THE FUTUREOF THE PUBLIC’S HEALTH in the 21st Century
THE NATIONAL ACADEMIES PRESS
Washington, D.C. www.nap.edu
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.
Additional copies of this report are available from the
National Academies Press,
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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.
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.
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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.
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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,
Professor of Public Health,
Johns Hopkins University; and
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,
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
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
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
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
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
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
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
Without health there is no happiness.
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
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
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);
inform more strategic investments by grantmakers for population health improvement (Chapter 4); and
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,
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.
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
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
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
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.
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.
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
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
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.
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
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.