The absence of state and federal funding in state and local public health departments is resulting in a declining and inexperienced workforce, forcing departments to shutter programs and reducing response capacity and capabilities. The United States public health system, created over a century ago, is struggling to better protect the population from disease threats and chronic illnesses. As the public health system decreases its size and activities, the country will become more susceptible to the next public health event that may have a greater impact than previous ones. Thus, this research addresses the question of how local public health can reconfigure itself and suggests alternative language to federal grant funding for the purpose of maintaining or increasing public health’s current response capacity.
To answer this question, the thesis traces the evolution of the public health system and its responsibility to identify diseases and create disease-specific response programs within state and local jurisdictions. To determine the preparedness needs for an effective response and reveal the consequences of a single program creation, this thesis features three case studies: the anthrax attacks of 2011, Hurricane Katrina response, and opioid public health emergency. These events illustrate how a singular public health need resulted in a new state or local program. Further comparison of the origination of decades-old programs illustrate how federal funding grants today generally fund a large percentage of state and local programs.
To emphasize the influence federal grant funding has on the organizational structure of state and local public health departments, this thesis compares federal grants awarded to the organizational charts of some state and local public health departments. To show a deeper connection, it includes examples of common public health programs operating at the federal level before funding flowed to state and local health departments such as tuberculosis. The organizational structure of state and local health departments mirrors the naming conventions of federal grants received. Historically, the identification of a new public health need precedes the creation of a program to address that need. For example, the Vaccine Assistance Act of 1962 allocated grant funding to state and local public health programs for the purpose of creating immunization programs, later to include Vaccine for Children (VFC).
This thesis details how the reliance on federal grant funding and language has led state and local health departments to a point of collapse. The public health grant language provides for a narrowly-focused work activity, typically for a certain disease, rather than supporting public health as a whole. Thus, individual programs and silos have been developed. Federal grant funding to state and local departments accounts for an average of 51% or greater of budgets, causing significant funding restrictions in maintaining quality and experienced staff. The discovery of new disease or chronic illness spurs federal legislation and funding for new public health programs tasked to mitigate new threats. This pattern continues to limit local and public health departments’ preparedness ability to respond to ordinary local events, let alone any new emerging and unknown threats impacting the nation.
The data suggest that state and local jurisdictions have given little to no consideration to increasing public health budgets. Although programs are struggling to maintain operational capacity, the public health system has an opportunity to reconfigure itself from a disease-focused structure to one that will merge multiple programs into larger areas of service. This thesis includes the following four recommendations that require the collaboration of federal, state, and local public health departments:
- Amendments to Grant Language: modification of federal grant language from a narrow, singular mission to broader language that allows for greater inclusion of other programs with similar goals or for merging multiple grants into greater service areas. This change may increase efficiency and decrease the duplication of activities.
- State and Local Departments Restructuring: health departments need to reconfigure current structures from the individual federal grant programs to broader areas of need such as the domains created through the Public Health Emergency Preparedness (PHEP) Cooperative Agreement Public Health Accreditation Board (PHAB) standards and measurements. Such a change would allow individual programs to merge and focus on the greatest need.
- Change Grant Types Awarded: federal block grants allow for a broader use and do not typically follow a narrow mission. A change does not mean less oversight, but the ability of state and local departments to be more inclusive with responsibility shared across the entire public health system.
- Responsible Funding for Maintaining Response Workforce: Restructuring from individual needs and programs may allow state and local public health departments to fund the public health system at an appropriate response workforce level.
 Association of State and Territorial Health Officials, “ASTHO Profile of State and Territorial Public Health Vol. 4,” November 2017, 127–83, www.astho.org/profile.