ble and creative, to serve the American people adequately. Federal programs must learn and share all they can from on-the-ground experiences at the state and local levels to promote quality improvements.

Some prominent former HHS leaders have advocated that a population-health model be implemented across the department (Boufford and Lee, 2001). In 2002, the Institute of Medicine recommended adoption of “a population health approach that considers the multiple determinants of health.” That committee also recommended strengthening the governmental public health infrastructure (both federal and state), building partnerships across diverse communities, enhancing communication within the public health system, and, like the authors of this report, recommended improved systems of accountability and strengthening evidence for decision making (IOM, 2002a).

FIGURE 3-1 Key factors in personal and population health.

^aSocial conditions include economic inequality, urbanization, mobility, cultural values, and attitudes and policies related to discrimination.

^bOther national conditions might include major sociopolitical shifts, such as recession, war, and government collapse.

^cThe built environment includes transportation, water and sanitation, housing, and urban planning (Worthman, 1999).

SOURCE: Adapted from Dahlgren and Whitehead (1991), as printed in The Future of the Public’s Health in the 21st Century (IOM, 2002b).