The Public Health Infrastructure

Individual and societal behavior now plays a more central role in the development of disease. The Unites States' personal health care delivery system has grown rapidly, while public health infrastructure has decayed. In contemplating a multibillion-dollar federal investment in the public health infrastructure, it is critical to ask whether the task is simply one of rebuilding what was once there, or whether a major redesign is needed. The personal health services delivery system has finally confronted the fact that putting more money into medical care is unlikely to achieve the desired goals without major system redesign. The same is probably true of public health. Outdated public health laws, regulations, and technologies create serious inefficiencies and disperse the functions of public health to other agencies. Most of the recent discussion about the public health infrastructure has focused on rebuilding surveillance and laboratory capacity to detect and respond to a bioterrorist event. Yet in many areas of the country, infectious disease surveillance has changed little since the nineteenth century, computers and fax machines notwithstanding. Largely absent from the bioterrorism discussion has been the notion that the country still needs a system to prevent the development of naturally occurring disease, to promote health, to link people with appropriate health services, and to ensure the provision of health care when it is otherwise unavailable. An infrastructure must support those public health functions, too. The infrastructure must support public health systems' accountability for results. Increasingly, personal health care delivery systems that are not accountable for outcomes face negative consequences, such as losing market share, losing accreditation, or legal sanctions. There is, as of yet, no clear structure in which to enforce the accountability of public health systems. This should be a subject of serious public policy discussion. An immediate need is accountability for the current massive infusion of federal funds into state public health systems.