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Perspectives in Disease Prevention and Health Promotion Strengthening Public Health Practice: Survey of State Health Officers -- United States, 1989

In 1988, the Institute of Medicine (IOM) released a report entitled The Future of Public Health (1), which included 55 recommendations directed at state health departments to improve public health practice in the United States. Following the IOM report, the Association of State and Territorial Health Officials (ASTHO) conducted a national survey of state health officers* regarding these recommendations. This report summarizes the survey findings for 25 IOM recommendations.

In March 1989, ASTHO mailed to the 50 state health officers a questionnaire that asked whether they agreed with the IOM recommendations; whether specific recommendations were part of their program responsibilities; and whether their states planned to implementany recommendations not already in place. All 50 states returned questionnaires; rates of nonresponse to specific questions were low(0-4%).

Of the 50 state health agencies, 25 (50%) were independent, cabinet-level public health agencies; 13 (26%) were located in a department of health that was combined with another function (i.e., social services, welfare services, human services, or environmental health); six (12%) were located in an integrated human services or human resources department; and six were "other." Respondents agreed nearly unanimously with the three core functions of public health as defined by the IOM report: assessment** (100%), policy development*** (100%), and assurance**** (94%). However, these functions were being performed by 82%, 72%, and 56% of respondents, respectively.

State health officers overwhelmingly agreed with the IOM recommendations to improve community involvement, including the need to strengthen relationships with physicians and other health professionals (100%), voluntary health organizations (100%), and legislators and other public officials (98%). At the time of the survey, however, 20%, 52%, and 38% of states, respectively, had implemented efforts to strengthen ties to these groups.

State health officers strongly agreed (greater than or equal to 84%) with all IOM recommendations regarding specific duties of state public health programs (Table 1). However, the proportion of states that had implemented these recommendations ranged from 26% (linkages to mental health) to 86% (regulation of health facilities).

State health officers strongly supported public health involvement in a wide range of environmental health issues (e.g., drinking-water quality and toxic exposure evaluation) (Table 2); involvement was expanding for indoor air pollution and occupational hazards.

The survey detected moderate support from state health officers for expanding their responsibilities to include substance abuse (72%), Medicaid (52%), mental health (48%), and regulation of health professionals (38%). Twenty-six percent of health departments were responsible for substance abuse, 22% for regulation of health professionals, 14% for Medicaid, and 12% for mental health. Adapted from: J Public Health Policy 1990;11:296-304, as reported by: HD Scott, MD, Association of State and Territorial Health Officials; JT Tierney, MSW, WJ Waters, Jr, PhD, M Buban, D Perry, Rhode Island Dept of Health. Public Health Practice Program Office, CDC.

Editorial Note

Editorial Note: The Future of Public Health has provided a critical assessment of the U.S. public health system and has focused attention on the needs to reform all levels of the public health system, mobilize the public health community (including federal, state, and local agencies and public and private components), and initiate action to strengthen the system. The IOM report received support from the U.S. Public Health Service (PHS) and the Kellogg Foundation and was developed by a committee representing state and local public health agencies and universities; appointed and elected officials; private practitioners; academicians in health, economics, medicine, and law; and the private sector. To develop key background information for the report, committee members conducted site visits and regional hearings, commissioned original papers, and completed a comprehensive literature review.

The IOM committee perceived a lack of consensus regarding the mission of public health in the United States***** ; this perception is consistent with substantial variations in organizational structure and available services (2). In addition, despite major achievements by the U.S. public health system, the IOM report cited several limitations in a substantial portion of the system, including 1) weak and unstable leadership, 2) decreased professional competence in public health agencies, 3) ineffective organizations, 4) outdated statutes, 5) inadequate resources for public health activities, 6) inadequate data gathering and analysis, and 7) lack of effective links between the public and private sectors (1). Because of these limitations, comprehensive and effective preventive health services are not uniformly available to the U.S. population.

The ASTHO survey indicates strong support for most of the IOM recommendations and documents that many states are implementing recommendations. However, for some of the recommendations, no consensus exists; for others, consensus exists but implementation is lacking. For example, only 48%-72% of state health officers indicated that substance abuse, Medicaid, and mental health should be the responsibility of the health department. The National Association of County Health Officials and the U.S. Conference of Local Health Officials have expressed similar concerns (3,4). Incomparison, 90%-100% of state health officers agreed that states should support local health services with subsidies and technical assistance, establish standards specifying minimum services for local public health, and hold localities accountable. Although 74% were supporting local public health services, only 32% had set minimum standards and were holding local public health agencies accountable.

In response to the IOM report, ASTHO has proposed new legislation that would increase support to state and local health agencies and schools of public health and augment the capacities of public health agencies to achieve health objectives for the nation for the year 2000 (5). In addition, PHS has developed a plan for strengthening public health in the United States (6) in which each PHS agency describes plans to assist states and localities in strengthening the core functions of assessment, policy development,and assurance. For example, CDC is working with ASTHO, NACHO, schools of public health, and other organizations to 1) strengthen the professional competence of the public health work force through initiatives such as the National Laboratory Training Network; 2) identify a core data set to strengthen the public health knowledge base for decision-making; and 3) broaden CDC involvement with state and local agencies, the medical community, community-based organizations,and volunteer groups.


  1. Institute of Medicine Committee for the Study of the Future of Public Health. The future of public health. Washington, DC: National Academy Press, 1988.

  2. CDC. Selected characteristics of local health departments--United States, 1989. MMWR 1990;39:607-10.

  3. National Association of County Health Officials. NACHO's response to the IOM report: the future of public health. J Public Health Policy 1989;10:95-8.

  4. US Conference of Local Health Officers. Comments on the IOM report: the future of public health. J Public Health Policy 1989;10:88-94.

  5. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (PHS)90-50212.

  6. Public Health Service. A plan to strengthen public health in the United States. Public Health Rep (in press).

    • For this report, state health officer is defined as the chief public health official of a state as specified by law or as designated by the chief executive of each state. ** Regular and systematic collection, assembly, analysis, and dissemination of information on the health of the community, including statistics on health status, community health needs, and epidemiologic and other studies of health problems. *** Use of the scientific knowledge base in planning, priority-setting, allocating resources, and decision-making about what should be done in public health. **** Assuring constituents that services necessary to achieve agreed-upon goals are provided by encouraging actions by others, requiring action through regulation, or providing services directly. ***** The committee defines the mission of public health as fulfilling society's interest in assuring conditions in which persons can be healthy.

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