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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 problemstilde Bee] [~( an effective public health system remains as urgent I ' ¢ I 7 ~ J
|~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
/ gas/ art/ ma\ ~ / ~ \ A Fume ~ Ih~k~g About He Determining of ~pul~on Mealy , 22>c. cultural, '~..~ /' # ~ ~ ~-ii3~ ~ ~ ~ / ha.' -4 --' ??'~-~` ~ ', ~ / ~ , ad, ~> ~ cab ~ ,` a\ /~/"" ,,P'Z'r'~ "\ ~ ~ ~~.~ a\ ~ ha\ ' ~ >~ ~~/~nd7~'uti~l trolls: ., ~ ~%, , ~ ~ ~ f ~~ ~ ' ~ P ~ : ~ ~ 1 ~~ ~ ~ 33 7 ~ >> s dams ,'~-~ ~1' ~ , `~`t~ aim IS 1 I,! , / // ~ / `~ ~ ~~,s,~' ,' \ \ \ '` \ ~# ~ ad). `` " a, ~~` 'a-''---.. ~ / \# ~ a' ,' ^ \ #! ~~B ~70S 'T>~ .~ ~,~ 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.~<f~g [~1~ ~0f><f\9 ] as my ~~:~r Pedal ts.:1~5 ~ E~p$~me~t slang ad o:cclpatior~s} lactors Saws SITS fir~C~r`~ duo ^~Up~t~C171 ' ~ ~l~n~ 1 ~ lath me As assessed the qualm of beach care far various racial and ethnic minority groups, while holding constant variations in insurance status, patient income, alla other access~elaced Actors. The research revealed that minorities tend to receive a lower qualm of care Man non-minorkies, In when they have similar insurance or the abUi~ to pay far care. Rally poten- dal sources far these health care disparities were identified, including the need to make medical decisions under time pressure with Embed in~rl~a- don, patiellt attitudes alla behaviors, and health care providers' biases, a. be
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<nowledge to improve health status of incli- viduals or populations. Health and Be1?c~vior: TO Interplay of Bio/ogical, Behaviora/ and Societa/ Influences (2001) presents current I<nowlecige about links between heat and bel~avio~; acid about interventions to improve health through moclifying behavior or personal relationships. Tire report outlines what must still be learned in orcler to better understand tire com- plex relationship between healths and behavior and to clesign and imple- mer~t cost-effective metl~ods for promoting behavioral charges Fiat will foster goof! healths. JO
~.~IN(, 71-~£ i3~( $ ~77-] 440 - ~ - - w~, - ..~. 240 - ~ 7 ~~ ~~ - _ 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<nown for decades, r ougI~ly 48 million aclultsnearly one-quarter of the adult population continue to smelly cigarettes. Several IOM reports have been important in scraping public opinion and national policy regarding tire use of tobacco. Tire most recent is Cleansing the Smoke: Assessing the Science Base for Tobacco Harm Recluction (2001) wI~ich focuses off the army of proclucts that claim to be less risIcy: low-tar Alice low-nicotine cigarettes cigarette-like devices tight cage tire composition of smoke initialed and gums that recluce tobacco craving. Taxis report fount! treat there is not enough scientific evidence to conclude that any of otiose products actually confers any clegree of health protection. It outlines how classic public I~ealtI, tools research surveillance, co~nmuni- cation. ant! regulation sI,ould be used to prevent misleading claims of lower risk of ti~ese proclucts to individuals or populations. Tire growing ~ ate of obesity is another public I~ealtI, challenge float leas reacl~ec] epiclemic proportions in tire United States wield tire Department ~7
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<s for greater health problems ant! earlier mortality 1~ 2001, tire U.S. Surgeon General issued a call to action to prevent and decrease overweight and obesity in tire United States. Recognizing tire need for greater attention clirected to children and youth, Congress requester! Fiat Else l~stitute of Meclicine develop an action plan targeted specifically at tire prevention of obesity among youngsters. The study com- ~nittee will assess social, environmental, meclical, dietary and other factors responsible for tire increasing prevalence of cI~ildI~ood obesity and identi- fy tire most promising mutinous for prevention, inclucling interventions and policies for immediate action and for the longer term. In tandem witty taxis study, tire IOM is also focusing on a stucly on tire effects of transporta- tion and lane] use on physical activity levels. Taxis study will adctress the role of transportation and lane! use on receipt increases in sedentary bel~avio~: It is clesignec! as a Faming effort to Steep sort out tire complex factors affecting development and travel; assess tire potential for policies that pro- mote snore walking, cycling, and transit trips through cleanses in land case and transport systems; and identify Pleas for further r esearcI~. AMMAN ITY ~ EAtIt] Two otI~er recent reports exemplify the coordinating role treat public I~ealtl~ plays in linIcing tire actions of community services sucks as law- enforcement, schnooks, and social services with clinical services to address complex tI~reats to health: family violence and suicide. Family violenceclinch Obtuse and neglect, intimate partner violence, and elder abuseis a deeply troubling problem in American society. Studies consistently report tI1at SUCi1 violence affects as many as 25 percent of children and adults during their lifetin1es, as victims, as perpetrators or
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 inclividualsas 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 othersimmunization safety x.~C State Iaws require that ch'ldt~, b~ VaCCInated I,0 enter days C8~C dH] SCilOQl' in p~t iD protect otIlerSi~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 electsant! 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 evidencethough 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 ~ Y it<
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'<ocedu~es of the ACIP the entity that currently ~-ecom- n~ends vaccines. CHIt.~' Y(.~-~! ANI>) fAi~.~S There are 85 n~illion families in tire United States today ant! a new births col~ort of 11 000 infants arrives tacit day. Todays cI~ilciren adolescents and you confront a work! in wl~icI~ rapidly evolving technology changing social and healths environments, and growing multicultural diversity pose new opportunities and complex cl~allenges. An explosion of research ilk tire ~eurobiological, behavioral, acid social sciences leas led to major advances in understanding tl~e conditions that influence core. Although we have long know law to identify problems acid risk behaviors agog Chile and adolescents, only recently has tire science of positive child and youths development emerged. Sucks r esearcI~ leas profounc! implications for employment trends and child care practices, fam- ily and neigl~borl~ood processes and relation- sl~ips, educational programs and I~ealtI~ care services, amuck community initiatives within focal jurisdictions, states, and tire nation as a whole. Research on children, youths, and families is talus watcI~ec! carefully by mil- lions offamilies, policy-mal~ers, employers, ant! service proviclers wire seek authoritative guicia'~ce as tizzy actress tire challenges of promoting tire Stealth and well-being of toclay's children, aclolescents, ant! families. *~t decades have allered ~ he Iandscape for earI i ch ~ Id hoor! pot icy' Jo 601 jaunty 3~] ~6 rearing In tIle United To address Direst concerns, tire Board on CI~ild~et~, Youths, and Families (BCYF) was establisher! in 1993 uncler tire joint aegis of the Institute of Meclicine and tire National Research Council. The Boarc! alas sponsored over 40 activities since bleat time, including broad consensus-basec! studies Lucid as tire lancimarI< report From Neurosis to Neighborhoods, published in 2000) and smaller workshop reports (examples inclucle projects on tire quality of after-scI~oo] programs, tile education of language minority cI~il- dren, tile impact of welfare assistance Ott civic! clevelopme~t, and efforts to w ~5
|~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<S reduces the cost arid improvers the Salty off en care o-t In Ing exposures. been limiter! ant! unstable. In response to a request frown tire Maternal and CI~ild Health Bureau of tire Healths Resources and Services Administration, an IOM committee is considering the future of poison prevention ant! con- tro! services in tire United States. To aciciress taxis charge, tire committee is evaluating tire role funcling organizational structure, ant! scope of servic- es of tire PCCs, ant! providing recommendations for assuring tire optimal pi ovision of poison prevention and control services in the future. TO com- mittee is also consiclering future demographic and population trencis, and flow these ~nig-ht have an impact on po,oulatio~ needs for poison preven- tion acid control services, and oilier relevant factors. 77
[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<ey role in malting health decisions ant! in ensuring that their own stealth care and that of their fannies is of high quality, appropriate, and error free. Health literacy, the degree to which indivicluals leave the capacity to obtain, process, and unde~sta'~c! basic health information ant! services 'beetles! to make appropriate health clecisio~s, is the'-efo'-e an increasingly impo~ta'~t aspect of public healths. It leas been estimates! treat 46 percent of American aclults, 60 million people, are functionally illiterate in clearing witty health. This problem is as profounc! as any new infectious or chronic disease, but is not spoken of by patients and is not appreciated by policy makers and the general public. Without significant imps ovements in health liter acy, the promise of all tire scientific advances to improve stealth outcomes will be sig- ~ificantly dimi'~isI~ed. Low levels of I~ealtl~ literacy can lead to Rigor levels of mortality, mor- bidity, inequity, anti cost. One study in 1997 found Fiat poor literacy resulted in five times tire slumber of mis- takes in interpreting prescriptions and twice tire number of visits to tire doctor compared to those witty acetate literacy skills. These costs fall riot only on patients, but also on employers, insurers, Medicaid/Meclicare, anti health care providers. Conversely, Leigh levels of healths literacy cart lead to lower levels of cost as well as greater improvement in One studly~.l:~d that poor bitt aCy ~x~f jO five tjn'10S the number t,[ m 'slakes in Interprets ing presCripliOnS and twice tile nu'~r `~f visits to the doctor con~d t`, th`~e with ace. q ~ ate ~ ite racy ~ k' f ~ ~ D mortality, morbidity, inequity, health and well fig. To Late, policy efforts to address quality of care are focusing principal- ly on the healths care system but do not consider tire impact of heath liter- acy. Aid IOM stucly is currently assessing tire problem of health literacy and is considering else next steps within a public l~ealth/public education frame- work. Tire study will evaluate approaches that leave been attempter! to increase stealth literacy anti iclentify tire gaps in research and programs that Sect to be acicIressecl. 78
A.~! ~IN(, AFRO J)[ ~~( ~S HI~-AL7~ Underage DJil?king. Multiple strategies are currently in operation to reduce underage drinI<ing, lout little is renown about tire effects of differing approaches. In response to a request frown tire U.S. Congress, tire IOM established a committee to review governmental acid non~,overnn~ental programs, including mectia-basec! programs, designed to change youth atti- tucles anti shrinking behaviors. Tire final study, A Strategy for Rerlucing and Prever2ti'~g Utacle rage Drinking, assesses programs that focus directly on behavio' changes as well as those treat seek to ~ educe adolescent access to alcohol (tl~rougi~ higher taxes, aggressive enforcement of age acid iclentifi- catio~ cI~ecks, acid restriction of alcohol Ott college campuses, for exam- ple). Tire study is expected to be releaser! in fall 2004. ~,` BY
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)
