation techniques we now take for granted reduced the spread of communicable diseases and were important factors in increasing life expectancy and improving the health of the population.

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The modern public health agenda focuses on new challenges. It is no longer smallpox and polio epidemics plaguing our nation. The “new” public health directs its attention not just to infectious disease but also to chronic disease, injury prevention and the social determinants of health. The leading causes of death are heart disease, cancer and stroke.5   For people, age 1 to 34, motor vehicle-related injuries are the leading cause of death.6  

Public health emphasizes prevention though a whole array of actions which promote healthy lifestyles, including support for tobacco prevention, substance abuse treatment, bike and pedestrian paths to increase physical activity, seat belt use, clean air laws and improved diets.

Public health professionals are concerned with emergency preparedness in case of a pandemic (such as the recent H1N1 flu outbreak), bioterrorism, or natural disaster occurrence. They also deal with environmental health and climate change, sprawl, anti-biotic resistance and other threats that were not on the radar screen when public health as a discipline and profession was in the developmental stages.

The U.S. Surgeon General’s Office highlights five areas of focus in addressing public health concerns for the nation 7 :

  • Promoting wellness and prevention, which  includes addressing obesity through adopting healthy lifestyles, increasing physical activity, eating healthier diets and reducing stress levels (See chart, “Prevalence of Obesity Among U.S. Children and Adolescents.”)
  • Educating the American people about reducing their rates of smoking and tobacco use
  • HIV/AIDS education and prevention
  • Mental health
  • Health reform implementation 

The U.S. Surgeon General’s Office released a report in 2010 entitled The Surgeon General’s Vision for a Healthy and Fit Nation.  The report outlines ways of achieving several important goals:8

  • Individual healthy choices
  • Healthy home environments
  • Creating healthy child care settings
  • Creating healthy schools
  • Creating healthy work sites
  • Mobilizing the medical community
  • Improving our communities

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Public Health in Health Reform

The 2010 health reform law (the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010) do much to strengthen the public health system, invest in prevention, improve the health of the American people and move us closer to providing comprehensive and affordable health coverage for all Americans. 

The new law offers the opportunity for changes to the health care delivery system as well as the public health system.  The public health system will benefit from a significant influx of funds for population-based wellness and prevention initiatives.  There are a wide array of programs in the law that address population health, including:9  

  • A National Prevention, Health Promotion and Public Health Council chaired by the Surgeon General.  The Council will develop a national prevention strategy, working with federal departments and agencies on prevention, wellness and health promotion practices, the public health system and integrative health care providers in the U.S.
  • A Public Health Investment Fund to support core public health functions, community prevention initiatives, increased support for the public health workforce, and public health prevention and research activities
  • Community Transformation grants to state and local governmental agencies and community-based organizations. These grants will support evidence-based community preventive health activities in order to reduce chronic disease rates, prevent the development of secondary conditions, address health disparities, and develop a stronger evidence-base of effective prevention programming. 
  • Programs focusing on health education such as healthy aging, diabetes prevention, prevention research, nutrition labeling of standard menu items at chain restaurants and employer-based wellness programs
  • Workforce development programs with grants to enable state partnerships leading to health care workforce development strategies and for loan repayment for those individuals who, upon graduation, agree to work in the federal, state, local and tribal public health agencies.

There are many other important provisions within the law that are not strictly public health but will have positive implications for changing the health system from one that focuses on sick care to one that focuses on creating healthy citizens. Some of these:

  • Enhance access to preventive services and programs through the creation of an essential health benefits package that limits out-of-pocket expenses for, and expands coverage of, wellness visits and clinical preventive services.
  • Prohibit coverage restrictions due to pre-existing conditions or health status
  • Promote primary care and disease management, and
  • Allow children through the age of 26 to remain on their parents’ health insurance plans

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The law does make great strides, but there are several areas of concern for the public health community.  Affordability of insurance was an ongoing discussion throughout the consideration of the bill, and still needs to  be watched as reform is implemented.   Abortion became a hot-button issue in the reform debate. As reform is implemented, will women in underserved communities be able to access abortion services if necessary? 

Many in the public health community see the maintenance of the current federal eligibility restrictions in Medicaid for immigrants, including the waiting period of at least five years for most lawfully residing immigrant adults, as problematic, as well as the complete exclusion of undocumented adult immigrants from coverage provisions of the health reform law.

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Healthy People 2020

Healthy People 2010 was a comprehensive, national health promotion and disease prevention agenda developed and promoted by the U.S. Department of Health and Human Services (HHS).10 It was a roadmap for improving the health of all people in the United States.

It had two primary goals: to increase the quality and years of healthy life, and to eliminate disparities in health status among segments of the population. Latest reported findings indicate that significant racial and ethnic disparities persist, even though life expectancy continues to increase.11 (See the disparities chapter for details.)

HHS is now finalizing the Healthy People 2020 objectives, building on the successes and challenges realized in the Healthy People 2010 initiative. 12     The vision for Healthy People 2020 is “A society in which all people live long, healthy lives.”  It strives to:

  • Identify nationwide health improvement priorities;
  • Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress;
  • Provide measurable objectives and goals that are applicable at the national, state, and local levels;
  • Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge;
  • Identify critical research, evaluation and data collection needs.

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Public Health Infrastructure

Public health in the U.S. is not embodied in a single entity. Rather, it is a network that encompasses several federal agencies; county, city, state, territorial and tribal health departments; local boards of health; and other public and private entities.

The federal public health component rests primarily in the agencies of HHS.13 These include the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), Agency for Healthcare Research and Quality (AHRQ), Substance Abuse and Mental Health Administration (SAMHSA)  and the National Institutes of Health (NIH).

Other agencies involved in health programs at the federal level are the Departments of Defense, Agriculture, Transportation, Housing and Urban Development and Veterans Affairs; the Environmental Protection Agency; and the Indian Health Service, which coordinates tribal health agencies. Other components of the public health infrastructure include public and private laboratories, hospitals and other healthcare providers, and volunteer organizations such as the American Red Cross and others.14

Major non-governmental public health associations complete the picture of the public health enterprise and include such groups as the American Public Health Association (APHA), Association of State and Territorial Health Officials (ASTHO) and the National Association of City and County Health Officials (NACCHO).  These organizations play essential roles and complement the work of federal, state and local governments.

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Role of Public Health

The job of maintaining population health through disease and injury prevention, health promotion and protection is carried out in a number of ways. Public health agencies monitor immunization activities and distribute vaccines through local health departments. The Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) conduct environmental surveillance and research and assure the availability of healthy water, air and food. Research institutions and laboratories investigate outbreaks of food borne and water borne diseases and educate the populace about avoiding or seeking treatment for such diseases. These functions involve federal and local government entities, and require community cooperation.

CDC allocates close to 75 percent of its funds directly to states and local communities for public health activities. 15 Public health programs on the local level funded by CDC include chronic disease prevention and health promotion, diabetes control, environmental health, HIV prevention, immunizations, infectious disease prevention and bioterrorism preparedness.

An example of such a project is the CDC Heart Disease and Stroke Prevention Program, which awards grants to states and conducts surveillance to improve cardiovascular health. In 2008, CDC’s $50 million appropriation for the project funded 14 states for basic program implementation and 27 states for program planning.16 The state cardiovascular disease prevention programs focused on controlling blood pressure and cholesterol, awareness of heart disease and stroke signs and symptoms, calling 9-1-1, improving emergency response and quality of care, and eliminating health disparities.

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Health Threats from Disaster and Disease

Some threats to our nation’s health come from beyond our geographic boundaries. We have, by and large, licked the last century’s communicable disease killers through antibiotics, immunizations and sanitation. But there are new threats on the horizon. With travel between countries and continents being easier and faster, so too can be the spread of disease.

H1N1 (originally referred to as “swine flu”) was a new influenza virus first detected in March 2009 and declared a pandemic emergency by the World Health Organization in June 2009 and a national emergency by President Barak Obama in October 2009.  The question that many public health professionals, political leaders, health care providers and others was would we be prepared for a pandemic?

Acts of terrorism also threaten our health security. Could our infrastructure, including hospitals, laboratories, information systems and public health workforce handle the expanded need in the event of another major terrorist attack? Would our surveillance systems provide sufficient warning to protect people from exposure and prevent the spread of disease? Would we have sufficient surge capacity to handle the results of bioterrorism? One year after H1N1 was first detected, these questions are being discussed and there are real world lessons learned being evaluated (See text box, “Major Components of CDC’s Public Health Information Network 17 ”)

Emergency preparedness deals not only with disease crises but with natural disasters as well. We learned several lessons from Hurricane Katrina about the usefulness of electronic information systems for retrieving health records, and for having sufficient resources to carry out evacuation plans. (See the Alliance issue brief on this topic, ("Rebuilding Louisiana's Health Care System."  ) Such events highlight the weaknesses in the complex public health network and the need for improvement in emergency preparedness.

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Funding Public Health

Though public health services are considered the first line of defense against disaster and disease, government public health expenditures amount to only 3 percent of national health care expenditures.18 Of the $2.3 trillion in national health expenditures in 2008, just $69.4 billion was spent on public health activities. 19

Recent research has shown that community-based prevention programs are successful in lowering rates of disease related to physical activity, nutrition and smoking. Researchers have concluded that $5.60 in health care expenditures could be saved for every dollar spent on programs to increase physical activity, improve nutrition and prevent smoking and other tobacco use. Such programs would reduce Type 2 diabetes, high blood pressure, heart disease, kidney disease, stroke, and other chronic diseases.20

The economic downturn has hurt public health departments around the country. States have cut hundreds of millions of dollars from public health programs, leaving many communities around the country struggling to deliver basic public health services. 21  

Most public health funding is considered discretionary, which makes it easy to cut if the state or local government is experiencing any type of budget difficulty.  In February 2010, President Obama signed the American Recovery and Reinvestment Act, which authorized $1 billion in resources for public health. But this was one-time funding for prevention programs and was not at a level sufficient to offset the deep level of cuts to state budgets.

In a climate of health reform, some advocates assert that more dollars for prevention would buy better value and save money in the long run on health care delivery.22

Public health programs are funded through a combination of federal, state and local dollars and private sector contributions. Local health departments, for example, receive 29 percent of their funding from local tax revenues. Another 23 percent comes from state revenue; and federal funds distributed through states account for 13 percent.23 Direct funding from federal agencies, such as CDC, accounts for 7 percent.

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Public Health Workforce

Estimates suggest that  250,000 more public health workers will be needed by 2020, and that 23 percent of the current workforce will be eligible to retire by 2012. Schools of public health estimate that three times the current number of graduates must be trained over the next 12 years in order to keep up with the demand and avert a crisis.24

The National Association of City and County Health Officials (NACCHO) in early 2010 completed the third in a series of surveys measuring the impact of the economic recession on local health departments (LHDs). The surveys found that between January 2008 and December 2009, LHDs lost 23,000 jobs to layoffs and attrition, roughly 15 percent of the entire LHD workforce.

In 2009, an additional 25,000 LHD employees were subjected to reduced hours or mandatory furloughs. More than half of LHDs had to make cuts during 2009 to important programs such as population-based primary prevention, maternal and child health, and environmental health. 25

Factors working against recruitment in this field include budget constraints; uncompetitive salaries and benefits, especially in local health departments; and lack of enthusiasm for public health as a career choice.26 Among the public health workers in short supply are public health nurses, epidemiologists, microbiologists, other environmental health scientists, and information technology specialists.27

Diversity of the public health workforce is also an issue. The workforces of local public health departments are often less diverse than the populations they serve.28 (See chart, “Diversity: How Local Health Department Workforces Compare to the Population Served.”) However, because of the overall concern about the workforce shortage and the already limited pool from which to hire, many communities have found it difficult to increase the diversity of their public health workforce.

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Population health plays an important role in the health of the nation. Yet its importance is sometimes overlooked in debates on health care reform. It is not well understood that public health is about avoiding illness and keeping people out of the health care delivery system.

Many public health concerns, though focused on populations, not individuals, cannot be separated from health care delivery. For example, chronic disease prevention – a focus of health promotion public awareness campaigns – is being much discussed in health care delivery circles.

Financing Public Health

The size of the public health budget is quite small in comparison to overall health care spending, yet its funding is critical. The CDC and NIH will surely be looking for revenue increases. Where will the money for public health come from, beyond initiatives in the  health reform law? Will return on investment be considered when discussing funding strategies for chronic care initiatives?

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Public Health Workforce

Some solutions to the workforce crisis that have been suggested by analysts and policymakers and tried by some states and local health departments include:

  • Increased support for education and training -- Some states and localities have provided such support. Will other states copy this model and will funding be forthcoming on the federal level?
  • Loan repayment and grant programs for those pursuing degrees or training in public health preparedness or biodefense -- Legislation introduced in the 110th Congress, “The Public Health Preparedness Workforce Development Act,” would have established such programs. 29
  • Keeping salaries and benefits in line with the private sector.30
  • Cultivating a positive perception of public health where and when people make career choices -- for example, making high school and college visits, and providing internship and shadowing opportunities to reach potential hires31 are possible solutions. At issue is, whose role is it to foster and implement such solutions?

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Accountability and Quality

Several organizations founded in the last several years address the twin issues of accountability and quality.  The National Board of Public Health Examiners offers public health student graduates the opportunity to prove they have met minimum standards and can become certified public health professionals.  The National Public Health Accreditation Board focuses on the public health system and is charged with improving the quality and performance of state, local, tribal and territorial health departments. 

The Task Force on Community Preventive Services evaluates and then helps to prioritize population-based programs and policies to improve health and prevent disease in communities. The task force produces a Community Guide with recommendations for or against dozens of interventions. 32 The U.S. Preventive Services Task Force is an independent task force that reviews the effectiveness and makes recommendations for clinical preventive services.

Do these entities begin to offer a more comprehensive approach to a public health system that too often offers inconsistent quality and accountability depending on where it is located?

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Prevention:  Return on Investment

Measuring return on investment is very hard when discussing public health and prevention. Public health and prevention interventions often don’t fit neatly within the requirements of local, state and federal budgets. Even so, as noted, data suggest that $5.60 could be saved for every dollar spent on programs to increase physical activity, improve nutrition and prevent smoking and other tobacco use.  Is there a way to realize the benefit of a public health program or intervention and not just the immediate cost or outlay required to build many programs?           

Prioritizing Public Health Programs

Who should take the lead in a fractured public health system that involves government agencies and departments at all levels – federal, state and local government? Will programs filter from the top down, the bottom up, or both? Do the surgeon general’s priorities now filter down to the local level? How can public health messages be best delivered to the public? What is the role of the private sector?

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Climate Change

Climate change can have dramatic public health consequences – increasing the likelihood of heat waves, drought and flooding, reducing potable water supplies, displacing populations and spreading infectious diseases.33   Though populations are affected, individuals become ill and interact with their health care providers, putting stress on the health care system. A public policy debate on climate change or global warming might be centered on energy issues but will also have a public health component. Is global warming the new public health challenge?

Health in all policies:  Addressing the social determinants of health

Many different policies and programs have implications for the public’s health, but are not considered public health.  An example is transportation spending. What role should the public health sector have in the development and implementation of such laws?  Should health concerns be considered when establishing new policies outside the traditional realm of public health?  What are the obstacles and challenges?  What are the advantages?

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  • Keep in mind that there is no one source for information about public health agencies. The U.S. Department of Health and Human Services (HHS) is the lead agency. But information about this complex network requires digging deeper. In addition to HHS components such as CDC, NIH, FDA and HRSA, other federal agencies and departments such as FEMA and Homeland Security all play a role.
  • Be aware that on the local level, most public health functions are carried out through local health departments. Their budgets depend on federal, state and local budget allocations. They likely will be making tough budgetary choices in the next few years.
  • The private sector plays a role in funding public health and delivering public health messages. Its role may be even more critical in an economic downturn.
  • It’s hard to separate public health issues and concerns from those of the health care delivery system. Keep in mind that an important role of public health is to prevent illness and thus avoid unnecessary use of the health care delivery system.

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  • In a time of tight budgets, how are public health departments in your area faring? If cuts need to be made because of budget shortfalls, what programs will suffer – vaccination programs, health awareness campaigns, smoking cessation programs? Will the importance of private sector contributions increase?
  • Are modern threats pushing out age-old public health programs that monitor the quality of the air we breathe and the water we drink? Are we still concerned about air quality, food contamination, and waterborne illness?
  • Have core public health programs suffered because of a focus on specialized concerns (e.g. H1N1)?
  • •How do your local and state public health officials feel about  climate change as a public health threat? What are the health impacts of climate change in your region?  How real is the threat? How imminent? What role are  public health agencies and programs playing  in reducing the threat posed by high energy consumption and climate change?  
  • Are health departments involved in land use and transportation decisions in your community? 
  • Where are public health workforce shortages the greatest – in the research labs, local public health departments, and hospitals? Are the problems in the  local workforce situation similar to the concerns and shortages experienced in  federal agencies such as the CDC. What tough choices will agencies need to make in the coming budget year? Can the already diminished workforce afford to be diminished by further staffing cuts?
  • How can new graduates be inspired to enter the public health workforce? How can students entering college be encouraged to study the public health sciences such as epidemiology, microbiology, biostatistics, etc?  What incentives have worked in your community to motivate graduates to pursue these careers?  What are the obstacles that graduates are experiencing to entering the public health workforce?
  • What public health programs in your state receive public health funding?  What are their achievements?
  • What public health programs have been under attack in your community?
  • What is the real return on investment for prevention?  What is the true value of public health interventions?

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Errol Alden , Executive Director, American Academy of Pediatrics, 847/228-5005,

Gerard Anderson , Director, Center for Health Finance and Management, Johns Hopkins University, 410/955-3241

Joseph Barbera , Associate Professor of Engineering Management, George Washington University, 202/994-8424

Kaye Bender,   President and Chief Executive Officer , Public Health Accreditation Board, 703/778-4859

Georges Benjamin , Executive Director, American Public Health Association, 202/777-2430, Communications Director: David Fouse --

Lynn Blewett , Associate Professor, School of Public Health, University of Minnesota , 612/626-4739

Jo Ivey Boufford , Professor of Health Policy and Public Service, New York University, 212/998-7410

Christine Cassel , President, American Board of Internal Medicine, 215/446-3500

Julie Fischer , Senior Associate, Global Health Security Program, Stimson Center, 202/223-5956,

Barbara Loe Fisher , Co-Founder and President, National Vaccine Information Center, 703/938- 3783

Lawrence Gostin , Linda D. and Timothy J. O’Neill Professor of Global Health Law, Georgetown University, 202/662-9373

Robert Helms , Resident Scholar, American Enterprise Institute, 202/862-5877,

Alan Hinman , Senior Public Health Scientist, Public Health Informatics Institute, 404/687-5636

Thomas V. Inglesby, Chief Executive Officer and Director , Center for Biosecurity, University of Pittsburgh, 443/573-3329,

Paul Jarris , Executive Director, Association of State and Territorial Health Officials, 202/371- 9090

Joy Johnson Wilson , Federal Affairs Counsel, National Conference of State Legislatures, 202/624-5400,

Jeffrey Koplan , Vice President for Global Health, Director of Emory Global Health Institute, Emory University, 404/778-2444,

Michael Kremer , Gates Professor of Developing Societies, Harvard University, 617/495-9145

Jeffrey Levi , Executive Director, Trust for America's Health, 202/223-9870

Robert Pestronk , Executive Director, National Association of County and City Health Officials, 202/783-5550

Howard Markel , Director, Center for the History of Medicine, University of Michigan, 734/647- 6914

James Marks , Senior Vice President, Director of Health Group, Robert Wood Johnson Foundation, 609/627-5796,

Stephen Morrison , Executive Director, HIV/AIDS Task Force and Director, Africa Program, Center for Strategic and International Studies, 202/775-3276

Matt Myers , President and CEO, Campaign for Tobacco Free Kids, 202/296-5469

Mike Osterholm , Director, Center for Infectious Disease Research and Policy, University of Minnesota, 612/626-6770,

Diane Rowland , Executive Vice President, Kaiser Family Foundation, 202/347-5270,

Eileen Salinsky , Principal Research Associate, National Health Policy Forum, 202/872-0238

Ray Scheppach , Executive Director, National Governors Association, 202/624-5320

James Tallon , President, United Hospital Fund, 212/494-0700,

Bernard J. Turnock , Clinical Professor, Community Health Sciences, University of Illinois at Chicago, 312/413-0107

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Norman Baylor , Director, Office of Vaccines, Food and Drug Administration, 301/827-5105,

Jack Beall , Director, National Disaster Medical System, Department of Health and Human Services, 202/646-4315

Regina Benjamin , U.S. Surgeon General,  301/443-4000,

 Frances Collins, Director, National Institutes of Health, 301/496-7322,

Janet Collins , Director, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 770/488-5401,

Marcia Crosse , Director, Health Care, Government Accountability Office, 202/512-3407,

Anthony Fauci , Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health, 301/496-2263,

Bruce Gellin , Director, National Vaccine Program Office, and Deputy Assistant, Secretary for Health, Department of Health and Human Services, 202/690-5566,

Margaret Hamburg , Commissioner, Food and Drug Administration, 301/796-5000,

Pamela Hyde , Administrator, Substance Abuse and Mental Health Services Administration, 240/276-2000

Howard Koh , Assistant Secretary for Health, U.S. Department of Health and Human Services, 202/690-7694,

Sarah Lister , Expert in Public Health and Epidemiology, Congressional Research Service, 202/707-7320,

Nicole Lurie , Assistant Secretary for Preparedness and Response, U.S. Public Health Service, U.S. Department of Health and Human Services, 202/205-2882, 

Gary Nabel , Director, Vaccine Research Center, National Institutes of Health, 301/496-1852

Tara Jeanne O’Toole , Under Secretary for Science and Technology,  U.S. Department of Homeland Security, 202/254-6033,

Sally Phillips , Director, Bioterrorism Preparedness Research, Agency for Healthcare Research and Quality, 301/427-1571,

Joshua Sharfstein , Principal Deputy Commissioner, Food and Drug Administration, 301/796-5040,

Mary Wakefield , Director, U.S. Health Resources and Services Administration, 301/443-2216,

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Carmella Bocchino , Senior Vice President, Clinical Affairs and Strategic Planning, America's Health Insurance Plans, 202/778-3200,

Christine Burch , Executive Director, National Association of Public Hospitals, 202/585-0100,

Rose Gonzalez , Director, Department of Government Affairs, American Nurses Association, 301/628-5000

Barbara Marone , Federal Affairs Director, American College of Emergency Physicians, 202/728-0610 ext. 3017

Alicia Mitchell , Vice President, Media Relations, American Hospital Association, 202/626-2339

Rick Smith , Senior Vice President for Policy and Research, PhRMA, 202/835- 3400, 

April Wood , Senior Associate for Disaster Health Services, American Red Cross, 202/303-8613

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American Academy of Pediatrics

American Enterprise Insititute

American Public Health Association

American Red Cross

Association of State and Territorial Health Officials

Bloomberg School of Public Health, Johns Hopkins University

Bright Futures

Campaign for Tobacco Free Kids

Center for Biosecurity, University of Pittsburgh

Center for Civilian Biodefense Studies, Johns Hopkins University

Center for Infectious Disease Research and Policy, University of Minnesota

Centers for Disease Control and Prevention (CDC)

CDC: Emergency Preparedness and Response

Centers for Law and the Public's Health  

Chemical & Biological Weapons Nonproliferation, Stimson Center 

Community Guide – recommendations on public health interventions

Council on Education for Public Health

Department of Health and Human Services

Federal Emergency Management Agency

George Washington University Institute for Crisis, Disaster and Risk Management  

Global Alliance for Vaccines and Immunization

Government Accountability Office

Health Affairs

Institute for Biosecurity

Institute of Medicine

Kaiser Family Foundation HIV/AIDS Policy Research, Analysis, Media, and Public Health Partnerships  

National Academy of Sciences

National Association of County and City Health Officials

National Association of Public Hospitals

National Board of Public Health Examiners,

National Cancer Institute Surveillance, Epidemiology and End Results

National Center for Chronic Disease Prevention and Health Promotion  

National Diabetes Education Program

National Disaster Medical System, DHS

National Governors Association

National Institute of Allergy and Infectious Diseases, NIH

National Vaccine Information Center

National Vaccine Program Office, DHHS  

National Women's Health Information Center

Office of Homeland Security

Office of the Surgeon General

Pan American Health Organization

Public Health Accreditation Board

Public Health Informatics Institute

Robert W.Woodruff Health Sciences Center, Emory University

Robert Wood Johnson Foundation

Substance Abuse and Mental Health Service Administration

Trust for America's Health

U.S. Army Medical Research Institute of Infectious Diseases

Vaccine Research Center, NIH

World Health Organization (WHO)


1 Micah Hartman, Anne Martin, Olivia Nuccio, Aaron Catlin and the National Health Expenditure Accounts Team (2010). “Health Spending Growth At A Historic Low In 2008.” Health Affairs, January, Exhibit 1. (

2 Association of Schools of Public Health. Confronting the Public Health Workforce Crisis. (

3 David S. Ludwig, M.D., Ph.D. “Childhood Obesity — The Shape of Things to Come,” New England Journal of Medicine, Vol. 357:2325-2327, Dec. 6, 2007, No. 23

4 AMedNews (2008).  “AMA meeting:  Global warming has health toll, delegates warn.”  (

5 Heron MP, Hoyert DL, Murphy SL, Xu JQ, Kochanek KD, Tejada-Vera B. Deaths: Final data for 2006. National vital statistics reports; vol 57 no 14. Hyattsville, MD: National Center for Health Statistics. 2009.

6 National Vital Statistics System, National Center for Health Statistics , Centers for Disease Control and Prevention  (

7 Q&A with Surgeon General Benjamin: ‘Transform our sick care system into a wellness system’: Benjamin to health workers: ‘We must continue to stay the course’ The Nation's Health April 2010 vol. 40 no. 3 5
8 U.S. Department of Health and Human Services (2010). The Surgeon General’s Vision for a Healthy and Fit Nation. Office of the Surgeon General, January. ( )

9 Health Care and Education Reconciliation Act (Public Law No: 111-152) 

Patient Protection and Affordable Care Act (Public Law No: 111-148)

10 U.S. Department of Health and Human Services (2000). “Healthy People 2010: With Understanding and Improving Health and Objectives for Improving Health.” 2nd ed. Midcourse Review Summary of Progress. ( ).

11 Agency for Healthcare Research and Quality. (2010). National Healthcare Disparities Report, 2009, pgs. 3-9. Rockville, MD: U.S. Department of Health and Human Services. (  

12 Proposed Healthy People 2020 Objectives – List for Public Comment.

13 Tilson, H.; Berkowitz B. (2006). “The Public Health Enterprise: Examining our Twenty-First-Century Policy Challenges.” Health Affairs, p. 904. (

14 Congressional Research Service (2005). “An Overview of the US Public Health System in the Context of Emergency Preparedness.” (

15 Shortchanging America’s Health A State by State look at how public health dollars are spent and key facts, Trust for America’s Health March 2010

16 American Heart Association. Fact sheet: “Making Progress: Making a Difference CDC. Heart Disease and Stroke Prevention Program.”(

17 California HealthCare Foundation (2008). “Snapshot: Health Care Costs 101.” (

18 Micah Hartman, Anne Martin, Olivia Nuccio, Aaron Catlin and the National Health Expenditure Accounts Team (2010). “Health Spending Growth At A Historic Low In 2008.” Health Affairs, January, Exhibit 1. (

19 Trust for America’s Health (2008). Issue Brief: “Prevention for a Healthier America: Investments in Disease Prevention Yield Significant Savings, Stronger Communities.” ( ).

20 Trust for America’s Health (2008). Issue report: “Shortchanging America’s Health 2008: A State-by-State Look at How Federal Public Health Dollars are Spent.”. (

21 Association of Schools of Public Health. Confronting the Public Health Workforce Crisis. (

22 Some researchers caution that what often is labeled as “prevention” – clinical screenings, medications for many chronic conditions, etc. – often add more to medical costs than they save. See, e.g.: Russell, Louise (2009). “Preventing Chronic Disease: An Important Investment, But Don’t Count On Cost Savings.” Health Affairs, January/February, p. 42-45. (

23 Trust for America’s Health (2008). Issue report: “Shortchanging America’s Health 2008: A State-by-State Look at How Federal Public Health Dollars are Spent.”. (

24 Association of Schools of Public Health. Confronting the Public Health Workforce Crisis. ((

25  National Association of County & City Health Officials (2010). “LHD Budget Cuts and Job Losses.” January/February. (

26 Draper, Debra; Hurley, Robert; Lauer, Johanna (2008). “Public Health Workforce Shortages Imperil Nation’s Health.” Center for Studying Health System Change. Research Brief No.4. (

27 Draper, Debra; Hurley, Robert; Lauer, Johanna (2008). “Public Health Workforce Shortages Imperil Nation’s Health.” Center for Studying Health System Change. Research Brief No.4. (

28 Draper, Debra; Hurley, Robert; Lauer, Johanna (2008). “Public Health Workforce Shortages Imperil Nation’s Health.” Center for Studying Health System Change. Research Brief No.4. (

29 Center for State and Local Government Excellence. “Wake Up, America! The Future Public Health Workforce is at Risk.” ( ).

30 Draper, Debra; Hurley, Robert; Lauer, Johanna (2008). “Public Health Workforce Shortages Imperil Nation’s Health.” Center for Studying Health System Change. Research Brief No.4. (

31 Draper, Debra; Hurley, Robert; Lauer, Johanna (2008). “Public Health Workforce Shortages Imperil Nation’s Health.” Center for Studying Health System Change. Research Brief No.4. (

32 Community Guide (2010). Task Force on Community Preventive Services. (

33 AMedNews (2008). “AMA meeting: Global warming has health toll, delegates warn.” (



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