There are many forces shaping the health of Americans today, creating an environment of uncertainty and rapid change. In this context, it is critical that practitioners recognize that the health of the public is successfully protected and promoted by the entire governmental public health enterprise, the interconnected system of federal, state, and local health agencies that together comprise our national system. No individual component of the system can function effectively without the other partners, and forces that affect one affect them all.

Budget Cuts: The Multiplier Effect

Budget cuts are taking a toll on our national public health enterprise at all levels: federal, state, and local. The March 2012 issue of this journal documented budget cuts at the local level, which paints a critical but only partial picture of our current situation. In our interdependent national enterprise, cuts at each level have a cascading effect on our ability as a system to promote and protect the health of the public. Federal funding for public health has been steadily declining over the past several years. The Centers for Disease Control and Prevention budget decreased from $6.5 billion in fiscal year (FY) 2010 to $5.7 billion in FY2012, a 12.3% decrease. The administration's budget recommendation for FY2013 would slash the budget again, to only $5.1 billion, representing a cumulative cut of 21.5% from FY2010 to FY2013-and those are real dollars that have not been adjusted for inflation.1 Other federal agencies that safeguard the public's health are not immune. The Health Resources and Services Administration budget decreased by 17.0% over the same time span (up to 18.9% in the President's FY2013 budget recommendation), and the Environmental Protection Agency's funding for state and tribal assistance grants for clean drinking water is down 31.6% (41.9% in the President's FY2013 budget recommendation). Overall, these cuts represent a drastic reduction in federal support that had funded vital public health programs at the state and local level. Unfortunately, the fiscal situation of most states and localities is just as bad, if not worse, than the federal level.

Public health budgets at the state level have been going down for years: since 2008, 87% of state and territorial health agencies have experienced budget cuts. These health agencies have lost about 17 800 jobs to layoffs and attrition since 2008. On top of the job losses, more than half of state and territorial health agencies (58%) have been forced to implement furloughs. State public health workers have taken more than 247 000 furlough days, which is roughly equivalent to the loss of 1073 additional full-time employees. Approximately 45% of state health agency employees are assigned to local and regional offices. State health agencies have largely shielded their local staff from the budget cuts: only 15% of state health agency job losses and 2% of furloughs apply to the state employees assigned to local and regional offices.2

The impact to the public's health is better understood in the context of total cuts to state and local health departments. When job losses at the state and local level are combined, the total number of public health jobs lost rises to 55 000. Although growing US gross domestic product signaled the end of the recession in 2009, local and state budgets have continued their downward spiral through 2011. Over half (55%) of state and territorial health agencies reported cuts to the fiscal year 2012 budget between July and December 2011, and 41% of local health departments reported in January 2012 that their current fiscal year budget is less than the previous one.3

It is easy to show, using these numbers, that governmental public health agencies are hurting at the federal, state, and local levels. What the numbers do not show, however, is the extent to which the 3 levels of the governmental public health system are interconnected and interdependent. The total impact of the cuts on the health of the public is worse than just the sum of budget reductions, because one part of the system relies on the other parts to perform their functions. Recent events such as the tornados in Joplin and the Escherichia coli outbreak in Missouri illustrate the interdependence of the public health enterprise. These events also demonstrate why the previous investment in public health infrastructure was so important and provide a chilling backdrop of what could have happened if that infrastructure had been allowed to erode.

Joplin Tornadoes

Tornados present a classic example of the fallacy that "all public health is local"-or that it's all state or all federal either. All public health, in fact, relies on federal, state, and local public health resources acting as a common enterprise to protect the public. Although the physical impact of the E-5 tornado that hit Joplin, Missouri, in May 2011, may have a limited geographical scope-the tornado itself was three-quarters of a mile wide and destroyed buildings within a 6 mile radius-local, federal, and state players were critical to the response. Local health departments played crucial boots-on-the-ground roles in responding at the scene, administering 13 000 tetanus shots, and providing up-to-the-minute information. But when St. John's Regional Hospital took a direct hit, the state health agency, as a vital participant in the Incident Command System, coordinated the evacuation of 713 patients to 42 hospitals in 4 states. The state health agency also activated "Show-Me Response," an online registration system for medical volunteers and worked with hospitals to provide waivers to allow them to expand their capabilities to treat the increased number of patients. ESSENCE, a state-based, real-time syndromic surveillance system enabled effective tracking of tornado-related injuries and issues such as fungal infections. To augment state and local efforts and resources, federal assistance in the form of crisis counseling centers and the deployment of Disaster Mortuary Operational Response Teams was invaluable. In addition, federal disaster designation was key to the support of federal family assistance centers. The health of Joplin residents was effectively protected by the ability of federal, state, and local partners to rapidly, skillfully, and cooperatively utilize their different authorities, resources, and capabilities in the public health response.

Multistate E coli Outbreak

Food safety provides another example of the importance of an aligned public health enterprise. In October 2011, the St. Louis County Department of Health played a critical role in collecting and responding to food safety-related consumer complaints within their jurisdiction, but the outbreak quickly spread to 9 other states, sickening 60 people within 2 months. St. Louis health officials quickly notified the Missouri Department of Health and Senior Services, which collaborated with the Centers for Disease Control and Prevention, the Food and Drug Administration, and public health and agriculture officials in the other states. Health investigators at the state and at the Centers for Disease Control and Prevention used DNA fingerprinting of E Coli bacteria to identify cases of illness that may have been part of this outbreak, and obtained multistate data from PulseNet, a national network of state and local public health laboratories and federal food regulatory laboratories, which performs molecular surveillance of food-borne infections. Trace back investigations and collaborative investigative efforts of the state, local, and federal public health agencies indicated that romaine lettuce sold primarily at several locations of a single grocery store chain in Missouri was the likely source of illness in this outbreak. Although illnesses often are first reported at a local health department, the state health department plays a critical role in operating the state laboratory and understanding the pattern of the outbreak across the state and the federal government's national surveillance resources are integral to the investigation. Regulation at the state and federal levels also play an important role. Without the contributions of all 3 levels, the source is much harder to identify and many more lives are put at risk.

The Enterprise and the Health Department of the Future

Although budget cuts threaten our existing systems and practices, they also present potential opportunities. The current environment of rapid change enables practitioners to rethink the way we do things-to reassess the scope, effectiveness, and efficiency of existing programs and foster innovation. Recent research indicates that the current economic environment has prompted some introspection among health agencies seeking to identify which programs and services are really "mission critical."4 Unfortunately, the budget cuts and subsequent job losses have created an environment where many health agency employees are now doing the work of 2 or 3 full-time positions and time for reflection and innovation is a scarce commodity.

The economic and political environment only intensifies the need for systematically improving the scope, quality, and efficiency of our work. The Public Health Accreditation Board's timely launch of the public health accreditation process as a component of an overall quality improvement approach provides essential tools and skills to support this endeavor. If the governmental public health enterprise, as a whole, does not define an integrated and integral role for itself within the greater health system, our role will be defined by others who may not understand the importance, breadth or depth of governmental public health, and the capabilities we worked so hard to build will erode quickly. Now is the time for our common enterprise to collaborate within public health and with other governmental and nongovernmental players in the health care arena to envision public health's role in the health system of the future. What should public health agencies look like, and how do we transition to our future state? What are the critical public health needs of our population and who can best provide for these? What do agencies need to directly provide versus ensure versus let go of? What are some effective ways to ensure that as public health illuminates the broad scope of the social determinants of health, we successfully enlist and support other sectors, such as transportation, education, agriculture, and housing, in addressing those determinants within their sphere of influence? And importantly, how do we ensure a viable financial model to support the critical functions and leadership the public health agencies comprising our enterprise will require?

There are no easy answers to these questions, but we must approach these questions honestly and openly, without concern for protecting territory or political advantage. We share the goal of protecting and promoting the health of the public, but we will do so much more effectively as partners in an integrated governmental public health enterprise.

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