In 1988 the Institute of Medicine published a study of public health in the United States. [Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press; 1988.] The report was scathing in its review of quality of state and local public health agencies, describing them as “… a hodgepodge of agencies, and well-intended but unbalanced appropriations—without coherent direction by well- qualified professionals.” The lack of direction by well-qualified professionals is because of the intense political pressure on state and local agency personnel, especially directors of agencies. In many states and localities, agency salaries are set well below market rates, and agency directors can be dismissed without notice and with no severance pay. Thus a local health director who closes the mayor’s brother’s restaurant for health code violations, or who objects to the misuse of agency funds by the city administration, will be fired with no recourse. This ensures that local agency personnel are selected for their willingness to accommodate political pressure, rather than their expertise or commitment to the public welfare. Although there are many dedicated professionals in state and local agencies, they have only limited ability to resist improper political pressures.