In practice, health departments at the state and local level are extremely varied. Some state departments are primarily data-oriented and play little role in policy development or the administration of direct services. Others, especially some departments in the large industrial states, have multiple duties in both the conventional public health domains and medical assistance policy. As a result, some of these jobs make extraordinary intellectual and managerial demands: the commissioner of health in California, for example, is responsible for areas as diverse as toxicology and management of the Medical program (California's version of Medicaid), while also managing a $6.5 billion budget and a department with over four thousand employees. The commissioner of health in New York State, in addition to the traditional operations of public health, is responsible for regulation of healthcare facilities and the development and maintenance of healthcare reimbursement for a large and heterogeneous healthcare industry. Thus, in the course of his work as New York's commissioner, Dr. David Axelrod has had to defend controversial regulations against smoking in public places as well as oversee the design of a technically complex and politically charged hospital reimbursement system. At times, the responsibilities of public health officials can assume a stochastic quality, as random events that have the potential to jeopardize the public health take center stage. It is state and local public health officials, among others, who have to respond to product-tampering episodes, such as the infamous cases. In California it was the health commissioner's task to reassure the public that fallout from the Chernobyl accident was not a threat to the population of the state.
Before the early 1980s the job of the public health executive had relatively low visibility and stature in state and municipal government. At a national level, the perception that public health problems such as legionnaires disease, the swine flu affair, and toxic shock syndrome had been successfully managed created a view that contagion was controllable. Even within the public health profession, there was an underlying belief that the control of infectious disease had been largely accomplished; one head of a state infectious disease unit began looking for other work because the task of controlling such contagion had become "routine."3 In addition, many preventive measures, the so-called life-style changes of reduced smoking and improvements in cardiovascular fitness, had at least been recognized, if not adopted, by the public. In the early 1980s the center of gravity in the health policy debate was clearly on issues of cost containment and access to acute healthcare, not public health. Although the tasks of epidemiological monitoring, administering a large and technically complex bureaucracy, and, in some states, managing health financing and delivery programs are all difficult, few observers of state public health administration in the late 1970s would have labeled the executive's job "impossible" or "intractable."
By the criteria that define impossibility in this volume, public health executives did not serve, or at least were not perceived to be serving, a particularly unattractive or unpopular clientele before the mid-1980s. If anything, public health executives were in the business of protecting the "public good," and their actions typically did not provoke either intense support or intense opposition. Activities such as the conduct of epidemiological surveillance, the regulation of food establishments, or even the enforcement of quality assurance in health facilities do not directly engage clients or constituencies that are highly stigmatized, nor are they activities that raise the questions of deservedness or moral hazard that are prevalent in the administration of social services or corrections agencies. Where public health administration becomes most closely aligned with problematic clients, as in the area of maternal and child health, the emphasis is usually placed on the health of the children, thus diffusing somewhat the controversies over entitlement and incentives that are paramount in the large welfare debate.
Public health officials, generally medical doctors with additional public health credentials, also have benefited from the sovereignty and authority of these professions. Most issues of public health are technically and scientifically complex, and administrators with specialized expertise (or access to that expertise) in fields such as epidemiology or toxicology have enjoyed considerable hegemony over their enterprise and received substantial deference from legislators, budget officers, and the executive branch.
By these measures, the job of a public health official looks more possible than impossible. In John Glidewell and Erwin Hargrove's framework, the clients are "legitimate," the number of constituencies is limited, the intensity of conflict is low, and the public confidence in authority is high. Although the tractability of many clients may be low-many people will not cease smoking, will not wear seatbelts, and will not utilize appropriate prenatal care-the accountability of health officials for such behaviors is also low. Furthermore, the time horizon over which progress in these health indicators is measured is much longer than the expected tenure of any health official. The one exception to this picture of the manageability of a health official's job is in the event of a health emergency. If people become sick or die because of food poisoning or a viral outbreak and there are political consequences, then public health officials will be early candidates for scapegoat. Even so, although many of the responsibilities of public health officials are challenging, the overall job is manageable and possible. The prospect of essentially random outbreaks of infection or illness introduces a political hazard into the job that distinguishes it from many other public sector positions, but these events are relatively rare and usually self-contained.
