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Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
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THE FUTUREOF THE PUBLIC’S HEALTH in the 21st Century

Committee on Assuring the Health of the Public in the 21st Century

Board on Health Promotion and Disease Prevention

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C. www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
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THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W. Washington, DC 20001

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

Support for this project was provided by the Centers for Disease Control and Prevention; the National Institutes of Health; the Health Resources and Services Administration; the Substance Abuse and Mental Health Services Administration; the Department of Health and Human Services, Office of the Secretary, Assistant Secretary for Planning and Evaluation; and the Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Contract No. 200-2000-00629. The views presented in this report are those of the Institute of Medicine Committee on Assuring the Health of the Public in the 21st Century.

Library of Congress Cataloging-in-Publication Data

The future of the public’s health in the 21st century / Committee on Assuring the Health of the Public in the 21st Century, Board on Health Promotion and Disease Prevention.

p. ; cm.

Includes bibliographical references.

ISBN 0-309-08622-1 (hardback) — ISBN 0-309-08704-X (pbk.) — ISBN 0-309-50655-7 (pdf)

1. Public health—United States. 2. Medical policy—United States. [DNLM: 1. Public Health—trends—United States. WA 100 F9955 2003]

I. Institute of Medicine (U.S.). Committee on Assuring the Health of the Public in the 21st Century.

RA445.F885 2003

362.1’0973’0905—dc 21

2003008322

Additional copies of this report are available from the
National Academies Press,
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For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.

Copyright 2003 by the National Academy of Sciences. All rights reserved.

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The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
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“Knowing is not enough; we must apply. Willing is not enough; we must do.”

—Goethe

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

Shaping the Future for Health

Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
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THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences.

The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering.

The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.

The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council.

www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
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COMMITTEE ON ASSURING THE HEALTH OF THE PUBLIC IN THE 21ST CENTURY

JO IVEY BOUFFORD, M.D. (co-chair), Professor of Health Policy and Public Service,

Robert F. Wagner Graduate School of Public Service, New York University

CHRISTINE K. CASSEL, M.D. (co-chair), Dean,

School of Medicine, Oregon Health & Science University

KAYE W. BENDER, Ph.D., R.N., F.A.A.N., Deputy State Health Officer,

Mississippi State Department of Health

LISA BERKMAN, Ph.D., Chair,

Department of Health and Social Behavior,

Thomas Cabot Professor of Public Policy and Epidemiology,

School of Public Health, Harvard University

JUDYANN BIGBY, M.D., Associate Professor of Medicine and Director,

Community Health Programs, School of Medicine, Harvard University

THOMAS A. BURKE, Ph.D., M.P.H., Associate Professor of Environmental Health Policy,

Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University

MARK FINUCANE, Principal,

Leadership Development Solutions, Health Sciences Advisory Services, Ernst & Young LLP

GEORGE R. FLORES, M.D., M.P.H., Consultant, and Public Health Advisor to the California Endowment

LAWRENCE O. GOSTIN, J.D., Professor of Law,

Georgetown University;

Professor of Public Health,

Johns Hopkins University; and

Director,

Center for Law and the Public’s Health

PABLO HERNANDEZ, M.D., Administrator,

Mental Health Division, Wyoming Department of Health

JUDITH R. LAVE, Ph.D., Professor of Health Economics,

Department of Health Services Administration, Graduate School of Public Health, University of Pittsburgh

JOHN R. LUMPKIN, M.D., M.P.H., Director,

Illinois Department of Public Health

PATRICIA A. PEYSER, Ph.D., Professor,

Department of Epidemiology, University of Michigan School of Public Health

GEORGE STRAIT, Chief Executive Officer,

MedComm Inc.

THOMAS W. VALENTE, Ph.D., Associate Professor, Preventive Medicine Director, Master of Public Health Program,

Department of Preventive Medicine, University of Southern California School of Medicine

PATRICIA WAHL, Ph.D., Dean,

School of Public Health and Community Medicine, University of Washington

Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
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LIAISONS FROM THE BOARD ON HEALTH PROMOTION AND DISEASE PREVENTION

GEORGE J. ISHAM, M.D., Medical Director and Chief Health Officer,

HealthPartners, Inc., Minneapolis, MN

HUGH H. TILSON, M.D., Dr.P.H., Senior Advisor to the Dean of the School of Public Health,

University of North Carolina at Chapel Hill

STAFF

MONICA S. RUIZ, Ph.D., M.P.H., Senior Program Officer, Study Director (until June 2002)

ALINA BACIU, M.P.H., Program Officer

LYLA HERNANDEZ, M.P.H., Senior Program Officer

ROSE MARIE MARTINEZ, Sc.D., Director,

Board on Health Promotion and Disease Prevention

LORI YOUNG, Project Assistant

RITA GASKINS, Administrative Assistant,

Board on Health Promotion and Disease Prevention

Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
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LIAISON PANEL ON ASSURING THE HEALTH OF THE PUBLIC IN THE 21ST CENTURY

MOHAMMAD N. AKHTER, M.D., M.P.H., Executive Director,

American Public Health Association

HENRY ANDERSON, M.D., Chief Medical Officer,

Wisconsin Department of Health and Family Services

EDWARD L. BAKER, M.D., M.P.H., Director,

Public Health Practice Program Office, Centers for Disease Control and Prevention

JAMES BAKER, Executive Director,

Institute for Public Strategies

WIL BAKER, Ed.D., Co-Project Director,

Alabama Southern Rural Access Program

LEONARD BATES, Ph.D., Health Policy Fellow,

Office of the Honorable Donna Christian-Christiansen, Congressional Black Caucus Health Braintrust

ERIC T. BAUMGARTNER, M.D., M.P.H., Former Director,

Community Access Program and State Planning Programs

SCOTT BECKER, Executive Director,

Association of Public Health Laboratories

BOBBIE BERKOWITZ, Ph.D., Director,

Turning Point National Program Office

RONALD BIALEK, M.P.P., Executive Director,

Public Health Foundation

BARBARA CALKINS, M.A., Executive Director,

Association of Teachers of Preventive Medicine

WILLIAM CALVERT, M.S., M.B.A., M.P.H., Chairman,

Department of Defense Sexually Transmitted Diseases Prevention Committee, and

Program Manager,

Sexual Health and Responsibility Program, Navy Environmental Health Center, Department of Navy

ANN CARY, Ph.D., M.P.H., A-CCC, Director,

Institute for Research, Education and Consultation, American Nurses Credentialing Center

MARY CHUNG, MBA, President,

National Asian Women’s Health Organization

NATHANIEL COBB, M.D.,

Indian Health Service

DEBORAH DAMERON, M.P.S.H., President,

Association of State and Territorial Directors of Health Promotion and Public Health Education

NILS DAULAIRE, M.D., M.P.H., President and Chief Executive Officer,

Global Health Council

GEM DAVIS, M.A., Legislative and Governmental Affairs Coordinator,

Policy Division, National Advocates for Asian and Pacific Islander Health

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MORGAN DOWNEY, Executive Director,

American Obesity Association

CLYDE H. EVANS, Ph.D., Vice President, Director of American Network of Health Promoting Universities,

Association of Academic Health Centers

PATRICIA EVANS, Executive Director,

Council on Education for Public Health

ADOLPH P. FALCON, M.P.P., Vice President,

Science and Policy, National Alliance for Hispanic Health

MARIE FALLON, Executive Director,

National Association of Local Boards of Health

MARY E. FOLEY, R.N., M.S., President,

American Nurses Association

MARIANNE FOO, M.P.H., Director,

Orange County Asian and Pacific Islander Community Alliance

MARILYN H. GASTON, M.D., Former Director,

Health Resources and Services Administration

MARY J. R. GILCHRIST, Ph.D. President,

Association of Public Health Laboratories

JESSIE C. GRUMAN, Ph.D., Executive Director,

Center for the Advancement of Health

GEORGE HARDY, M.D., M.P.H, Executive Vice-President,

Association of State and Territorial Health Officials

RUTH HARRELL, R.N., M.P.H., Co-Project Director,

Alabama Southern Rural Access Program

BARBARA J. HATCHER, Ph.D., M.P.H., R.N., Director of Scientific and Professional Affairs,

American Public Health Association

TRACEY HOOKER, Program Director,

Prevention Project Programs, National Conference of State Legislatures

MARY JUE, P.H.N., M.S.N., Coordinator,

Statewide Public Health Nurse Advocacy Group

STEPHEN KALER, M.D., M.P.H., Deputy Associate Director for Disease Prevention,

National Institutes of Health

MIMI KISER, M.P.H., C.H.E.S., Health Program Coordinator,

Interfaith Health Program, Emory University

DONNA KNUTSON, Executive Director,

Council of State and Territorial Epidemiologists

CHARLES KONIGSBERG, Health Director,

Alexandria Health Department

CHRISTINE MAKRIS, Executive Assistant,

Global Health Council

LUCY MARION, Ph.D., R.N., C.S., F.A.A.N., Immediate Past President,

National Organization of Nurse Practitioners

KAY McVAY, R.N., President,

California Nurses Association

Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
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TOM MILNE, Executive Director,

National Association of County and City Health Officials

SHARON MOFFATT, R.N., M.S.N.,

Vermont Department of Health, Association of State and Territorial Directors of Nursing

PEARL MOORE, R.N., M.N., F.A.A.N., Chief Executive Officer,

Oncology Nursing Society

ANTHONY MOULTON, Associate Director for Policy and Programs,

Public Health Practice Program Office, Centers for Disease Control and Prevention

ELLEN MURRAY, R.N., Consultant, National TB Nurse Consultant,

Corrections Committee, Florida Department of Health, Bureau of TB and Refugee Health

MICHAEL O’DONNELL, Ph.D., M.B.A., M.P.H., Editor in Chief and President,

American Journal of Health Promotion

ELIZABETH SAFRAN, M.D., M.P.H., Assistant Professor of Medicine and Community Health,

Morehouse School of Medicine, Association of American Public Health Physicians

SARENA SEIFER, M.D., Executive Director,

Community-Campus Partnerships for Health

BRUCE SIMONS-MORTON, Ed.D., M.P.H., Chief, Prevention Branch,

National Institute of Child Health and Development, and Society for Public Health Education

HARRISON C. SPENCER, M.D., Ph.D., President,

Association of Schools of Public Health

MELISSA STIGLER, President,

Public Health Student Caucus

JESSICA TOWNSEND, Ph.D. Senior Fellow,

Health Resources and Services Administration

KATE TREANOR, Program Associate,

Grantmakers in Health

JONATHAN B. VANGEEST, Ph.D., Director,

Section of Medicine and Public Health, American Medical Association

JIMMY VOLMINK, M.D., Ph.D., M.P.H., Director of Research and Evaluation,

Global Health Council

ABRAHAM WANDERSMAN, Ph.D.,

Department of Psychology, University of South Carolina

RANDOLPH F. WYKOFF, M.D., M.P.H, T.M., Deputy Assistant Secretary, Director,

Office of Disease and Health Promotion

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Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
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Preface

Without health there is no happiness.

Thomas Jefferson

In 1988, the Institute of Medicine (IOM) report The Future of Public Health presented strong evidence to indicate that the governmental public health infrastructure was in disarray. The report provided a common language for national discussion about the role of public health (what we as a society do collectively to assure the conditions in which people can be healthy) and about the steps necessary to strengthen the capacity, especially of governmental public health agencies (e.g., local and state health departments and federal agencies), to fulfill that role. Moreover, the 1988 report prompted significant actions by policy makers, public health agencies, and educational institutions, including some remarkably successful efforts in several states to increase investment in governmental public health activities and to define more clearly the desired outcomes of such activities and the resources necessary for governmental agencies, such as health departments, to perform essential public health functions.

Much has changed in public health practice since 1988. Many of these changes reflect progress in the science of improving health at the population level, the emergence of innovative public–private partnerships in communities, and the development of new ways to dialogue and act on health. The Public Health Functions Steering Committee, as representatives of the national public health community,1 developed a broad consensus definition

1  

The committee comprised the American Public Health Association, the Association of Schools of Public Health, the Association of State and Territorial Health Officials, the Environmental Council of the States, the National Association of County and City Health Offi-

Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
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of the essential public health services in 1994 (see Chapter 1, Box 1-1). Moreover, a national plan has been developed as part of Healthy People 2010 to strengthen the public health infrastructure; significant progress has been made in describing the nation’s public health workforce and its shortcomings, and the framework for a National Health Information Infrastructure has been defined.

At the same time, the broader context of public health practice has been undergoing a radical transformation, as evidenced by the demographic change in the age and diversity of the population, the shifting epidemiology of disease from acute to chronic illness, the explosion in technology, and the importance of global health to our national health. Further, state- and especially federal-level investment in governmental public health infrastructure—workforce, information systems, laboratories, and other organizational capacity—has been uneven and unsystematic. Recently, substantial appropriations to this infrastructure have been directed to address bioterrorism in the wake of the events of October 2001. However, concerns remain about the adequacy and sustainability of funding needed to assure the balanced capability of this infrastructure to act effectively across the spectrum of public health activities, not only in response to crises. These and other factors place unprecedented stress on governmental public health agencies as they struggle to carry out their mandates in an evolving microbiological, political, and social environment.

Given existing and anticipated challenges to assuring the health of the public, the Centers for Disease Control and Prevention (CDC); the National Institutes of Health (NIH); the Health Resources and Services Administration (HRSA); the Substance Abuse and Mental Health Services Administration (SAMHSA); the Department of Health and Human Services (DHHS), Office of the Secretary, Assistant Secretary for Planning and Evaluation (DHHS/OS/ASPE); and the DHHS Office of Disease Prevention and Health Promotion (ODPHP) entered into an interagency agreement to support an Institute of Medicine study. The Committee on Assuring the Health of the Public in the 21st Century was convened with the charge to create a framework for assuring population health2 in the United States that would

   

cials, the National Association of State Alcohol and Drug Abuse Directors, the National Association of State Mental Health Program Directors, the Public Health Foundation, and several agencies of the U.S. Public Health Service (Agency for Health Care Policy and Re-search, Centers for Disease Control and Prevention, Food and Drug Administration, Health Resources and Services Administration, Indian Health Service, National Institutes of Health, Office of the Assistant Secretary for Health, and Substance Abuse and Mental Health Services Administration).

2  

Population health (also referred to in this report as the health of the population or the public’s health) is the focus of public health efforts. It refers to “the health of a population as measured by health status indicators and as influenced by social, economic and physical

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be more inclusive than that of the 1988 report and that could be effectively communicated to and acted upon by diverse communities. In support of that overall goal, the study sought to:

  • enhance understanding of the core purposes, functions, and roles of governmental public health agencies and other entities engaged in public health action in improving health outcomes for all;

  • crystallize knowledge about the conditions under which improvements in population health occur and how to affect those conditions (Chapter 2);

  • set an agenda for scientifically credible research that informs efforts to improve population health outcomes and that also fits the complex, adaptive systems in which population health occurs (Chapter 8);

  • provide evidence-based recommendations for improving the practices and the broader conditions that affect population health outcomes (Chapters 3, 4, and 5);

  • address the capacity and workforce needed to support improvements in population health (Chapters 3 and 4);

  • inform more strategic investments by grantmakers for population health improvement (Chapter 4); and

  • promote engagement in the civic work of building healthier communities by a broad array of sectors, organizations, and people (Chapters 3 through 8).

To complete the report, entitled The Future of the Public’s Health, in acknowledgment of the 1988 report but to suggest the broader scope, the committee met nine times over a 19-month period between January 2001 and July 2002. During this time, four workshops were held with representatives from a variety of federal agencies, state and local nongovernmental public health entities, private companies, and researchers in the field of public health. The committee also engaged in a visioning activity to forecast alternative scenarios for the status of population health in the United States in the coming decade and to assist with the development of recommendations that would appropriately address future challenges to public health and health care. Additional data collection activities provided input regarding the current status of the public health system and examples of how challenges to population health and health care delivery are being addressed at the state and local levels. Members of the committee also conducted site visits to two Turning Point projects (New Orleans, Louisiana; Franklin,

   

environments, personal health practices, individual capacity and coping skills, human biol-ogy, early childhood development and health services” (Federal, Provincial and Territorial Advisory Committee on Population Health, 1999).

Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
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New Hampshire) and three Community Voices projects (Baltimore, Maryland; Denver, Colorado; Oakland, California).3,4 Additionally, multiple requests were made for public comment. The committee also reviewed the current literature on a wide range of subjects and received information from its liaison panel of representatives from federal, state, and local agencies, as well as advocacy and nongovernmental organizations (see the Acknowledgments for a complete listing).

Based on a consideration of this evidence, the committee decided against crafting a new vision statement. Instead, the committee embraced the vision articulated by Healthy People 2010, healthy people in healthy communities, and turned its attention to developing recommendations for the priority actions necessary to attain that vision.

Given the immensity of the charge, the committee struggled to select these priorities from the vast array of areas in need of consideration and response. Several broad themes emerged from the committee’s discussion, including the need for a policy focus on population health; the need for greater understanding and emphasis on the broad determinants of health; and the importance of strengthening the public health infrastructure, building partnerships, developing systems of accountability, emphasizing evidence, and enhancing communication. These are the areas of action and change needed to improve our ability to protect and promote health.

The concept of a “public health system”—a complex network of individuals and organizations that, when working together, can represent “what we as a society do collectively to assure the conditions in which people can be healthy” (IOM, 1988:1)—occurred early in committee deliberations. The committee also found that many entities and sectors are needed to act on the multiple factors that shape population health, and focused on several key partners who can have a particularly significant impact on health by working individually and as potential actors in a public health system. In addition to the governmental public health infrastructure, the committee examined the community, the health care delivery system, employers and business, the media, and academia.

3  

Turning Point is a grant program of the W. K. Kellogg and Robert Wood Johnson foundations that began in 1996 and that ended in 2002. The goal of Turning Point has been to “transform and strengthen the public health infrastructure in the United States” by supporting states and local communities to “improve the performance of their public health functions through strategic development and implementation processes” (ww.wkkf.org).

4  

Community Voices is a 5-year initiative launched by the W. K. Kellogg Foundation in 1998 in 13 U.S. communities. The goal of Community Voices is to improve health care for the uninsured and underinsured by strengthening and securing the safety net and community support services.

Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
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The broad themes outlined above are discussed in more detail in Chapter 1, which also provides a discussion about the status of the health of Americans at the beginning of the twenty-first century, with a special focus on the mismatch of health spending and health outcomes, the nation’s shortcomings in health status (especially disparities in health among population groups), and the potential future challenges and threats to population health.

Chapter 2 presents a framework to illustrate the well-supported hypothesis that the health of populations and individuals is shaped by a wide range of factors in the social, economic, natural, built, and political environments. These factors interact in complex ways with each other and with innate individual traits such as race, sex, and genetics. The chapter then focuses specifically on several social determinants of health most robustly supported by the evidence. Approaching health from a broad perspective takes into account the potential effects of social connectedness, economic inequality, social norms, and public policies on health-related behaviors and health status. The chapter discusses seat belt and tobacco control policies as examples of public policies that have had considerable positive impacts on health status because they acknowledge the population-level and ecological factors involved in producing good or ill health.

The chapters that follow provide evidence of the positive impacts that key potential participants can have acting individually or in partnership, as appropriate, in a public health system working for the health of the public in the twenty-first century.

When most people think of public health, they think of state and local health departments, which have traditionally been responsible for public health services. Chapter 3 discusses the role of the governmental public health agencies at the federal, state, tribal, and local levels as the backbone of the public health system. In particular, the chapter examines the unique role and responsibility that governmental public health agencies have in promoting and protecting the public’s health by facilitating, supporting, and empowering other potential participants in a public health system. This chapter also discusses the importance of political will to support and finance the development and maintenance of a strong governmental public health infrastructure that can ensure that all communities have access to the essential public health services.

Chapter 4 discusses the community, defined as narrowly as a neighborhood or as broadly as the nation. The community is both a setting—the place where health is supported and protected by social connections and healthy social, built, economic, and natural environments or risked and damaged by detrimental environments and social norms—and a potential partner in the public health system through its organizations, associations, and networks. Communities have the knowledge and resources that are

Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
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necessary ingredients in assuring population health, and Chapter 4 illustrates clearly the significance of authentic community engagement in the public health system.

The health care delivery system and the role that it can play in maintaining both individual and community health are discussed in Chapter 5. Particular attention is given to this system’s current fragility and the implications of this fragility for the effectiveness of governmental public health agencies and the broader public health system. The chapter makes note of the historic gap in priorities for investment between public health and health care. Also, it proposes ways for the health care delivery system to refocus its efforts in health improvement and strengthen its collaboration with governmental public health agencies to ensure the best possible disease surveillance, the promotion of healthier communities as well as healthier individuals, and preparedness for any emergencies.

Chapter 6 highlights the current and potential contributions of employers and businesses (private and public) to the health of their workforces and to the communities in which they are located. Although employers do not typically see themselves as partners in the public health system, their potential contribution to assuring population health cannot be underestimated. Most people spend at least a third of their days on the job; and the workplace may supply their health care insurance, may offer messages or activities that support or undermine health, and may also shape their health with occupational and environmental exposures and psychosocial stresses. Businesses and employers are also significant members of communities everywhere, and in recent years, many have acknowledged and acted upon their role as corporate citizens by fostering improvement in the economic and physical health of communities.

The role of the media in promoting health is the subject of Chapter 7. That chapter explores the unique potential of the news and entertainment media in communicating and informing the public about health risks and benefits, health policy, and related matters. Although their approaches and end goals are somewhat different, the news media’s mandate coincides with that of the public health system: to serve and be accountable to the public. It is imperative for its own objectives and those of the public that the media “get it right.” Also, a continuous dialogue among public health officials and educators and reporters, media leaders, and educators can play a crucial role in facilitating the development of media expertise in public health and public health expertise in providing timely, accurate, and understandable health information.

Chapter 8 highlights the responsibilities of academia in training the individuals who work in public health and health care professions and in building the science base for health promotion, disease prevention, and community health action. Assuring the health of the public depends in part

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on the efforts of well-trained professionals who are supported by an adequately funded research infrastructure.

The Future of the Public’s Health began with an extensive charge. The committee thus endeavored to (1) examine and (2) explain the nation’s health status, as well as (3) describe the key individuals and organizations needed to work individually or together as a public health system to create the conditions in which people can be healthy and (4) recommend the evidence-based actions necessary to make this system an effective force in attaining the vision of healthy people in healthy communities, and, ultimately, a healthier nation and a healthier world.

Achieving this vision will be a dynamic process as our knowledge about the factors that create the conditions for health increases. The sophistication of our actions must evolve to shape forces in the global, national, and local environments that can act for or against health. Finally, we must sustain our commitment to a healthier nation through education, investment, and political will.

Jo Ivey Boufford, Committee co-chair

Christine K. Cassel, Committee co-chair

REFERENCES

Federal, Provincial and Territorial Advisory Committee on Population Health. 1999. Toward a healthy future: second report on the health of Canadians. Ottawa: Minister of Public Works and Government Services Canada.


IOM (Institute of Medicine). 1988. The Future of Public Health. Washington, DC: National Academy Press.

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Acknowledgments

This report represents the collaborative efforts of many organizations and individuals, without whom this study would not have been possible. The committee extends its most sincere gratitude to the organizations and individuals mentioned below.

Numerous individuals and organizations generously shared their knowledge and expertise with the committee through their active participation in workshops that were held on February 8–9, April 4–6, June 4–5, and July 31–August 1, 2001. These sessions were intended to gather information related to relevant issues to the future of population health and ongoing public health activities and initiatives, and helped to inform the committee’s vision for assuring the health of the public in the twenty-first century. Members of the study’s liaison panel contributed valuable information and suggestions that were helpful in preparing this report. These organizations and their representatives to the liaison panel are listed on pp. vii–ix. Additionally, the committee is grateful to all of the individuals who shared their experiences via their responses to the committee’s request for public comment.

The committee is most grateful to Barbara and Jerome Grossman for sponsorship of the committee’s visioning workshop. The workshop, held early in the process, helped focus the committee’s thinking about the public health system and its actors. Also, the committee would like to thank Katherine Haynes-Sanstad from the Institute for the Future for her work in guiding the committee through the visioning workshop. Christina Merkley also assisted in facilitating the visioning workshop and provided lovely graphic representations of the future scenarios created during that workshop.

Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
×

The committee is most grateful to the Henrie Treadwell and Barbara Sabol and the W. K. Kellogg Foundation for sponsorship of site visits to select Community Voices and Turning Point projects. Special appreciation goes to the directors and staff of the projects who graciously hosted committee members and project staff during site visits and enthusiastically shared their projects:

The Men’s Health Center, Baltimore, Maryland: Jayne Mathews, Hakim Farrakhan, and project staff

Healthy New Orleans, New Orleans, Louisiana: Shelia Webb, Patrice Lee

Denver Health, Denver, Colorado: Patricia Gabow, Elizabeth Whitley, Raylene Taylor

Asian Health Center/Clinica de la Raza, Oakland, California: Tomiko Conner and project staff

Caring Community Network of Twin Rivers, Twin Rivers, New Hampshire: Rick Silverberg and Network members

We are also grateful to William B. Walker and the Bay Area Health Officials for hosting a very informative data-gathering meeting for the Oakland site visit by committee members and staff.

Additionally, the committee would like to thank all of the individuals who, at various points in the study, assisted the committee and project staff by providing insight and information pertaining to the many various population health and public health issues upon which the committee was deliberating.

Raymond Baxter, The Lewin Group

Ronald Bialek, Public Health Foundation

M. Gregg Bloche, Georgetown University

Julie Carlson, Research!America

Lori Cooper, Research!America

Kristine Gebbie, Columbia University School of Nursing

Dana Goldman, RAND

Robert Goodman, Tulane University Health Sciences Center

Bethney Gundersen, Economic Policy Institute

Shelley Hearne, Trust for America’s Health

James G. Hodge, Jr., Center for Law & the Public’s Health, Johns Hopkins University School of Public Health

Bruce Jennings, The Hastings Center

Laura Marie Kidd, Georgetown University Law Center and Johns Hopkins University School of Public Health

Vincent LaFronza, National Association of County and City Health Officials

Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
×

Tom Milne, National Association of County and City Health Officials

Eugene Seskin, Bureau of Economic Affairs

Barney Turnock, University of Illinois, Chicago

Abraham Wandersman, American Psychological Association

The committee would like to thank the numerous staff members of the Institute of Medicine (IOM), the National Research Council, and the National Academies Press who contributed to the development, production, and dissemination of this report. The committee is most grateful to Monica Ruiz, who did a remarkable job of directing the study until June 2002, and to Alina Baciu, who stepped up courageously to shepherd the report through the internal and external review process and to bring the study to successful completion. A special thanks to Lyla Hernandez, who participated fully in the study process and contributed significantly to the development of the chapter on academia (Chapter 8). Carolyn Fulco, Carrie Szlyk, Mark Smolinski, and Rick Erdtman also deserve special thanks for their writing contributions. Margaret Gallogly, Sylvia Martinez, Gretchen Opper, and Marc Ehman provided outstanding research support to the project staff. Lori Young and Rita Gaskins provided excellent administrative support through the study and coordinated committee meetings, organized site visits, and maintained project records and files. Judy Estep competently prepared the report for publication. Rose Marie Martinez and Susanne Stoiber provided guidance and assistance above and beyond the call of duty, including research and writing. Melissa French handled the financial accounting of the study until June 2002, and James Banihashemi handled the financial accounting from June through project completion. Jennifer Bitticks provided editorial assistance. Jennifer Otten, Hallie Willfert, Christine Stencel, and Barbara Rice provided assistance with report dissemination. We are especially grateful to Bronwyn Schrecker, Clyde Behney, and Janice Mehler for cheerfully and skillfully guiding the staff through the report review process.

In addition to IOM staff, we are most grateful to Katrina Abuabara for her assistance in preparing the data needed for the determinants of health discussion in Chapter 2 and to Ron Goetzel from Medstat, Inc., for his assistance in preparing the background paper for Chapter 5. Special thanks go to Stephen Fawcett, Irving Rootman, and Barney Turnock for their noteworthy contributions to Chapters 4 (Fawcett and Rootman) and 8 (Turnock). Great appreciation goes to Patricia Peacock for her editorial assistance with Chapter 6 and to Jane Durch for her invaluable assistance in editing the report as a whole.

This project was jointly sponsored by six Department of Health and Human Services agencies—the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the Health Resources and

Suggested Citation:"Front Matter." Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10548.
×

Services Administration (HRSA), the Substance Abuse and Mental Health Service Administration (SAMHSA), the Department of Health and Human Services (DHHS) Office of the Secretary, Assistant Secretary for Planning and Evaluation (DHHS/OS/ASPE), and the DHHS Office of Disease Prevention and Health Promotion (ODPHP)—which generously provided funding and lent support to this project. Our project liaisons—Edward Baker and Anthony Moulton (CDC)—were extraordinarily helpful in providing data, information, and support throughout the course of the study. Their encouragement and support are gratefully acknowledged.

REVIEWERS

The report was reviewed by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments to assist the authors and the Institute of Medicine in making the report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. The committee wishes to thank the following individuals for their participation in the report review process:

Bobbie Berkowitz, Ph.D., R.N., Turning Point National Program Office

Haile T. Debas, M.D., School of Medicine, University of California at San Francisco

Gordon DeFriese, Ph.D., School of Medicine, University of North Carolina at Chapel Hill

Lori Dorfman, Dr.P.H., Berkely Media Study Group

David P. Fidler, J.D., University of Indiana School of Law

Claude Earl Fox, M.D., M.P.H., Johns Hopkins Urban Health Institute

Fernando A. Guerra, M.D., M.P.H., San Antonio Metropolitan Health District

Andrew Holtz, independent media consultant

LaVohn E. Josten, Ph.D., R.N., F.A.A.N., Center for Child and Family Health Promotion Research, School of Nursing, University of Minnesota

Jeffrey Milyo, Ph.D., The Harris School, University of Chicago

William L. Roper, M.D., M.P.H., School of Public Health, University of North Carolina at Chapel Hill

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Mark A. Rothstein, J.D., Health Law and Policy Institute, University of Houston

Douglas Scutchfield, M.D., University of Kentucky Medical Center

Mary Selecky, Department of Health, Washington State

John D. Stobo, M.D., The University of Texas Medical Branch

S. Leonard Syme, Ph.D., School of Public Health, University of California at Berkeley

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by R. Don Blim, M.D., appointed by the Institute of Medicine, and Henry W. Riecken, Ph.D., appointed by the National Research Council’s Report Review Committee, who were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the Institute of Medicine.

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3

 

THE GOVERNMENTAL PUBLIC HEALTH INFRASTRUCTURE

 

96

   

Prior Assessments of the Public Health Infrastructure,

 

97

   

The Role of Governments in Public Health: An Overview and Legal Framework,

 

101

   

The Federal Public Health Infrastructure,

 

111

   

Critical Components of the Public Health Infrastructure,

 

116

   

Financing the Public Health Infrastructure,

 

147

   

Concluding Observations,

 

169

4

 

THE COMMUNITY

 

178

   

Defining the Community,

 

178

   

Community-Based Collaboration,

 

180

   

Framework for Collaborative Community Action on Health,

 

186

   

Evaluating and Researching Community Health Improvement,

 

199

   

Sustaining Community Action on Health,

 

201

   

Concluding Observations,

 

204

5

 

THE HEALTH CARE DELIVERY SYSTEM

 

212

   

Access to Health Care,

 

214

   

Neglected Care,

 

221

   

Problems in Quality of Care,

 

231

   

Capacity of the Health Care System to Serve the Population,

 

234

   

Collaboration with Governmental Public Health Agencies,

 

244

   

Collaboration with Other Public Health System Actors,

 

251

   

Implications of Growing Health Care Costs,

 

255

   

Concluding Observations,

 

257

6

 

EMPLOYERS AND BUSINESS

 

268

   

Employers’ Role in Health Insurance Coverage,

 

269

   

Employers’ Role in Assuring Health Care Quality,

 

271

   

Employer Interest in Promoting the Health of Employees: A Rationale for Corporate Investment in Health,

 

275

   

Role of Businesses and Industries in Promoting a Healthy Environment,

 

289

   

A Case for Improving the Health and Well-Being of Communities,

 

292

   

Concluding Observations,

 

300

7

 

MEDIA

 

307

   

News Media and the National Public Agenda,

 

308

   

News Media as a Catalyst to Promote Health at the Community Level,

 

311

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The Future of the Public's Health in the 21st Century Get This Book
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The anthrax incidents following the 9/11 terrorist attacks put the spotlight on the nation’s public health agencies, placing it under an unprecedented scrutiny that added new dimensions to the complex issues considered in this report.

The Future of the Public’s Health in the 21st Century reaffirms the vision of Healthy People 2010, and outlines a systems approach to assuring the nation’s health in practice, research, and policy. This approach focuses on joining the unique resources and perspectives of diverse sectors and entities and challenges these groups to work in a concerted, strategic way to promote and protect the public’s health.

Focusing on diverse partnerships as the framework for public health, the book discusses:

  • The need for a shift from an individual to a population-based approach in practice, research, policy, and community engagement.
  • The status of the governmental public health infrastructure and what needs to be improved, including its interface with the health care delivery system.
  • The roles nongovernment actors, such as academia, business, local communities and the media can play in creating a healthy nation.

    Providing an accessible analysis, this book will be important to public health policy-makers and practitioners, business and community leaders, health advocates, educators and journalists.

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