THE FUTUREOF THE PUBLIC’S HEALTH in the 21st Century

Committee on Assuring the Health of the Public in the 21st Century

Board on Health Promotion and Disease Prevention

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C. www.nap.edu



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The Future of the Public’s Health in the 21st Century THE FUTUREOF THE PUBLIC’S HEALTH in the 21st Century Committee on Assuring the Health of the Public in the 21st Century Board on Health Promotion and Disease Prevention INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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The Future of the Public’s Health in the 21st Century THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Centers for Disease Control and Prevention; the National Institutes of Health; the Health Resources and Services Administration; the Substance Abuse and Mental Health Services Administration; the Department of Health and Human Services, Office of the Secretary, Assistant Secretary for Planning and Evaluation; and the Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Contract No. 200-2000-00629. The views presented in this report are those of the Institute of Medicine Committee on Assuring the Health of the Public in the 21st Century. Library of Congress Cataloging-in-Publication Data The future of the public’s health in the 21st century / Committee on Assuring the Health of the Public in the 21st Century, Board on Health Promotion and Disease Prevention. p. ; cm. Includes bibliographical references. ISBN 0-309-08622-1 (hardback) — ISBN 0-309-08704-X (pbk.) — ISBN 0-309-50655-7 (pdf) 1. Public health—United States. 2. Medical policy—United States. [DNLM: 1. Public Health—trends—United States. WA 100 F9955 2003] I. Institute of Medicine (U.S.). Committee on Assuring the Health of the Public in the 21st Century. RA445.F885 2003 362.1’0973’0905—dc 21 2003008322 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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The Future of the Public’s Health in the 21st Century “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Shaping the Future for Health

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The Future of the Public’s Health in the 21st Century THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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The Future of the Public’s Health in the 21st Century COMMITTEE ON ASSURING THE HEALTH OF THE PUBLIC IN THE 21ST CENTURY JO IVEY BOUFFORD, M.D. (co-chair), Professor of Health Policy and Public Service, Robert F. Wagner Graduate School of Public Service, New York University CHRISTINE K. CASSEL, M.D. (co-chair), Dean, School of Medicine, Oregon Health & Science University KAYE W. BENDER, Ph.D., R.N., F.A.A.N., Deputy State Health Officer, Mississippi State Department of Health LISA BERKMAN, Ph.D., Chair, Department of Health and Social Behavior, Thomas Cabot Professor of Public Policy and Epidemiology, School of Public Health, Harvard University JUDYANN BIGBY, M.D., Associate Professor of Medicine and Director, Community Health Programs, School of Medicine, Harvard University THOMAS A. BURKE, Ph.D., M.P.H., Associate Professor of Environmental Health Policy, Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University MARK FINUCANE, Principal, Leadership Development Solutions, Health Sciences Advisory Services, Ernst & Young LLP GEORGE R. FLORES, M.D., M.P.H., Consultant, and Public Health Advisor to the California Endowment LAWRENCE O. GOSTIN, J.D., Professor of Law, Georgetown University; Professor of Public Health, Johns Hopkins University; and Director, Center for Law and the Public’s Health PABLO HERNANDEZ, M.D., Administrator, Mental Health Division, Wyoming Department of Health JUDITH R. LAVE, Ph.D., Professor of Health Economics, Department of Health Services Administration, Graduate School of Public Health, University of Pittsburgh JOHN R. LUMPKIN, M.D., M.P.H., Director, Illinois Department of Public Health PATRICIA A. PEYSER, Ph.D., Professor, Department of Epidemiology, University of Michigan School of Public Health GEORGE STRAIT, Chief Executive Officer, MedComm Inc. THOMAS W. VALENTE, Ph.D., Associate Professor, Preventive Medicine Director, Master of Public Health Program, Department of Preventive Medicine, University of Southern California School of Medicine PATRICIA WAHL, Ph.D., Dean, School of Public Health and Community Medicine, University of Washington

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The Future of the Public’s Health in the 21st Century LIAISONS FROM THE BOARD ON HEALTH PROMOTION AND DISEASE PREVENTION GEORGE J. ISHAM, M.D., Medical Director and Chief Health Officer, HealthPartners, Inc., Minneapolis, MN HUGH H. TILSON, M.D., Dr.P.H., Senior Advisor to the Dean of the School of Public Health, University of North Carolina at Chapel Hill STAFF MONICA S. RUIZ, Ph.D., M.P.H., Senior Program Officer, Study Director (until June 2002) ALINA BACIU, M.P.H., Program Officer LYLA HERNANDEZ, M.P.H., Senior Program Officer ROSE MARIE MARTINEZ, Sc.D., Director, Board on Health Promotion and Disease Prevention LORI YOUNG, Project Assistant RITA GASKINS, Administrative Assistant, Board on Health Promotion and Disease Prevention

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The Future of the Public’s Health in the 21st Century LIAISON PANEL ON ASSURING THE HEALTH OF THE PUBLIC IN THE 21ST CENTURY MOHAMMAD N. AKHTER, M.D., M.P.H., Executive Director, American Public Health Association HENRY ANDERSON, M.D., Chief Medical Officer, Wisconsin Department of Health and Family Services EDWARD L. BAKER, M.D., M.P.H., Director, Public Health Practice Program Office, Centers for Disease Control and Prevention JAMES BAKER, Executive Director, Institute for Public Strategies WIL BAKER, Ed.D., Co-Project Director, Alabama Southern Rural Access Program LEONARD BATES, Ph.D., Health Policy Fellow, Office of the Honorable Donna Christian-Christiansen, Congressional Black Caucus Health Braintrust ERIC T. BAUMGARTNER, M.D., M.P.H., Former Director, Community Access Program and State Planning Programs SCOTT BECKER, Executive Director, Association of Public Health Laboratories BOBBIE BERKOWITZ, Ph.D., Director, Turning Point National Program Office RONALD BIALEK, M.P.P., Executive Director, Public Health Foundation BARBARA CALKINS, M.A., Executive Director, Association of Teachers of Preventive Medicine WILLIAM CALVERT, M.S., M.B.A., M.P.H., Chairman, Department of Defense Sexually Transmitted Diseases Prevention Committee, and Program Manager, Sexual Health and Responsibility Program, Navy Environmental Health Center, Department of Navy ANN CARY, Ph.D., M.P.H., A-CCC, Director, Institute for Research, Education and Consultation, American Nurses Credentialing Center MARY CHUNG, MBA, President, National Asian Women’s Health Organization NATHANIEL COBB, M.D., Indian Health Service DEBORAH DAMERON, M.P.S.H., President, Association of State and Territorial Directors of Health Promotion and Public Health Education NILS DAULAIRE, M.D., M.P.H., President and Chief Executive Officer, Global Health Council GEM DAVIS, M.A., Legislative and Governmental Affairs Coordinator, Policy Division, National Advocates for Asian and Pacific Islander Health

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The Future of the Public’s Health in the 21st Century MORGAN DOWNEY, Executive Director, American Obesity Association CLYDE H. EVANS, Ph.D., Vice President, Director of American Network of Health Promoting Universities, Association of Academic Health Centers PATRICIA EVANS, Executive Director, Council on Education for Public Health ADOLPH P. FALCON, M.P.P., Vice President, Science and Policy, National Alliance for Hispanic Health MARIE FALLON, Executive Director, National Association of Local Boards of Health MARY E. FOLEY, R.N., M.S., President, American Nurses Association MARIANNE FOO, M.P.H., Director, Orange County Asian and Pacific Islander Community Alliance MARILYN H. GASTON, M.D., Former Director, Health Resources and Services Administration MARY J. R. GILCHRIST, Ph.D. President, Association of Public Health Laboratories JESSIE C. GRUMAN, Ph.D., Executive Director, Center for the Advancement of Health GEORGE HARDY, M.D., M.P.H, Executive Vice-President, Association of State and Territorial Health Officials RUTH HARRELL, R.N., M.P.H., Co-Project Director, Alabama Southern Rural Access Program BARBARA J. HATCHER, Ph.D., M.P.H., R.N., Director of Scientific and Professional Affairs, American Public Health Association TRACEY HOOKER, Program Director, Prevention Project Programs, National Conference of State Legislatures MARY JUE, P.H.N., M.S.N., Coordinator, Statewide Public Health Nurse Advocacy Group STEPHEN KALER, M.D., M.P.H., Deputy Associate Director for Disease Prevention, National Institutes of Health MIMI KISER, M.P.H., C.H.E.S., Health Program Coordinator, Interfaith Health Program, Emory University DONNA KNUTSON, Executive Director, Council of State and Territorial Epidemiologists CHARLES KONIGSBERG, Health Director, Alexandria Health Department CHRISTINE MAKRIS, Executive Assistant, Global Health Council LUCY MARION, Ph.D., R.N., C.S., F.A.A.N., Immediate Past President, National Organization of Nurse Practitioners KAY McVAY, R.N., President, California Nurses Association

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The Future of the Public’s Health in the 21st Century TOM MILNE, Executive Director, National Association of County and City Health Officials SHARON MOFFATT, R.N., M.S.N., Vermont Department of Health, Association of State and Territorial Directors of Nursing PEARL MOORE, R.N., M.N., F.A.A.N., Chief Executive Officer, Oncology Nursing Society ANTHONY MOULTON, Associate Director for Policy and Programs, Public Health Practice Program Office, Centers for Disease Control and Prevention ELLEN MURRAY, R.N., Consultant, National TB Nurse Consultant, Corrections Committee, Florida Department of Health, Bureau of TB and Refugee Health MICHAEL O’DONNELL, Ph.D., M.B.A., M.P.H., Editor in Chief and President, American Journal of Health Promotion ELIZABETH SAFRAN, M.D., M.P.H., Assistant Professor of Medicine and Community Health, Morehouse School of Medicine, Association of American Public Health Physicians SARENA SEIFER, M.D., Executive Director, Community-Campus Partnerships for Health BRUCE SIMONS-MORTON, Ed.D., M.P.H., Chief, Prevention Branch, National Institute of Child Health and Development, and Society for Public Health Education HARRISON C. SPENCER, M.D., Ph.D., President, Association of Schools of Public Health MELISSA STIGLER, President, Public Health Student Caucus JESSICA TOWNSEND, Ph.D. Senior Fellow, Health Resources and Services Administration KATE TREANOR, Program Associate, Grantmakers in Health JONATHAN B. VANGEEST, Ph.D., Director, Section of Medicine and Public Health, American Medical Association JIMMY VOLMINK, M.D., Ph.D., M.P.H., Director of Research and Evaluation, Global Health Council ABRAHAM WANDERSMAN, Ph.D., Department of Psychology, University of South Carolina RANDOLPH F. WYKOFF, M.D., M.P.H, T.M., Deputy Assistant Secretary, Director, Office of Disease and Health Promotion

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The Future of the Public’s Health in the 21st Century Preface Without health there is no happiness. Thomas Jefferson In 1988, the Institute of Medicine (IOM) report The Future of Public Health presented strong evidence to indicate that the governmental public health infrastructure was in disarray. The report provided a common language for national discussion about the role of public health (what we as a society do collectively to assure the conditions in which people can be healthy) and about the steps necessary to strengthen the capacity, especially of governmental public health agencies (e.g., local and state health departments and federal agencies), to fulfill that role. Moreover, the 1988 report prompted significant actions by policy makers, public health agencies, and educational institutions, including some remarkably successful efforts in several states to increase investment in governmental public health activities and to define more clearly the desired outcomes of such activities and the resources necessary for governmental agencies, such as health departments, to perform essential public health functions. Much has changed in public health practice since 1988. Many of these changes reflect progress in the science of improving health at the population level, the emergence of innovative public–private partnerships in communities, and the development of new ways to dialogue and act on health. The Public Health Functions Steering Committee, as representatives of the national public health community,1 developed a broad consensus definition 1   The committee comprised the American Public Health Association, the Association of Schools of Public Health, the Association of State and Territorial Health Officials, the Environmental Council of the States, the National Association of County and City Health Offi-

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The Future of the Public’s Health in the 21st Century necessary ingredients in assuring population health, and Chapter 4 illustrates clearly the significance of authentic community engagement in the public health system. The health care delivery system and the role that it can play in maintaining both individual and community health are discussed in Chapter 5. Particular attention is given to this system’s current fragility and the implications of this fragility for the effectiveness of governmental public health agencies and the broader public health system. The chapter makes note of the historic gap in priorities for investment between public health and health care. Also, it proposes ways for the health care delivery system to refocus its efforts in health improvement and strengthen its collaboration with governmental public health agencies to ensure the best possible disease surveillance, the promotion of healthier communities as well as healthier individuals, and preparedness for any emergencies. Chapter 6 highlights the current and potential contributions of employers and businesses (private and public) to the health of their workforces and to the communities in which they are located. Although employers do not typically see themselves as partners in the public health system, their potential contribution to assuring population health cannot be underestimated. Most people spend at least a third of their days on the job; and the workplace may supply their health care insurance, may offer messages or activities that support or undermine health, and may also shape their health with occupational and environmental exposures and psychosocial stresses. Businesses and employers are also significant members of communities everywhere, and in recent years, many have acknowledged and acted upon their role as corporate citizens by fostering improvement in the economic and physical health of communities. The role of the media in promoting health is the subject of Chapter 7. That chapter explores the unique potential of the news and entertainment media in communicating and informing the public about health risks and benefits, health policy, and related matters. Although their approaches and end goals are somewhat different, the news media’s mandate coincides with that of the public health system: to serve and be accountable to the public. It is imperative for its own objectives and those of the public that the media “get it right.” Also, a continuous dialogue among public health officials and educators and reporters, media leaders, and educators can play a crucial role in facilitating the development of media expertise in public health and public health expertise in providing timely, accurate, and understandable health information. Chapter 8 highlights the responsibilities of academia in training the individuals who work in public health and health care professions and in building the science base for health promotion, disease prevention, and community health action. Assuring the health of the public depends in part

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The Future of the Public’s Health in the 21st Century on the efforts of well-trained professionals who are supported by an adequately funded research infrastructure. The Future of the Public’s Health began with an extensive charge. The committee thus endeavored to (1) examine and (2) explain the nation’s health status, as well as (3) describe the key individuals and organizations needed to work individually or together as a public health system to create the conditions in which people can be healthy and (4) recommend the evidence-based actions necessary to make this system an effective force in attaining the vision of healthy people in healthy communities, and, ultimately, a healthier nation and a healthier world. Achieving this vision will be a dynamic process as our knowledge about the factors that create the conditions for health increases. The sophistication of our actions must evolve to shape forces in the global, national, and local environments that can act for or against health. Finally, we must sustain our commitment to a healthier nation through education, investment, and political will. Jo Ivey Boufford, Committee co-chair Christine K. Cassel, Committee co-chair REFERENCES Federal, Provincial and Territorial Advisory Committee on Population Health. 1999. Toward a healthy future: second report on the health of Canadians. Ottawa: Minister of Public Works and Government Services Canada. IOM (Institute of Medicine). 1988. The Future of Public Health. Washington, DC: National Academy Press.

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The Future of the Public’s Health in the 21st Century Acknowledgments This report represents the collaborative efforts of many organizations and individuals, without whom this study would not have been possible. The committee extends its most sincere gratitude to the organizations and individuals mentioned below. Numerous individuals and organizations generously shared their knowledge and expertise with the committee through their active participation in workshops that were held on February 8–9, April 4–6, June 4–5, and July 31–August 1, 2001. These sessions were intended to gather information related to relevant issues to the future of population health and ongoing public health activities and initiatives, and helped to inform the committee’s vision for assuring the health of the public in the twenty-first century. Members of the study’s liaison panel contributed valuable information and suggestions that were helpful in preparing this report. These organizations and their representatives to the liaison panel are listed on pp. vii–ix. Additionally, the committee is grateful to all of the individuals who shared their experiences via their responses to the committee’s request for public comment. The committee is most grateful to Barbara and Jerome Grossman for sponsorship of the committee’s visioning workshop. The workshop, held early in the process, helped focus the committee’s thinking about the public health system and its actors. Also, the committee would like to thank Katherine Haynes-Sanstad from the Institute for the Future for her work in guiding the committee through the visioning workshop. Christina Merkley also assisted in facilitating the visioning workshop and provided lovely graphic representations of the future scenarios created during that workshop.

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The Future of the Public’s Health in the 21st Century The committee is most grateful to the Henrie Treadwell and Barbara Sabol and the W. K. Kellogg Foundation for sponsorship of site visits to select Community Voices and Turning Point projects. Special appreciation goes to the directors and staff of the projects who graciously hosted committee members and project staff during site visits and enthusiastically shared their projects: The Men’s Health Center, Baltimore, Maryland: Jayne Mathews, Hakim Farrakhan, and project staff Healthy New Orleans, New Orleans, Louisiana: Shelia Webb, Patrice Lee Denver Health, Denver, Colorado: Patricia Gabow, Elizabeth Whitley, Raylene Taylor Asian Health Center/Clinica de la Raza, Oakland, California: Tomiko Conner and project staff Caring Community Network of Twin Rivers, Twin Rivers, New Hampshire: Rick Silverberg and Network members We are also grateful to William B. Walker and the Bay Area Health Officials for hosting a very informative data-gathering meeting for the Oakland site visit by committee members and staff. Additionally, the committee would like to thank all of the individuals who, at various points in the study, assisted the committee and project staff by providing insight and information pertaining to the many various population health and public health issues upon which the committee was deliberating. Raymond Baxter, The Lewin Group Ronald Bialek, Public Health Foundation M. Gregg Bloche, Georgetown University Julie Carlson, Research!America Lori Cooper, Research!America Kristine Gebbie, Columbia University School of Nursing Dana Goldman, RAND Robert Goodman, Tulane University Health Sciences Center Bethney Gundersen, Economic Policy Institute Shelley Hearne, Trust for America’s Health James G. Hodge, Jr., Center for Law & the Public’s Health, Johns Hopkins University School of Public Health Bruce Jennings, The Hastings Center Laura Marie Kidd, Georgetown University Law Center and Johns Hopkins University School of Public Health Vincent LaFronza, National Association of County and City Health Officials

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The Future of the Public’s Health in the 21st Century Tom Milne, National Association of County and City Health Officials Eugene Seskin, Bureau of Economic Affairs Barney Turnock, University of Illinois, Chicago Abraham Wandersman, American Psychological Association The committee would like to thank the numerous staff members of the Institute of Medicine (IOM), the National Research Council, and the National Academies Press who contributed to the development, production, and dissemination of this report. The committee is most grateful to Monica Ruiz, who did a remarkable job of directing the study until June 2002, and to Alina Baciu, who stepped up courageously to shepherd the report through the internal and external review process and to bring the study to successful completion. A special thanks to Lyla Hernandez, who participated fully in the study process and contributed significantly to the development of the chapter on academia (Chapter 8). Carolyn Fulco, Carrie Szlyk, Mark Smolinski, and Rick Erdtman also deserve special thanks for their writing contributions. Margaret Gallogly, Sylvia Martinez, Gretchen Opper, and Marc Ehman provided outstanding research support to the project staff. Lori Young and Rita Gaskins provided excellent administrative support through the study and coordinated committee meetings, organized site visits, and maintained project records and files. Judy Estep competently prepared the report for publication. Rose Marie Martinez and Susanne Stoiber provided guidance and assistance above and beyond the call of duty, including research and writing. Melissa French handled the financial accounting of the study until June 2002, and James Banihashemi handled the financial accounting from June through project completion. Jennifer Bitticks provided editorial assistance. Jennifer Otten, Hallie Willfert, Christine Stencel, and Barbara Rice provided assistance with report dissemination. We are especially grateful to Bronwyn Schrecker, Clyde Behney, and Janice Mehler for cheerfully and skillfully guiding the staff through the report review process. In addition to IOM staff, we are most grateful to Katrina Abuabara for her assistance in preparing the data needed for the determinants of health discussion in Chapter 2 and to Ron Goetzel from Medstat, Inc., for his assistance in preparing the background paper for Chapter 5. Special thanks go to Stephen Fawcett, Irving Rootman, and Barney Turnock for their noteworthy contributions to Chapters 4 (Fawcett and Rootman) and 8 (Turnock). Great appreciation goes to Patricia Peacock for her editorial assistance with Chapter 6 and to Jane Durch for her invaluable assistance in editing the report as a whole. This project was jointly sponsored by six Department of Health and Human Services agencies—the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the Health Resources and

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The Future of the Public’s Health in the 21st Century Services Administration (HRSA), the Substance Abuse and Mental Health Service Administration (SAMHSA), the Department of Health and Human Services (DHHS) Office of the Secretary, Assistant Secretary for Planning and Evaluation (DHHS/OS/ASPE), and the DHHS Office of Disease Prevention and Health Promotion (ODPHP)—which generously provided funding and lent support to this project. Our project liaisons—Edward Baker and Anthony Moulton (CDC)—were extraordinarily helpful in providing data, information, and support throughout the course of the study. Their encouragement and support are gratefully acknowledged. REVIEWERS The report was reviewed by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments to assist the authors and the Institute of Medicine in making the report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. The committee wishes to thank the following individuals for their participation in the report review process: Bobbie Berkowitz, Ph.D., R.N., Turning Point National Program Office Haile T. Debas, M.D., School of Medicine, University of California at San Francisco Gordon DeFriese, Ph.D., School of Medicine, University of North Carolina at Chapel Hill Lori Dorfman, Dr.P.H., Berkely Media Study Group David P. Fidler, J.D., University of Indiana School of Law Claude Earl Fox, M.D., M.P.H., Johns Hopkins Urban Health Institute Fernando A. Guerra, M.D., M.P.H., San Antonio Metropolitan Health District Andrew Holtz, independent media consultant LaVohn E. Josten, Ph.D., R.N., F.A.A.N., Center for Child and Family Health Promotion Research, School of Nursing, University of Minnesota Jeffrey Milyo, Ph.D., The Harris School, University of Chicago William L. Roper, M.D., M.P.H., School of Public Health, University of North Carolina at Chapel Hill

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The Future of the Public’s Health in the 21st Century Mark A. Rothstein, J.D., Health Law and Policy Institute, University of Houston Douglas Scutchfield, M.D., University of Kentucky Medical Center Mary Selecky, Department of Health, Washington State John D. Stobo, M.D., The University of Texas Medical Branch S. Leonard Syme, Ph.D., School of Public Health, University of California at Berkeley Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by R. Don Blim, M.D., appointed by the Institute of Medicine, and Henry W. Riecken, Ph.D., appointed by the National Research Council’s Report Review Committee, who were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the Institute of Medicine.

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The Future of the Public’s Health in the 21st Century Contents     EXECUTIVE SUMMARY   1     Areas of Action and Change,   3     Findings and Recommendations,   4 1   ASSURING AMERICA’S HEALTH   19     Achievement and Disappointment,   20     Health as a Social and Political Undertaking,   22     Issues That May Shape the Nation’s Health Status,   23     The Public Health System and Its Key Actors,   28     Present and Future Changes Needed for a Healthy Nation,   33     Broad Trends Influencing the Nation’s Health,   34     Concluding Observations,   41 2   UNDERSTANDING POPULATION HEALTH AND ITS DETERMINANTS   46     A Population Perspective,   47     The Physical Environment as a Determinant of Health,   53     The Social Determinants of Health,   56     Population-Level Preventive Interventions,   71     The Public Health System in Action: A Scenario,   76     Concluding Observations,   83

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The Future of the Public’s Health in the 21st Century 3   THE GOVERNMENTAL PUBLIC HEALTH INFRASTRUCTURE   96     Prior Assessments of the Public Health Infrastructure,   97     The Role of Governments in Public Health: An Overview and Legal Framework,   101     The Federal Public Health Infrastructure,   111     Critical Components of the Public Health Infrastructure,   116     Financing the Public Health Infrastructure,   147     Concluding Observations,   169 4   THE COMMUNITY   178     Defining the Community,   178     Community-Based Collaboration,   180     Framework for Collaborative Community Action on Health,   186     Evaluating and Researching Community Health Improvement,   199     Sustaining Community Action on Health,   201     Concluding Observations,   204 5   THE HEALTH CARE DELIVERY SYSTEM   212     Access to Health Care,   214     Neglected Care,   221     Problems in Quality of Care,   231     Capacity of the Health Care System to Serve the Population,   234     Collaboration with Governmental Public Health Agencies,   244     Collaboration with Other Public Health System Actors,   251     Implications of Growing Health Care Costs,   255     Concluding Observations,   257 6   EMPLOYERS AND BUSINESS   268     Employers’ Role in Health Insurance Coverage,   269     Employers’ Role in Assuring Health Care Quality,   271     Employer Interest in Promoting the Health of Employees: A Rationale for Corporate Investment in Health,   275     Role of Businesses and Industries in Promoting a Healthy Environment,   289     A Case for Improving the Health and Well-Being of Communities,   292     Concluding Observations,   300 7   MEDIA   307     News Media and the National Public Agenda,   308     News Media as a Catalyst to Promote Health at the Community Level,   311

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The Future of the Public’s Health in the 21st Century     News Media Coverage and Health Information,   313     Media and Health Communication,   319     Health Communication Campaigns: Theory, Evaluation, and Research Needs,   341     Concluding Observations,   348 8   ACADEMIA   358     Education and Training,   360     Research,   374     Service,   387     Concluding Observations,   395     APPENDIXES         AModels of Health Determinants   403     BModels for Collaborative Planning in Communities   406     CRecommendations from The Future of Public Health   411     DHealthy People 2010 Objectives for the Public Health Infrastructure   421     ECompetencies for Public Health Workers: A Collection of Competency Sets for Public Health-Related Occupations and Professions   423     FData-Gathering Activities   441     GAgendas for Public Committee Meetings   461     HCommittee Biographies   465     INDEX   475

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