1. Describe the system and actors who can work together to assure the nation’s health;

  2. Propose action steps to help attain the vision; and

  3. Discuss national and global trends that may affect America’s health in the coming decades.


The health of the American people at the beginning of the twenty-first century would astonish those living in 1900. By every measure, we are healthier, live longer, and enjoy lives that are less likely to be marked by injuries, ill health, or premature death. In the past century, infant mortality declined and life expectancy increased (DHHS, 2002). Vaccines and antibiotics made once life-threatening ailments preventable or less serious; and homes, workplaces, roads, and automobiles became safer. In addition to the many health achievements facilitated by public health1 efforts such as sanitation and immunization, unparalleled medical advances and national investment in health care also have contributed to improvements in health outcomes. Roughly 13 percent of our gross domestic product—about $1.3 trillion in 2000, which represents a higher percentage than that of any other major industrialized nation—goes toward health-related expenditures (DHHS, 2001; Levit et al., 2002).

Despite the nation’s wealth, expenditures for health care and research, and scientific and technical accomplishments, the United States is not fully meeting its potential in the area of population health (Kindig, 1997). For years, the life expectancies of both men and women in the United States have lagged behind those of their counterparts in most other industrialized nations (Starfield, 1998; Jee and Or, 1999). Life expectancy in the United States was slightly below the Organisation for Economic Cooperation and Development (OECD) median in 1999 (Reinhardt et al., 2002), and in 1998, the average life expectancy at birth for women was 79.5 years in the United States (73.9 for men), compared with 81.9 (76.9 for men) in Sweden and 84.0 (77.2 for men) in Japan (Anderson and Hussey, 2001). In 1998, the United States also ranked 28th in infant mortality among 39 industrialized nations (DHHS, 2002). In the area of chronic disease, reported inci


The definition of public health used throughout this report is “what we as a society do collectively to assure the conditions in which people can be healthy” (IOM, 1988:1). Although government bears special legal responsibility (discussed elsewhere in this chapter), this and similar definitions extend to more than just the activities of government, broadly referring to the efforts, science, art, and approaches used by all sectors of society (public, private, and civil society) to assure, maintain, protect, promote, and improve the health of the people (IOM, 1988; Last, 1995; Petersen and Lupton, 1996; Acheson, 1998; ASPH, 1999; Kass, 2001; Turnock, 2001).

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