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Rm~-~^ ~ ^F D hit' Ah Public health is what we, as a society, do collectively to assure the conditions for people to be healthy. This requires that continuing and emerging threats to the health of the public be successfully countered. The Future of Public Health, 1988 The boundanes between public health and medicine are again undergoing significant redefinition. The roots of public health are open traced to the case of John Snow, an English physician of the 19th century. Dunng the 1854 cholera epidemic in London, Snow observed that the disease mainly afflicted people who used wa- ter from the Broad Street Pump. Snow, who had spent years research- ing the causes and transmission of cholera, convinced the goverrunent to . . . each person's health and remove the pump handle, thus averting well-being are shaped by the fixture outbreaks of cholera. Until the interaction of genetic endowment, early 20th century, public health arid environmental exposures, lifestyle medicine were closely intertwined. and food choices, income, anc! However, as clinical interventions be- medical care. came more effective, the fields of medicine focused on the care and treatment of the individual axed public health focused on populations~iverged. The previous dec- ade has brought a growing realization that individual and population- level interventions must be joined to improve health. We now recog- nize that each person's health and well-being are shaped by the inter- 59

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Informing the Future: Critical Issues in Health action of genetic endowment, environmental exposures, lifestyle and food choices? income, and medical care. The Institute of Medicine has played a significant role in the rediscovery of population-level health. 77: e Future of Public Health (1988) documented a public health system in disarray, charactenzed by inadequate capacity in the field, organizational fragmentation, and disjointed decision-making. The report was a wake-up call to the nation that an essential set of activities was in a precmous condition. It offered a new vision of public health and presented art action plan to strengthen public health capability throughout the nation. This reinvigor- ated system~nented toward disease prevention arid health promotion would engage entire communities for science-based action. While parts of The Future of Public Health (1 988) documenter! a public health system in disarray, characterized! by inadequate capacity in the field, organizational fragmentation, and disjointed decision-making. this new public health system have come to Tuition, other aspects remain unrealized, and investments in popu- lation-leve! health are still poorly sup- ported in comparison with biomedical research or clinical medicine. Since the 1988 report, the IOM has continued to play an impor- tant role in advancing public health and guiding public policy to sup- port its application. We are beginning a major new study to create an action plan for population-level health in the 2ISt century. PROMOTING HEALTH AT THE NATIONAL LEVEL "Healthy People" is the nation's game plan for improving the health of the American people. Now in its third decade, Healthy People es- tablishes national goals for improving health and preventing disease and details strategies and interventions to be utilized in reaching those goals. As mentioned above, the Department of Health and Human 60

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Rediscovery of Public Health Services has called upon the TOM for assistance in developing each decade's plan. In developing Healthy People 2010, the Department asked the TOM to recommend leading indicators or core objectives that focus on and monitor the nation's progress in achieving the na- tion's goals. At the community level, effective public health including the realization of Healthy People goals requires active participation by a host of parties. However, limited guidance has been available to pr~ontize and assess community efforts. Two TOM reports address this challenge. Healthy Communities: New Partnerships for the Fu- ture of Public Health (1996) provides a framework for the partnerships between At the community level, effective governmental health agencies and man- public health . . . requires active aged care organizations arid between participation by a host of parties. public health agencies and communi- tiesthat will be necessary to revitalize the nation's public health system. Improving Health in the Community: A Role for Performance Monitoring (1997) advises communities on how to develop and use a variety of measurement tools to assess local public health threats and measure progress in reducing them. The report recommends that ac- 61

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Informing the Future: Critical Issues in Health countability for actions to improve public health collaborating be es- tablished not unilaterally assigned. Performance monitoring is the too! that communities can use to hold groups or individuals account- able for meeting their commitments. Most Americans Mow that they should eat more healthfi~] foodsalthough their success at doing so is un- even. Barriers include school, work, arid other environ- ments that do not offer healthfi~l choices, as well as a fast- food industry that supplies tasty, high-calone foods arid thus shapes eating habits. Improved information about food and nutrition can help consumers make better choices. Since 1941, He lOM's Food and Nutrition Board has provided scientifically based information on the role nutrients and other food components play in health, Tom deficiency to chronic disease. The reports on Recom- mended Dietary Allowances (RDAs) are important to a The DRIs will help individuals opti- vanety of users, Dom individual con- sumers to government agencies. The maze their health, prevent disease, U S Food and Drug Administration anc! avoid consuming too much of ~ a nutrient. uses the RDAs as the basis for devel- op~ng percent dally values those numbers Rat must appear on the labels of everyday food products. The reports are also used to guide food fortification and nutrition assistance programs such as WIC, and for estimating the extent of nu~ition- related problems in vulnerable population groups in the United States. Beginning in ~ 998, the IOM has introduced a series of reports on Die- tary Reference Stakes (DRIs), as an expanded approach for providing quantitative estunates of nutrient requirements that expand upon the RDAs. The DRIs will help individuals optimize their health, prevent disease, and avoid consuming too much of a nutnent. REDUCING PUBLIC HEALTH THREATS Tobacco Tobacco is the nation's leading health threat. Several IOM reports have been innportant in shaping public opinion and national policy 62

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Rediscovery of Public Health Tobacco use kills more Americans than homicide, suicide, car accidents, AIDS, alcohol, and illegal drugs combined - - - AIDS (30, 000J in--- Alcohol (105,000) l Other causes Smoking I--- Caraccidents (46,000) I--- Homicide (25,000) I ~ - - - Illegal drugs (9, 000) ~ | | , --- Suicide (31,000) (418,000) 0 100 200 300 400 500 Number of deaths (thousandsJ SOURCE: State Programs Can Reduce Tobacco Use, 2000; page 2. regarding efforts to curtail its use. Growing Up Tobacco Free: Pre- ver~ting Nicotine Addiction in Children arid Youths (1994) established the elements of a tobacco control policy centered on reducing smoking among young people. The report called on Congress to increase fed- eral excise taxes on tobacco products, and it called for the elimination of all features of advertising and promotion of tobacco products that encourage tobacco use among children arid youths. The National Can- cer Policy Board built on this foundation. ~ Taking Action' to Reduce Tobacco Use (1998) and State Programs Can Reduce Tobacco Use (2000), the board called for strengthening federal regulation of the de- sign and composition of tobacco products, conducting research to de- tennine which tobacco control measures are most effective, and elimi- nating government policies that contribute to increased smoking in other countries. Clearing the Smoke: Assessing the Science Base for Tobacco Harm Recluctior', to be issued in early 2001, assesses prod- ucts that claim to reduce the consequences of tobacco use and recom- mends policies to regulate their marketing and use. 63

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Informing the Future: Critical Issues in Health The estimated total costs associated with STDs were more than 43 and 94 times greater than the national public investment in STD prevention and research, respectively, in 1994 1 0,000 8,000 In o 6,000 o 4 000 ._ , 2,000 o $9,954 it. $230.8 $105.4 Prevention Biomedical and Total Cost Clinical Research Comparison of estimated annual direct and indirect costs for selected STOs and their complications in 1994 versus national public investment in STD prevention and re- search in federal Fiscal Year 1995. The estimate for in- vestment in STD prevention provided here represents public funding for all interventions behavioral, curative, or otherwise that are needed to reduce the spread of infection in a population. SOURCE: The Hidden Epi- demic: Confronting Sexually Transmitted Diseases, 1997; page 21 1. Infectious Disease The world faces a serious, growing threat from infectious diseases. Emerging Infections: Microbial Threats to Health in the whited States (1992) attracted attention to this problem and mobilized action in the public arid private sectors. The TOM's Forum on Emerging Infections provides a venue for ongoing deliberation regarding these threats. The Forum includes academic researchers, government officials, industry scientists, and consumer representatives. Antimicrobial Resistance: Issues and Options (1998) identifies ways for policymakers, health officials, and the pharmaceutical industry to deal with the increasing 64

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Rediscovery of Public Health numbers of disease-causing bacteria that are becoming resistant to drugs. Public Health Systems and Emerging Infections: Assessing the Capabilities of the Public and Private Sectors (2000) discusses the core capability of the public health system for infectious disease sur- veillance, response, prevention, and control. The report considers ap- proaches to communication and collaboration between the scientific and policy-making communities, among professional organizations, and among public health officials and the public. The United States leads the industrialized world in overall rates of sexually transmitted diseases (STDs), with 12 million new cases annu- ally. About 3 million teenagers contract an STD each year, and many will suffer long-term health problems as a result. In addition, people who have STDs are at increased risk of acqu~nug arid transmitting HIV/AIDS. The Hidden Epidemic: Confronting Sexually Transmitted Dis- The United States leads the indus- eases (1997) challenged the country to trialized world in overall rates of recognize the explosive rise In STDs sexually transmitted diseases, with art increase that was swamping the ca- 12 million new cases annually. pacify of the nation's public heath system. The unwillingness of the general public and government offi- cials to deal with issues regarding sexuality (e.g., the reluctance to promote condom use or to provide comprehensive sex education for teenagers) is identified as a main contnbut~ng factor to the rise in STDs. Issues discussed in the report continue to be prominent, includ- ing the key elements of effective, culturally appropriate programs to promote healthy sexual behavior by adolescents and adults. The IOM has advised the nation on HIV/AIDS science and policy for more than a decade, starting with our 1986 report Confronting AIDS: Directions for Public Health, Health Care, a7tdl Research. This and succeeding IOM reports challenged the federal government arid the public to recognize the threat posed by HIV, recommended scien- tifically based policies to reduce new infections, proposed ways to reduce the spread of HIV via blood transfusions, and addressed ways to reduce mother-to-child HIV transmission. Public and private ef- forts to thwart the spread of HIV have slowed the growth of the epi- 65

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Informing the Future: Critical Issues in Health demic in the United States, but the number of people who become infected each year remains unacceptably high. Our most recent report, No Time to Lose: Getting More from HIV Preventior' (2000), recommends a na- tional strategy based on an explicit policy of taking ac- tions necessary to prevent the maximum number of new infections. This strategy would include better Backing of HIV infections, coupled with funding the most cost- effective prevention programs, and could significantly cut the rate of new infections. Prevention efforts must address the epidemic's "new face," as the number of new HIV/AIDS cases among women, m~nonties, and adoles- cents has increased dramatically in recent years. Other key needs include making HIV-prevention services for at-risk key needs include making H~V- and infected individuals routine in act prevention services for at-risk and conical arid other health-care settings, infected individuals routine in a'' an] abolishing laws and policies that block the use of proven prevention strategies, such as needle exchange programs and comprehensive sex edu- cation in schools. clinical and other health-care settings, and abolishing laws and policies that block the use of proven prevention strategies. . . Bioterrorism Terronst attacks, both in the United States and abroad, are of in- creasing concern. Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response (1998) assesses the state of the art for detecting potential chemical and biological agents and for protecting both the targets of attack and the health care providers who will be vital in responding to such attacks. The report recommended that every state and major metropolitan area needs a system to ensure that medical facilities, including the state epidemiology office, receive information on actual, suspected, and potential terrorist activity, arid called for an improved surveillance infrastructure within the U.S. Centers for Disease Control and Pre- vention, and state and local government agencies. The report's rec- 66

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Rediscovery of Public Health ommendations are being implemented in approximately 100 cities, and a new study is under way to provide the Department of Health and Human Services with methods to evaluate their effectiveness. Safe Food The United States is considered by many to have one of the worId's safest food supplies. Yet as many as S! million illnesses and 9,000 deaths have been attributed each year to food-related hazards. Ensur- ing Safe Food: From Production to Consumption (1998) evaluated the organizational structure and scientific ur~de~pinnings of the nation's system for assessing food safety. The conclusion: The system is facing tremendous pressures, with at least 12 federal agencies responsible for various segments. To guide improvement efforts, the report identified five major attributes of an effective The United States is considered by food safety system. (~) It should be many to have one of the worIcl's science-based, with a strong emphasis safest food supplies. Yet, as many on risk analysis. (2) It should be as 81 million illnesses end 9,000 grounded on a national food law that is deaths have been attributed each clear, rational, and scientifically based. year to food-related hazards. (3) It should have a unified mission arid a single official who is responsible for food safety at the federal level and who has the authority and the resources to implement sci- ence-based policy in all federal activities related to food safety. (4) It should be organized to be responsive to and work in true partnership with nonfederal partners. And (5), it must be supported by funding adequate to catty out its major functions and mission to promote the public's health and safety. 67

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Selected Recommendations for Large-Scale Biology National Institutes of Health Research Priorities: Congress should use its authority to mandate specific programs and entities at NIH only when other approaches have proven inadequate. In turn, NIH should periodically report on the structure of NIH in light of changes in science and the health needs of the public. Congress could adjust the levels of funding for re- search management and support so that NIH can improve the priority set- ting process. (Scientific Opportunities and Public Needs: Improving Priority Setting and Public Input at the National Institutes of Health) Confidentiality of Health Information: DHHS, other federal departments, and private organizations should continue or expand educational efforts re- garding the protection of the confidentiality of personally identifiable health information in research. Organizations that furnish health services re- searchers with personally identifiable health information should ensure that the data are prepared in a manner that protects confidentiality. (Protecting Data Privacy in Health Services Research) Definition of Special Populations: NIH should develop and implement across all institutes a uniform definition of "special populations" with cancer. This definition should be flexible, but should be based on disproportionate or insufficiently studied burdens of cancer, as measured by cancer incidence, morbidity, mortality and survival statistics. Emphasis should be on ethnic groups rather than race in surveillance and other population research. This implies a conceptual shift away from the emphasis on fundamental biological differences among "racial" groups to an appreciation of the range of cultural and behavioral attitudes, and lifestyle patterns that may affect cancer risk. (The Unequal Burden of Cancer: An Assessment of NlH Research and Pro- grams for Ethnic Minorities and the Medically Underserve~ Clinical Trials: NIH and other federal agencies (particularly HCFA) should continue to coordinate to address funding for clinical trials, particularly to address the additional diagnostic costs associated with prevention trails and third-party payment barriers associated with clinical trials. (The Une- qual Burden of Cancer) Marijuana and Medicine: Clinical trials of cannabinoid drugs for symptom management should be conducted to develop rapid-onset, reliable, and safe delivery systems. (Marijuana and Medicine: Assessing the Science Base) Rehabilitation Research: Rehabilitation science and engineering should receive greater financial support, and should serve as the basis for develop- ing new opportunities in multidisciplinary research and education related to disability. (Enabling America: Assessing the Role of Rehabilitation Science and Engineering)