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Professional Version

Public Health System in the United States


Donald L. Noah

, DVM, DACVPM, College of Veterinary Medicine and DeBusk College of Osteopathic Medicine, Lincoln Memorial University

Reviewed/Revised Dec 2022 | Modified Jun 2023

In the US, responsibilities and authorities for health services are spread across federal, state, local, and tribal levels of government. In addition, certain nongovernmental organizations (NGOs) and community-based organizations (CBOs) perform critical functions regarding the provision and influence of public health policies.

Federal Public Health System

The US Constitution contains no legal basis for the provision of health care to the general population. Therefore, as per the Tenth Amendment, this responsibility automatically falls to the states. When the federal government directly influences national health care issues, it generally does so under the auspices of the Constitution’s interstate commerce clause, which gives Congress the power “to regulate commerce with foreign nations, and among the several states, and with the Indian tribes.” The federal government also heavily influences health care issues in an indirect fashion through the provision of federal funds. Commonly, funds allocated to state and local governments for health issues are contingent on that entity participating in national programs such as disease reporting and adhering to national health goals and standards.

The Department of Health and Human Services (DHHS) is the primary public health agency at the federal level and serves to assess the general health of the nation, establish national goals and policies, and direct federal efforts in support of the states. Major public health–oriented components of DHHS include:

Other federal departments hold major equities in national health care and public health responsibilities:

  • The USDA is responsible for meat inspection and disease prevention and control.

  • The Department of Defense (DoD) is responsible for health care policies and provision of health care for active duty members, family members, and retirees.

  • The Department of Homeland Security (DHS) is responsible for disaster planning and response.

  • The Department of the Interior (DoI) operates the National Park Service (public health and disease outbreak investigations on National Park lands), the Bureau of Indian Affairs (treaty obligations to tribes, including provision of health care and environmental health infrastructure projects), and the Bureau of Reclamation (provides potable drinking water and agricultural irrigation water to much of the western US).

  • The Department of Veteran Affairs (VA) is responsible for health care policies and the provision of health care for qualified veterans and administers important civilian medical education systems.

  • The EPA sets and enforces national environmental health standards.

State Public Health Systems

The state is the primary public health legal authority. Although specific activities and delegations may vary from state to state, state public health responsibilities generally include the following:

  • collection and maintenance of vital health data

  • maternal and child health

  • diagnostic and public health laboratories

  • state-wide nutrition programs

  • regulation of health facilities (including nursing homes)

  • environmental health programs (eg, safe drinking water and waste treatment)

  • state Medicaid program

  • regulation and licensing of medical professionals (veterinarians, physicians, dentists, etc)

Local Public Health Systems

Local public health agencies are structured and empowered to provide services at the community level, where they are most effective. These services may be primary or delegated from the state level and commonly include the following:

  • immunizations not covered under private insurance systems

  • disease surveillance and investigation

  • communicable disease control

  • inspection and licensing of food establishments

  • public health screening programs

  • tobacco control programs

  • disaster preparedness and response

  • care for the underserved, indigent, and disabled

Tribal Public Health Systems

IHS, an agency within the DHHS, is responsible for providing federal health services to American Indians and Alaska Natives (AI/AN). In partnership with CDC, the IHS established a Tribal Epidemiology Centers division to perform activities such as surveillance for disease conditions; epidemiological analysis; interpretation and dissemination of surveillance data; investigation of disease outbreaks; development and implementation of epidemiological studies, disease control, and prevention programs; and coordination of activities with other public health authorities in the region.

In addition to providing direct tribal care, the federal government also works with the Native American Research Centers for Health (NARCH) initiative to support partnerships between AI/AN tribes or tribally based organizations and institutions that conduct intensive academic-level biomedical, behavioral, and health services research. NARCH provides opportunities for conducting research, research training, and faculty development to meet the needs of AI/AN communities. In this developmental process, tribes and tribal organizations are able to build a research infrastructure, including a core component for capacity building and the possibility of reducing the many health disparities prevalent in AI/AN communities.

Nongovernmental Organizations and Community-Based Organizations in the Public Health System

A nongovernmental organization (NGO) is any nonprofit, voluntary citizens group organized on a local, national, or international level. A community-based organization (CBO) is a public or private nonprofit organization of demonstrated effectiveness that is representative of a community or appreciable segments of a community, and provides educational or related services to individuals in the community. NGOs and CBOs perform a variety of service and humanitarian functions. Functions of health-oriented NGOs and CBOs may include raising citizen concerns to governments, advocating and monitoring health policies, and encouraging political participation through public information dissemination. NGOs that exist and act domestically (and overseas in some cases) in the public health sector include the American Red Cross, the American Cancer Association, the American Lung Association, the CDC Foundation, Heifer International, the March of Dimes, and the Bill and Melinda Gates Foundation. Examples of CBOs include parent-teacher organizations, sports clubs, church groups, block or neighborhood associations, 4-H clubs, Boy Scouts of America, Girl Scouts of the USA, Junior Achievement, and the Junior Red Cross.

Relevant public health agencies include the following:

Agency Roles in Food and Drinking-Water Safety

From a global standpoint, WHO and the Food and Agriculture Organization of the United Nations (FAO) have the greatest influence and impact on worldwide foodborne and waterborne surveillance and guidance systems. WHO aims to enhance, at a global and country level, the capacity to prevent, detect, and respond to public health threats associated with unsafe food. Food safety, nutrition, and food security are closely linked. Unsafe food creates a vicious cycle of disease and malnutrition, affecting particularly infants, young children, elderly, and the sick. In addition to contributing to food and nutrition security, a safe food supply supports national economies, trade, and tourism, stimulating sustainable development. The globalization of food trade, a growing world population, climate change, and rapidly changing food systems have an impact on the safety of food. For more information, see WHO's Food Safety and Water Sanitation and Health web pages.

FAO is a recognized leader in the development of global food safety initiatives and translating these into country-level action. FAO's food safety and quality program supports an integrated and multidisciplinary approach to food safety management, and holistic and feasible food chain approach to specific food safety problems as laid out in FAO's Strategy for Improving Food Safety Globally. FAO's food safety and quality unit often works in mutually beneficial partnerships with national and international bodies and organizations where mandates and guiding principles are compatible.

In the US, food safety is a shared responsibility at various governmental and private levels. Federal departments and agencies have regulatory authority over virtually all food products. State and local governments typically are responsible for sanitary inspections of restaurants and food preparation sites. Food industry sectors have internal quality control procedures to ensure both safe products and adherence to regulatory requirements. Ultimately, consumers must be informed and take responsibility for the safe storage, preparation, and service of privately obtained foods.

At the federal level, responsibilities are shared between Congress, various regulatory agencies, and the court system. Congress enacts statutes that give agencies authority to regulate food safety and enforce those regulations. Typically, these statutes are specific in identifying individual agencies but broad in allowing discretion in how those agencies exercise their authority. Finally, the courts review challenges to statutes, regulations, and enforcement actions.

United States Department of Agriculture

The USDA is divided into a number of different agencies. Of note, the Food Safety and Inspection Service (FSIS) and the Animal and Plant Health Inspection Service (APHIS) both have responsibilities relative to animal health.

The FSIS is the primary food regulatory agency within the USDA and employs most of the veterinarians in federal service. As part of its mission, the FSIS is responsible for ensuring that domestic and imported meat, poultry, and egg products are safe, wholesome, and accurately labeled. FSIS responsibilities include inspecting food animals for disease before and after slaughter; inspecting meat and poultry slaughter and processing plants; inspecting domestic and imported meat and poultry products (raw and processed); inspecting processed egg products (liquid, dried, and frozen eggs, but not eggs in shells); analyzing food products for microbial, chemical, and toxic agents; seeking voluntary recalls of unsafe meat and poultry products; conducting and sponsoring research on meat and poultry safety; and educating industry and consumers on safe food-handling practices.

APHIS is responsible for production and transport (preslaughter) of food-producing animals; inspection and quarantine at US ports of entry; and veterinary services, including surveillance and disease control and eradication programs, as well as the representation of US animal agriculture internationally.

Department of Health and Human Services

The FDA and CDC are within DHHS.

FDA is the primary food regulatory agency within DHHS. It is responsible for domestic and imported food sold in interstate commerce, including shell eggs (but not meat and poultry), bottled water, wine beverages (< 7% alcohol), production animal feeds, veterinary drugs, infant formulas, and dietary supplements; adulteration and misbranding of foods, drugs, and cosmetics; inspection of food production establishments and warehouses for contamination by microbial, chemical, and toxic agents; and Hazard Analysis Critical Control Point (HACCP) programs for seafood products and fruit and vegetable juices. In addition to conducting research and educating industry and consumers, the FDA also works with industry to recall unsafe food products.

Also within FDA is the Center for Food Safety and Applied Nutrition (CFSAN), one of six product-oriented centers, in addition to a nationwide field force, that carry out the mission of FDA. CFSAN provides services to consumers, domestic and foreign industry, and other outside groups regarding field programs; agency administrative tasks; scientific analysis and support; and policy, planning, and handling of critical issues related to food and cosmetics.

CDC investigates foodborne illness outbreaks (in conjunction with states), maintains nationwide disease surveillance (FoodNet), develops and advocates for public health policies, conducts research and educational programs in foodborne illness, and trains state and local food safety personnel. See CDC's Food Safety web page.

CDC also operates the Division of Global Migration and Quarantine (DGMQ), which is the enforcement authority for International Health Regulations (IHR). DGMQ investigates deaths and disease outbreaks on all international vessels (commercial and cruise ships and aircraft) and is responsible for quarantine stations at major international ports of entry to intercept and destroy smuggled bushmeat, vector species, and other contraband of public health concern.

In addition, CDC operates the Vessel Sanitation Program, which is an enforcement authority responsible for sanitary inspection of cruise ships.

Department of Defense

The Defense Logistics Agency’s Food Safety Office is dedicated to providing service and responsible for food safety issues, food recall messages, and technical and quality assurance policies for food worldwide. In addition, DoD is responsible for emergency food supplies, conducts research activities on military food rations (many civilian applications), and approves food and water sources for all military bases. To procure food for US forces, both DoD and non-DoD agencies use the US Army Public Health Center’s Worldwide Directory of Sanitarily Approved Food Establishments for Armed Forces Procurement.

Department of Homeland Security

The DHS Office of Health Affairs oversees and manages the department’s implementation of Homeland Security Presidential Directive–9 (Defense of United States Agriculture and Food), and integrates with appropriate federal departments and agencies; tribal, state, and local governments; and the private sector to prevent terrorist attacks on US soil (to include the food supply, crops, and production animals) and ostensibly has primary authority during attack and response phases.

Department of Commerce

The Department of Commerce (DoC) is responsible for management of living marine resources, including fisheries. Within the DoC, the Seafood Inspection Program of the National Oceanic and Atmospheric Administration (NOAA) provides inspection services to the seafood industry for fish, shellfish, and fishery products.

Environmental Protection Agency

EPA has authority over pesticides, herbicides, and fungicides. EPA determines the safety of pesticides and sets tolerances (or maximum residue limits) in foods, regulates toxic substances to prevent entry into food and the environment, and establishes and enforces safe drinking-water standards. See EPA's Food and Pesticides and Safe Drinking Water Act (SDWA) web pages.

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