To Protect and Prevent: Rebuilding California’s Public Health System

Report #170, April 2003


The Little Hoover Commission on Thursday urged policy-makers to fortify California’s public health system so it can better detect and respond to a wide range of threats, from emerging diseases and hospital-acquired infections to bioterrorism.

The Commission recommended the State develop expert leadership, establish standards, increase training, improve communications and strengthen laboratory and other capacities essential to the public health infrastructure.

The comprehensive report – To Protect and Prevent: Rebuilding California’s Public Health System – was issued after 10 months of public meetings, interviews and deliberations, during which an array of experts identified specific weaknesses and practical improvements to a system that has gradually eroded over the last three decades.

The Commission initiated the project after the terrorist attacks of 2001 revealed that the traditional capacities of the public health system to detect and respond to epidemics and other disasters had been neglected as public attention focused on individual health care.  The Commission concluded that the improvements are needed to protect all California from a range of health risks. Experts said that a skilled and equipped public health system could save hundreds of lives in a bioterrorism attack – as well as reduce the 8,000 estimated deaths in California each year from infections that patients acquire while in hospitals.

“The complexity of today’s public health threats requires a new commitment by government to defend the public,” the Commission concluded. “Practices and procedures that block the swift ability to hire needed experts and employ life-saving technology are simply unacceptable in the face or risks so severe.”

“If well-organized, well-equipped and well-staffed, lives will be saved,” the Commission stated.  “If nothing is done, we risk millions of preventable illnesses and deaths.”

The Commission recommended that the core public health functions – now fragmented and buried within large departments – be consolidated into a single state department with a surgeon general providing expert and focused leadership and reporting directly to the Governor.

The Commission also recommended that the State re-establish a volunteer public health board to provide expert involvement and public accountability to the government’s efforts.

This fortified state structure must build strong partnerships with local health and other agencies, hospitals and clinics, doctors and nurses.  The Commission found that these strategic players do not function as a well-honed system – with clearly defined responsibilities, quality assurances, and effective communications.

The State needs to strategically develop and employ technologies and trained professionals to make sure the system detects and assesses health threats, develops the most effective responses, and communicates with health care providers and the public.

Together, the reforms would redefine public health as the third component of California’s public safety triad – police, fire and public health.

“An essential function of government is to protect the public’s safety, particularly from those threats that individuals cannot effectively deter themselves,” Chairman Michael Alpert said.  “Critical parts of this security function rest in the public health system, where skilled professionals are needed to prepare for, detect and respond to an array of hazards.”

Experts testified to the Commission that these public health functions have been neglected over the years as attention and resources have turned to the important needs of residents without the ability to pay for personal health care.  At the same time the ability of hospitals and emergency rooms to respond to large public health crises have diminished because of efforts to reduce costs and attempts to serve uninsured patients.

A fortified public health system would reduce the risk to all Californians, ensuring capacities in times of emergency, and reducing demands on the overall health system.  The Commission concluded that a strong public health system – and in particular, focused, expert and public deliberation at the state level – could help policy-makers resolve the larger health care challenges.

While the federal and state government have taken steps since September 11, 2001 to repair the system, the fundamental and structural problems have not been adequately addressed in California.

“These challenges would be formidable in good economic times, but with discipline they are possible even now,” Alpert said. “Our recommendations for organizational changes can be made by better using existing personnel and other resources.  Many of the specific initiatives can be paid for with federal funds coming to California to improve homeland defense.”

The Little Hoover Commission is a bipartisan and independent state agency charged with advising the Governor and the Legislature on ways to improve the efficiency and effectiveness of state programs.  The Commission’s report, along with written testimony from experts on this topic, is available on the Commission’s Web site: