Executive Summary

The beginning of the twenty-first century provided an early preview of the health challenges that the United States will face in the coming decades. The systems and entities that protect and promote the public's health, already challenged by problems like obesity, toxic environments, a large uninsured population, and health disparities, must also confront emerging threats, such as antimicrobial resistance and bioterrorism. The social, cultural, and global contexts of the nation's health are also undergoing rapid and dramatic change. Scientific and technological advances, such as genomics and informatics, extend the limits of knowledge and human potential more rapidly than their implications can be absorbed and acted upon. At the same time, people, products, and germs migrate and the nation's demographics are shifting in ways that challenge public and private resources. Against this background, the Committee on Assuring the Health of the Public in the 21st Century was charged with describing a framework for assuring the public's health in the new century.

The report reviews national health achievements in recent decades, but also examines the hidden vulnerabilities that undercut current health potential, and that, if not addressed, could produce a decline in the future health status of the American people. The concept of health as a public good is discussed, as is the fundamental duty of government to promote and protect the health of the public. The report describes the rationale for multisectoral engagement in partnership with government and the roles that different actors can play to support a healthy future for the American people. Finally, it describes major trends that are likely to influence the nation's health in the coming decades.

The committee's work began with a vision—healthy people in healthy communities. This is not a new idea, but it is the guiding vision of Healthy People 2010, the health agenda for the nation. The committee embraced that vision and began discussing who should be responsible for assuring America's health at the beginning of the twenty-first century—a duty historically assigned to governmental public health agencies, through the work of national, state, tribal, and local departments of health. Current realities indicate that this is no longer sufficient. On the one hand, government has a unique responsibility to promote and protect the health of the people built on a constitutional, theoretical, and practical foundation. However, governmental public health agencies alone cannot assure the nation's health. First, public resources are finite, and the public's health is just one of many priorities. Second, democratic societies define and limit the types of actions that can be undertaken only by government and reserve other social choices for private institutions. Third, the determinants that interact to create good or ill health derive from various sources and sectors. Among other factors, health is shaped by laws and policies, employment and income, and social norms and influences (McGinnis et al., 2002). Fourth, there is a growing recognition that individuals, communities, and various social institutions can form powerful collaborative relationships to improve health that government alone cannot replicate.

Health is a primary public good because many aspects of human potential such as employment, social relationships, and political participation are contingent on it. In view of the value of health to employers, business, communities, and society in general, creating the conditions for people to be healthy should also be a shared social goal. The special role of government must be allied with the contributions of other sectors of society. This report builds on the foundation of the Future of Public Health report, which asserted that public health is "what we as a society do collectively to assure the conditions in which people can be healthy" (IOM, 1988). In addition to assessing the state and needs of the governmental public health infrastructure—the backbone of the public health system—this report also focuses on the roles and actions of other entities that could be potential partners within such a system.

The emphasis on an intersectoral public health system does not supersede the special duty of the governmental public health agencies but, rather, complements it with a call for the contributions of other sectors of society that have enormous power to influence health. A public health system would include the governmental public health agencies, the health care delivery system, and the public health and health sciences academia, sectors that are heavily engaged and more clearly identified with health activities. The committee has also identified communities and their many entities (e.g., schools, organizations, and religious congregations), businesses and employers, and the media as potential actors in the public health system. Businesses play important, often dual, roles in shaping population health. In the occupational setting, through environmental impacts, as members of communities, and as purveyors of products available for mass consumption, businesses may undermine health by polluting, spreading environmental toxicants, and producing or marketing products detrimental to health. However, businesses can and often do take steps to contribute to population health through efforts such as facilitating economic development and regional employment and workplace-specific contributions such as health promotion and the provision of health care benefits. The media is also featured because of its deeply influential role as a conduit for information and as a shaper of public opinion about health and related matters.

The events of the autumn of 2001 placed the governmental public health infrastructure under unprecedented public and political scrutiny. Although motivated by concern about its preparedness to respond to a potential crisis, this scrutiny offered an opportunity to assess the overall adequacy of the governmental public health infrastructure to promote and protect the public's health in the new century. This status check revealed facts that were well known to the public health community but that surprised many policy makers and much of the public. The governmental public health infrastructure has suffered from political neglect and from the pressure of political agendas and public opinion that frequently override empirical evidence. Under the glare of a national crisis, policy makers and the public became aware of vulnerable and outdated health information systems and technologies, an insufficient and inadequately trained public health workforce, antiquated laboratory capacity, a lack of real-time surveillance and epidemiological systems, ineffective and fragmented communications networks, incomplete domestic preparedness and emergency response capabilities, and communities without access to essential public health services. These problems leave the nation's health vulnerable—and not only to exotic germs and bioterrorism. The health of the public is also at risk when social and other environmental conditions undermine health, including toxic water, air, and housing; inaccurate and confusing health information; poverty; a lack of health care; and unequal opportunities for health. Government's partners, potential actors in the public health system, can contribute to assuring population health by helping to change the conditions for health in communities, at work, and through the media.

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