levels, and public health departments have essential roles in informing and mobilizing public- and private-sector efforts.

The U.S. public health infrastructure—the constellation that includes federal, state, and local public health agencies, laboratories, and information technology and surveillance networks—is fragmented and lacks the resources necessary to carry out its roles effectively and ensure a basic level of health protection for all Americans. Historically, public health responsibilities emerged as primarily locally- and state-based, with the federal government intervening in the course of some epidemics. At the federal level, the Department of Health and Human Services (HHS) came together in piecemeal fashion in the 20th century, as discussed in more detail in the 2003 IOM report on the future of the public’s health. Today, this highly complex infrastructure is supported by diminishing resources, and that poses grave threats to and the loss of important opportunities for the nation’s health. Over 52,200 combined state and local public health jobs have been lost since 2008 (17 percent of the state and territorial public health workforce and 22 percent of the local public health workforce [ASTHO, 2012]).

The underinvestment in public health has ramifications for the nation’s overall health status, for its financially-strained health care delivery system, and, the committee argues, for its economic vitality and global competitiveness. Although 2012 is a challenging time in national and world economic history, the nation’s portfolio of investments in health must be reconsidered and rebalanced to lead the way toward an invigorated “health system,” economy, and society. In referring to the nation’s health system,2 the committee means not only the component that delivers medical care, but the intersectoral system that was first introduced in the 2003 report The Future of the Public’s Health in the 21st Century (IOM, 2003) and that comprises the governmental public health agencies and various partners, including communities, the health care delivery system, employers and businesses, the mass media, and the education sector.

At a time when expenditures on medical care are limiting its ability to make crucial investments in other arenas that are critical for the quality of life and economic health of Americans, the committee believes that a strong governmental public health infrastructure can mobilize strategies that reduce the occurrence of disease and injury, offset the need for ever-

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2In its report on measurement, the system was redefined by the committee as simply “the health system” because “the modifiers public and population are poorly understood by most people other than public health professionals and may have made it easier to misinterpret or overlook the collective influence and responsibility that all sectors have for creating and sustaining the conditions necessary for health. In describing and using the term the health system, the committee [sought] to reinstate the proper and evidence-based understanding of health as not merely the result of medical or clinical care but the result of the sum of what we do as a society to create the conditions in which people can be healthy (IOM, 1988)” (IOM, 2011b).



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