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OCR for page 63
The cOi7lmUni~ as a whole has a stake in environmental protections, hygiene
anc! sanitatio'?, clean air airy surface wate'; tt'?contaminatedfooc! ant! drink-
i'~g uvater, safe roacis and p'oclucts and tile cons' o! of infectious disease.
These collective goods, and many more, are esse'~tia/ conclitio'~sfor health,
but these "public" goocis can be secured only through organized action on
behalfof the population. The Ft~tt~re of the Pt~blic's Health ill the 21st
Century, 2003
In 1988, an lOM report on The Future of Public Health pronounced tire
nation's public health system to be in disarray. The report outlined a strat-
egy to improve the governmental public health system, and, incleed, signif-
icant progress has since been made in strength-
ening federal, state, and local healths clepart-
n~ents. But at a time when public Stealth threats
are so numerous and diverse- obesity, All:)S, and
bioter~-orism are but a few pressing problems—
the need for ala effective public healths system
remains as urgent as eves: Concurrently, our
understancli'~g of tire determinants for healths—
what snakes individuals or populations Meaty ~~ ~~`f~
leas expanded enormously. One important
insight is that the health of any incliviclual is appreciably influenced by the
Ilealtl~ of others living in tile salve local or even national community. TIlus,
actions needed to protect and improve individual and population health
require the en~gagelllent of multiple actors inside and outside tile public
*public health i:~ats are
so nt'nf~s aLud diverse—
obesity, A1 t3S, and Rioters
rt,`~ are but ~ few press
ing problems—tilde Bee] [~(
an effective public health
system remains as urgent
I '
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OCR for page 64
|~51~.~i 7~r It's- 6~L [~.S IN BALM
health ant! health care systems. Several recent IOM reports provicle boric
over-arcI~ing and specific guidance into flow well the current public health
system is meeting national needs ant! flow it can be further strengthenecI.
The Future ofthe P'`b~ic's Health in the 21st Century (2003) conclucles that
tire governmental public health system still suffers Cons ut~der-apprecia-
tio`, and under-investment while facing cI~^amatically snore complex amuck
menacing challenges. Tire report elaborates off tire con-
ceptual moclel of wheat society roust do to protect and
imps ove tire Stealth of its populations. It also ~ ecomn~ends
ways to maximize tl~e contributions that voluntary a,e~-
cies, gover~me'~ts, employers, inclivicluals, tile ~esearcl~
and health care delivery systems, ant:! even tire meclia can
maize in improving public health. One of tile require-
me'~ts of an effective public I~ealtI~ system is well-eciucat-
ed public loyalty professionals. A companion report, Who
Will Beep the Public Healthy? Eclucating Public Health
P`ofessio'~alsfor the 21st Century (2003) provides a frame-
worIc for flow scI~ools of public health can improve Elixir
education, training, and research over the next five years
in order to prepare tire public health workforce to play its role. At their
core, schnooks shouIc! built! their curricula and training programs on an eco-
fogical noodle! of public health which assumes tight health ant! well-bei'~g
are affecter! by interaction among n~ultiple factors, including not only per-
sonal and behavioral characteristics but also environmental, social, eco-
nomic, and political determinants.
Q(:~N FRt)~'N(:, ~ EAtTH C>~PARIT' ES
Not all Americans, widen looked at by population groups, are equally
Meaty, no' do alley square all of tire same I,ealtI~ behaviors. What is now
becoming mucks clearer is flow closely related an inctiviclual's lifetime
health is to tl~e Dealt of tire barber community in which that person lives.
In tl~e United States, significant I~ealtl~ disparities exist and across diverse
populations, clespite efforts to reduce or eliminate those disparities. The
problem will grow unless effective steps are talcen to adcIress tire causes of
inequality: these include income disparities; lack of access to health insur-
a'~ce and heat services; as well as language and culture barriers.
In Unequa/ Treatment: Confronting Racial and Eth'?ic Disparities ill Health
Care (20021, an IOM committee reviewed well over 100 studies titan
OCR for page 65
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Representative terms from entire chapter:
tire united
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A Fume ~ Ih~k~g About He Determining of ~pul~on Mealy
, 22>c. cultural, '~..~
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I
NCTLS: AdaRted Foal Oah~ron and Whitehead, 1991. The domed lines between
levee of the model denote interacEon each heathen and among the vshous leveh
of health determinant (Lehman, 1 999t
asocial conJidolls include, but are not whited to: economic Unequal; urbanlzadon;
mobile; cultural values; attitudes and policies related to discrimination and
intolerance on the bash of race, gender and other differences.
bather condiDons at the naDonal level might include labor socioRoITical shift,
such as recession, was and ~overnl~ental collapse.
CIhe bulk envlronl~ent includes transportation, water and sanitation, housing,
and other dimensions of urban planning.
SCURCE: Me Inure of [he ~b/~ meat )1 [he 21~! Century 2()03, Rage 53.
t.~
I1~-AlIl'\~! 'l~--~- I<~;yI-~.x CkI116-~L ~~S IN HE-~7yI!
prejudices arid uncertainty Glen treating minorities Tire report recom-
mencIs increasing awareness about tile Robe, improving provider train-
in,,, and empowering patients Grog education. Speaking of Henith:
Assessing Healths Com~nunicatio'? Strategies for Diverse Populations (2002)
explores the best ways to reach all segments of society
witty messages treat effectively promote healthy bel~av-
iors. The 'report reviews existing theory and research
applications in health communication and health bel~av-
ior cleanse, especially as they relate to culturally diverse
populations, and defines areas that wouIci benefit fiord
expanded or new research. Among the questions ripe for
explorations is flow else boom in new co~n~unication
technologies, sucks as tire Internet, can be I~arnessecl for
reaching diverse audiences. The report also recommends
flow health communication strategies may be designed
and implemented to achieve gains in public I~ealtl~
across population gtoups. National comn~unication cam-
paigns well funciec! ant! carried out with tire coorclina-
tion of ~nulti}'le Gove Net agencies will often be neeciec] if manly cliffer-
ent groups of people are to be reacher! ant! effects are to be sustainer!
over time.
EALTI] AND By-
Two of tire most important threats to tile healths of the American peo-
ple are obesity anti tobacco. Both exemplify tire necessity to consicler inter-
ventions at multiple levels a'~c! through many types of n~ecI~anisms. Do
unhealthy behaviors flow Tom a simple lack of willpower or knowledge of
risk? What actions work in Whelping to notify unhealthy behaviors?
1~ countless ways, our behavior i~flue~ces our health anc! thus health
professionals, patients, families, acid leaders at tile community and natiot~-
al level struggle to understand else complex interactions between healths
ancI behavior anti to use that I
~.~IN(, 71-~£ i3~( $ ~77-]
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7
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it'
P`~S Alch~cho! Motor HI Drug
Veh`~e t`~d
Sulfide SnIOkInO
Comparative Causes of Annual Deaths in tide United States. SOURCE: CDC.
National attention has focused on the dangers of tobacco uses particu-
la~ly cigarette smoking, for several decades, and tire knowledge and les-
sons learned in trout campaign are instructive for addressing other public
health r isles. Tobacco use is tire single largest environmental cause of Neatly
and clisease in tire Uniter! States, claiming more titan 400,000 lives a~nual-
ly. Although the cagers leave been I
I~, 777~- Few AL /~S IN ~EAL71-]
of Healths ant! Herman Services estimating that 64 percent of actults ale
overweight ant! obese, more titan 15 percent of cl~ildren and teens carry
excess pouts, ant! a total cost estimated to be $117 billion annually.
Research shows Fiat overweight cl~ilcIren are at risI; for serious health
problems, including diabetes and carcliovascular disease. Accorcli~g to one
report, about 60 percent of cI~ilciren ages 5 to 10, who are overweight or
obese, already have at least one cat ciiovascular dis-
ease lisp facto'; such as elevates! total cI~oleste~o!
levels or Rigor blood pressure, and 25 percent
e ~- 70~ perce`~t <~ f t~vc
weigI~t chIldren will
remain so aS adullS'w~h
aIt tI~e atie'~t risks fair
greal`~r Ash prt'Llen~s
alla earlier mortalll.y.
have two or store. Data suggest that 70 percent of
overweight children will remain so as adults, wield
all tire attendant risI
OCR for page 69
A.~l,.~If~rr, 71-~ /~.,[~(, ~ F1~,~,4~
as witnesses. Health professionals aloe often the first to encounter the vic-
tims of family violence ant! talus can play an important role in ensuring that
those inclividuals—as well as tire perpetrators get tire help they neecI.
Getting treat help requires engagement witty a range of actors outside of
the stealth care delivery system. But Stealth professionals now receive little
education in how to deal witty family violence. Confi^ontil~g Chronic Neglect:
The Eclucatio'~ anc] Training of Health Professionals on Fancily Violence (2002)
recommences a variety of steps foil improving else ability of heat profes-
sionals to screen, diagnose, treat, and reefer victims of abuse and neglect.
Tire report also noshes cleats treat health professionals alone cannot solve
taxis p~^obletn anti that society as a Dipole must pay greater attentions to
the tragedy of family violence.
Approximately 30,000 people die each year as a result of suicide in the
Unitec! States, malting it the theirs leading cause of fleetly among adoles-
cents and the elevenths leading cause of death for people of all ages.
St~icicle is air international problem as well, claiming arounc! a million lives
annually. Reducing Suicide: A National Inoperative (2002) summarizes current
knowledge about tire various factors- biological, genetic, psychological
ant! cultural that make people more or less likely to kill themselves, and
about methods ant! programs that leave proven elective
for treating ant! preventing suicicle. Prevention programs
built on tire public Stealth ~nocle! tI~ose treat acicIress ~ isk
and protective factors From tire individual to tire commu-
~ity level are most lithely to succeed. Tire report also
identifies areas where more '-esearcI~ is neecled ant! pro-
vicles a blueprint for filling those gaps. Taxis includes a
national network of laboratories clevotecI to interdiscipli-
nary research oat suicide and suicide preventions across
tile life cycle and a national system for monitoring
attempted ant! completed suicides. Efforts are needed to
better train primary care providers (who are often the
first and only contacts fiat suicidal indivicluals Slave with
tire medical system) in law to recognize ant! address
biotic chronic and acute risI; factors.
PREVEN~~0N
Prevention is tire core of public healths. Incleec] the roots of public
health are often tracer! to tile case of Solon Snow, act English physician of
tire 19tI~ century. During the 1854 cholera epiclemic in London, Snow
ii\~RMI`~t I~E ~Ct14~4 GAL ~~S Aft GAIL
observed treat tire disease mainly addicted people wire bead used water from
tire Broad Street Pump. Snow, also flack spent years resea~cl~i~g bite causes
ant! transmission of cholera, convincer! tire government to remove tire
puny handle, talus averting future outbreaks of circlers. Immunizations
might be called tire contemporary equivalent of tire removal of the Broad
Street Pump I~ancIle: it is wiclely regarded as one of the woricl's most effec-
tive tools for protecting public health.
Immunization programs leave resultec! in the elimination of wild small-
pox globally, and Else elimination of polio in tl~e developed world acid much
of tire developing worIci. A number of life-tl~reatening diseases treat were
once common, including ciiptheria, measles, mumps ant! pertussis have
been nearly eliminated its tire Unitec! States. However; as tI~ese terrible dis-
eases have largely disappeared, concern has
focusec! oat boric established rare sicle-effects and
those that have been hypothesized to result from
immunization. Because vaccines are so wiclely
user! - ant! because state laws require that cI~il-
dren be vaccinates! to enter ciaycare and school,
in part to protect others—immunization safety
x.~C State Iaws
require that ch'ldt~, b~
VaCCInated I,0 enter days
C8~C dH] SCilOQl' in p~t iD
protect otIlerS—i~n]~ jack
t:;~,n safely c<-~s are
serious matter.
concertos are a serious matte':
Toward taxis goal, tire IOM was asked lay tire Centet s for Disease Control
and Prevention and the National Institutes of Health to ~ eview some of the
emerging concerns about the safety of vaccination. Tire IOM has a long I~is-
tory in assessing vaccine safety, having issuer! its first major report on taxis
subject in 1977. For the current reviews, tire IOM committee includes i~de-
penclent health professionals wield wide-rangi~g- expertise. Tire members
leave loo ties to vaccine manufacturers, leave riot conducted r esearcI~ off vac-
cine safety, ant! leave not served on any vaccine acIvisory committees. Tire
committee to date leas issued six safety reviews:
· Measles-Mun?ps-Rt~belia Vaccine and Autism (2001~. Taxis report
conclucles that the total body of scientific evidence favors rejection of a
causal relationship between measles-mumps-rubella (MMRi vaccination
and autism at tire population level. But tire report could not exclucle tire
possibility that MMR vaccine might contribute to autism in a small number
of cI~ilclren ill part because existing epiciemiological tools may clot Slave
enough precision to detect the occurrence of such rare elects—ant! rec-
omn~e'~cis treat tire issue receive continued atte~tio~.
~.~IN(, TWO ]3l18~( ~S 0~
· Thin~erosal-Containing Vaccines Alice Neurodevelopme'~ta/ Disorders
(20011. TI~imerosal leas been used for decades as a preservative in vaccines
to prevent bacterial ant! fungal contamination. It contains mercury, which
at Digit doses is known to cause serious neuroclevelopmental Robes in
humans. Taxis leas promptest concerns that infants and children might accu-
mulate hazardous levels of mercury tl~'ougl~ vaccines. As a results
thimerosal is no longer used for cl~ilciren's vaccines in the U.S., but is con-
tained in a relatively small number of vaccines, including influenza vaccine.
Tl~e report conclucled float evidence is inadequate to accept or reject a
causal relationship frown vaccine exposure to neurodevelop~nental disor-
de~-s. But tire connection is at least biologically plausible, and additional
r esea~cI~ should be conducted.
· Multiple Immunizations and Immune Dysfat?ction (20021. By age two,
healthy infants in tire U.S. can receive up to 20 vaccinations to protect
against 11 diseases. Many parents are concerned that this level of immu-
nization can overwhelm an infant's immune system and increase tire risk
for immune dysfunction, resulting in vulnerability to diseases sucks as pnet~-
monia ad meningitis, type 1 diabetes, and asthma. Tire report concluded
that scientific evidence favors a rejection of a causal relationship between
multiple in~nunizations ant! increased risk of infections or type 1 diabetes,
while being inadequate to either reject or accept a causal relationship witty
allergic disorders.
.
Hepatitis B Vaccine and Demyelinating Neu1010gical Disorders (2002).
Immunization acIvisory groups recommend tight all
infants and adolescents. ant! all aclults at thigh risk of
exposure to tire hepatitis B vi-us, such as health care
workers, receive tire hepatitis B vaccine for protection
from serious liver disease. However; there is some clegree
of concern Fiat tire vaccine can cause demyelinating neu-
rological disorclers, sucks as multiple sclerosis. (in these
disorclers, tire protective coating of myelin that sur-
rounds nerve fibers is somehow clamaged or destroyed,
talus disrupting the transmission of nerve impulses that
control bodily functions and mobility.) The IOM report
concludes that scientific evidence—though scant and
indirect favors rejection of a causal relationship
between administration of the hepatitis B vaccine to
aclults and an increased risk of developing multiple sclerosis. The evidence
was inadequate to either reject or accept a causal relationship between the
vaccine and all other demyelinating conditions.
[~kMINrCr 1~- i4t,7~a CRI11~AL ~~>'ES IN BALM
· SV40 Contamination of Polio Vaccine and Cancer (2002~. It is known treat
some of tire polio vaccine administered to adults and children ifs tire
United States from 1955 through 1963 was contaminates] witty simian virus
40 (SV40), which came front money kidney cells used to produce tire vac-
cine. SV40 has biological properties that are similar to other viruses known
to cause cancer in humans, although it leas not been conclusively estab-
lishecl that SV40 actually has this ability. Prio'- to its elimination fiom the
vaccine, it is estimated treat between 10 millions and 30 n~illion people
receiver! contaminated vaccine, ant! researchers leave long wonclered about
tire l~ealtl~ effects, if any, of their exposure. The 10~1 report co~clucles that
scientific evidence is insuffcie~t to prove or dis-
prove tire theory that exposure to contaminated
polio vaccine leas triggered cancer ilk humans.
The vast majority of population studies, wl~icI
carry flee Impost weight in establishing causal
relationships, leave found no increased rates of
cancer ifs people Gino received the vaccine cluring tire period wisely it
was contaminated. However, a possible linIc cannot be completely ruled
out, because of limitations in tire available data Alice ifs tire way tire studies
were conductecI.
SY4~) has biological ProT>~3t
ties th`~t are sin~ilar to other
viruses known to cat'se~
Cance~r In 1~.
· Vaccinations and Sudden Unexpected Death in Infancy (2003~. Most
infants receive multiple closes of vaccines during their first year. Most
infants who die cluring Elixir first year do so sullenly and unexpectecIly.
Taxis overlap leas raised concern that vaccinations misfit play a role in sucl-
clen unexpected cleated in infants. The IOM report examines possible con-
elections between vaccinations and three outcomes: all cases of sudden
unexpected! infant deaths; cases of suciclen infant death syncirome (SIDS),
Plaice is the most common cause of cleated cluring tire 'neonatal period; and
cases in wl~icI~ infarcts die, wI~etl~e`- unexpectedly or not, citing their first
four weel~s. Tire report concludes that scientific evidence favors rejections
of a causal relatio~sI~ip between one type of vaccine Style combination
dipl~tIleria, tetanus, wI~ole-cell pertussis vaccine) and SIDS, but favors
acceptance of a causal relationship between taxis vaccine and cleath due to
anaphylaxis, which is an extremely rare event caused by an allergic reac-
tion. It says tire evidence is i'~aclequate to eitI~er reject or accept a causal
relationship between tire other vaccines stucliec! and all forms of sullen
unexpected! infant Neatly.
ray
J ~
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14i,\~/f~r(, 77-~£ Ply 'S -ANEW
Sil7~Ip(.~x Vat:'clndliot]
One of public I~ealth's greatest triumphs was tire WorIc} Healths
Organization declaration in 1980 that tire woric! was free from the ancient
scourge of smallpox. Tragically' l~oweve~; tire emergence of global terrorist
organizations preparing to use biological
weapons against tire United States ant! Oliver ta~-
gets has cat eaten a credible the eat of possible out-
breaks of smallpox in tile gene' al population as a
result of its use as a biological weapon. Tire
smallpox vaccine (vaccinia virus) is a highly effec-
tive immunizing agent against tile disease. But
its use is riot without risI<, anc] reintroduction of
wide-scale vaccination must be clone joctic~ously.
*~e emergence of gIobal
terrorist orgallilat;~nS
P`~ring to uSe li.)i(.~.)gIcal
we lnons against tile
4 ~ ~
i; State~s aiid t,the~r
targe~s has cre`~d ~ c'~:i'
ble threat of possibly
ouilare~aks of snnallipox~.x
Tire IOM leas issued several reports related to developing ant! i~nplement-
ing smallpox vaccination programs:
· Scientific and Policy Considerations in Developing Smallpox Vaccination
Options (2002) summarizes tire results of a public workshop organized by
tire IOM at the request of tire Centers for Disease Control and Prevention
(CD(~. Particinants discussed tire scientific clinical social. procedural and
. . .
administrative aspects of various im~nunizatio'~ strategies being consicI-
erect by tire fecleral government for smallpox immunization. The report
was presented to tire Advisory Committee Ott Immunization Practices
(AClP) an independent bocly that provides guidance to tire government
r egarcling else most appropriate use of vaccines alar} r elatecl agents for
effective disease control ifs the civilian population which used the work-
shop results in crafting updater! recommendations for smallpox vaccina-
tion of tire general population ant! for vaccination of indivicluals at risI<.
· Review of the Centers for Disease Control and Prevention s Sn~alipox
Vaccinations Program l'~,vieme'`tatio'~: Letter Report #1 (2003) is tire first of
several ~ eports requested by tire CDC to provide timely advice off flow best
to implement tire national smallpox immunization program announced in
late 2002 ant] begun in early 2003. Tire initial plan broken into pleases
first involved vaccinating 500 000 public healths and health care workers
Gino volunteered to be part of smallpox response wants treat would take
action during a bioterrorist attack. The second please wouIci inclucle vacci-
~atio~~ of 10 million healths workers and officer traclitional first respollclers
such as police and firefighters. Vaccination eventually would be available to
members of tire general public who want it but it is riot suggested. Among
its recommendations tire report urges tire CDC to proceec! with tire immu-
73
~f\~-~Nr(' Add- itch CRI11~AL iS~S IN ~~,ill71-!
nization program as cautiously as possible, allowing continuous opportu-
nity for deliberation anti analysis.
· Review of tire Centers for Disease Control and Prevention's Sf?lai~pOX
Vaccination Program Implementation: Letter Report #2 (2003) offers recom-
menclations that reflect changes macle by tire government to tire original
pi ogram based on pl~ased-irt vaccination. Uncles tire new plan, states woulc!
be allowec! to expanse voluntary vaccination to all health
care workers anti first-responcle~s before competing else
first please involving a mucks smaller group of key person-
nel. Tire report urges the CDC to malce every effort to
plan, implement, and evaluate tl~e program, even with-
out air official break between its pleases, in order to
improve its implementation and protect boric the people
Silo are vaccinated ant! tire public Tile main focus
should be on maximizing preparedness to clear with a
bioterrorist attack. In addition to increasing tire number
vaccinated, preparedness means that states and commu-
nities must Ilave coordinated their public IlealtI1 workers,
medical personnel, and otIler emergency responders to
erasure that they can react quickly and effectively when
needed. Letter Report #3 (2003) reaffix nils tile need for a pause in tire small-
l~ox vaccination program and provides commentary about tire Centers for
Disease Control and Preve~tion's smallpox program activities to date,
including next steps in tile p~-e-eve~lt vaccination program.
Vac~cine Finance
Concerns about vaccines include not only issues of safety, but also of
cost. Vaccine manufacture is not profitable for pha~'naceutical companies
wizen compared to drugs witty broad Clarinets, such as tile class of statins
that prevent liars disease. At the same time, tile new vaccines are expen-
sive, arid mucks of tile purchase burden falls on governments at tile federal
and state level. Tire IOM has issued several reports on approaches to vac-
cine finance, tire most recent being Financing Vaccines in the 21st Century:
Assur-i'~g Access acid Availability (2003), which recommends boIci, funclame~-
tal cl~anges to the current system of vaccine purchasing and clistributio'~.
Tile principal recommendation of tire report is that tire current govern-
ment vaccine purchasing programs be replaced witty a new gover'~ment-
funciec' insurance mandate and voucher plan for Advisory Committee Ott
Immunization Practices (ACIP)-approved vaccines. Tile mandate would
~4.~.~tr 77~: 3^~t ~3 ~~.AL71-]
r equire all public ant! private healths plans to incI~cie vaccine benefits cou-
plect witty vouchers for uninsured cI~ilciren and adults. The role of else feci-
eral government woulc! be to reimburse plans and heat care providers for
else costs of Albeit vaccine purchases. Tl~e report inclucles an analysis of
alternative strategies that were consiclerec] in formulating taxis approach. In
addition flee committee recommencis changes in the composition and
ciecision-making p'
|~RMI\~t 1~E /< t17-! ~~ CRI11~AL IS~)~S IN ~~
recluce child pornography). Current projects ant! recent repo'-ts inclucIe
evaluating r isk and protective factors for assessing child! health in tire com-
munity; promoting cI~ilc! and family well-being tl~rougI~ family work poli-
cies; training health professionals on family violence; achieving positive
outcomes for cI~itciren in child! care; acid drawing policy implications from
research on early cl~ilcIl~ood development Alice learning.
Recognizing tile persistent concertos about adolescence and yowls
development, tire Boarc! was supplemented! in 2000 by the Committee on
Adolescent Heath acid Development (CARD), a new stapling committee
that also generates consensus and workshop reports. The CARD assumer!
Low levels of heat{h Bite
cy can Iead to higher Ievels
of morteLlity,, ~£~)i~ity'
inequ;~'and coste..
resl~onsil~ility fo' taking stock of wheat is known
about adolescent health and cievelop~nent,
applying this knowledge to pressing issues fac-
ing adolescents and their families, and stimulat-
ing new directions for inquiry and innovation.
Current and recent projects include a stucly off
tra~sitiot~s to adulthood in developing counts ies apace ad~nir~ista-atio~ of tire
W.T. Grant Youths Development Prize.
Recent examples of IOM stuclies on children, youth, and families
include else following:
· Contemporary American thigh scI~ools are expecter! to meet able
bleeds of a diverse and glowing population of youths, provicti~g them witty
knowledge, skills, and credentials for successful transition into adulthoocI,
higher eclucation, and the won Icforce For many adolescents, scI~ools do not
meet tI~ese expectations, despite years of public debate. Engaging Schools:
Fostering High School Students' Motivatio'? to Learnt {20021 orovicles a cletailec!
~ ~ r' '. .. r,' ~ ~ · ~
~ , ~
analysis or now app~cat~on or tne psycno~og~ca' theories of motivation and
engagen~ellt can be appliecl to urban school reform.
· Two changes in recent decades leave altered tire landscape for early
cI~ilcil~ooc! policy, service clelivery, and chic earing in tire Unitec! States.
Tile first is the set of major advances in understancling interactions among
tire many factors treat illflue~ce clinch health anti development. Tire seconcI
is tire expansion of time that young cI~ildre'~ she'd! in child care settings,
Frequently starting in infancy, as a result of changed social and economic
circumstances of working families. Working Families apace G)^owi'~g
Kicis: Cari'~gfo'~ C/~ild'~e'~ acid Adolescents (2003) examines tI~ese cages and
~~! JR/I\~! 71-~E PLI81~( =S HE-AI7~
offers recommendations for employers, government agencies, civic
care providers, and parents to assure quality of care ant! family
fiienclly practices.
UPCOMING REPORTS
Damp l'~cloor Spaces ant! Health. Recent attention has been given to the
relationship between damp or moldy incloor e'~viro~n~e'~ts arch tire mani-
festation of adverse I~ealth effects, particularly respiratory and allergic
symptoms. In response to a request by tire Centers for Disease Control acid
Prevention, a comprehensive review will focus Ott fungi and ~nycotoxins,
inclucling StacI~ybotrys cI~artarum thought by some to be associated witty
a cluster of pediatric pulmonary hemosiclerosis in Cleveland during tire
early 1990s. In addition, it will malce recommendations or suggest guide-
lines for public health interventions and for future basic science, clinical,
and public heat research in Rinse areas.
T7'e Fixture of Poisons Prevention anc! Contro/ Services. Over 4 million poison
exposures occur annually ilk tile Uniter] States. Approximately I~alf of Vilest
exposures are r eported to tire Poison Control
Centers (PCCs), which provide free support to
callers trough a telephone hotline staffer' by
toxicology professionals. Ready access to PCCs
reduces tire cost and improves tire quality of
emergency care of poisoning exposures. Yet the
funcling for tire PCCs over the last 20 years leas
. . . ..
amply acCeSs [O ~ w
OCR for page 78
[I4'~yM~r 7~- /4 {1rI-~^ CAT i.~..~S IN ~~
Health Literacy. The stealth care system increases in complexity every
weel<. As a result, emphasis is being put off tire co'~sun~er to play a I
A.~! ~IN(, AFRO J)[ ~~( ~S HI~-AL7~
Underage DJil?king. Multiple strategies are currently in operation to
reduce underage drinI
Selected Recommendations for Health Care Delivery
Improving the Quality of Health Care: All health care or`gcanizat:ions, professional groups,
and private and public purchasers should pursue six major aims; specifically, health care
should be safe, effective, patient-centered, timely, efficient, and equitable. DHHS should be
given the responsibilit:y and necessary resources to establish and maintain a comprehensive
program aimed at making scientific evidence more useful and accessible to clinicians and
patients. Congress, the executive branch, leaders of health care organizations, public arid pri-
vate purchasers, and health intorma~ics associations and vendors should malice ~ renewed
national eon~mit~nent to buiRling an inforn~ation infrastructure to support health care deliv-
ery, consumer health, quality measurement and improvement, public accountability, clinical
and health services research, arid clinical education. Private and public purchasers should
examine their current payment methods to remove barriers that currently impede quality
improvement, and to build in stronger incentives for quality enhancement. (Crossing the
Quality Chasm: A New Health System for the 21st Century, 2001 )
The Role of Leadership in Health Quality: The federal government should assume a strong
leadership position in driving the health care sector to improve the safety and quality of
health care services provided to the approximately 100 million beneficiaries of the six major
government health care programs. Further, the federal government should take maximal
advantage of its unique position as regulator, health care purchaser, health care provider, and
sponsor calf applied health services research to set quality standards for the health care sector.
(Leadership by Example: Coordinating Government Roles in Improving Health Care
Quality, 2003)
Focus on Health Professions Education: All health professionals should be educated to
deliver patient-centered care as numbers of air interdisciplinary team, emphasizing evi-
dence-based practice, quality improvement approaches, and informatics. (Health Professions
Education: A Bridge to Quality, 2003)
Reducing Racial and Ethnic Disparities in Health Care: It is critical that all relevant policy
makers increase awareness of racial and ethnic disparities in health care among the general
public and key st-akeholders, especially including health care providers. The proportion of
underrepresented U.S. racial and ethnic minorities among health professionals should be
increased. Governments should strengthen the stability of patient-provider relationships in
publicly-funded health plans, and apply the same managed care protections to publicly funcl-
ed HMO enrollees that apply to private HMO enrollees. Payment systems should be struc-
tured to ensure an adequate supply of services l:o minority patients and limit provider incen-
tives that may promote disparities. (Unequal Treatment: Confronting Racial anc] Ethnic
Disparities in ~ Health Care, 2002)
Addressing cancer Risk Factors: A national strategy should be developed anal coordinated
by DHINS to address the epidemic of obesity, unhealthy diet, and physical inactivity in
America. The U.S. Congress and state ,3egislat~res should enact ante provide funding (or
enforc-etnent of laws to substantially reduce and ultimately eliminate the adverse public
health consequences of tobacco use and exposure. (Fulfilling the Potential of Cancer
Prevention and Early Detection, 2003)
