The committee's findings call attention to the fact that achieving the vision of healthy people in healthy communities is a difficult and complex task that cannot be accomplished through a single plan of action or by a single governmental agency or nongovernmental entity. Rather, broad societal action is required at every level; and such action needs to be better coordinated by all individuals, families and community members, businesses and workers, and health care providers and policy makers. Furthermore, responding to this vision requires a long-term public and political commitment to ensure that the policies, financial and organizational resources, and political and public wills are in place to assure the presence of the conditions necessary for all Americans to live longer, healthier lives. To support the creation of an effective intersectoral public health system, the committee identified six areas of action and change. These are reflected in the recommendations made to the potential public health system actors described in this report, but they are equally applicable to other components of the public health system not specifically addressed. Action and change are needed to:
1. Adopt a population health approach that builds on evidence of the multiple determinants of health;
2. Strengthen the governmental public health infrastructure—the backbone of any public health system;
3. Create a new generation of partnerships to build consensus on health priorities and support community and individual health actions;
4. Develop appropriate systems of accountability at all levels to ensure that population health goals are met;
5. Assure that action is based on evidence; and
6. Acknowledge communication as the key to forging partnerships, assuring accountability, and utilizing evidence for decision making and action.
The unique responsibility of government to assure action for health has been discussed and will be discussed further. The essence of the intersectoral public health system described in this report is partnerships linking those who contribute their expertise, resources, and perspectives to the process of assuring population health. Government agencies are subject to more formal systems of accountability through the political process, yet the success of specific activities for health depends on the setting of standards for program and workforce performance and in meeting the needs of the populations served. Emphasizing evidence as the basis for policies and programs acknowledges that information and data should form the basis for effective planning and decision making at all levels and among all partners within the public health system. There is strong and growing evidence that "healthy" public policy must include consideration of domains that are not traditionally associated with health but whose influences have health consequences (e.g., the education, business, housing, and transportation domains). Finally, improving communications is an essential component in the activities of all potential public health system actors. Improving communications capacity will involve, among other things, investment of resources, efficient adoption of cutting-edge technologies, training of workers, and even change in institutional cultures.
The vision of healthy people in healthy communities can be achieved only if the governmental backbone of the public health system is strong; intersectoral partnerships create environments and conditions conducive to the best population health; accountability is valued and practiced by all stakeholders; evidence is effectively developed, shared, and translated into practice; and effective communication becomes a priority among all public health partners. In the next section, we describe a number of contextual changes and trends that will influence the kinds of health problems we will face as a society and the strategies we select to address them.
BROAD TRENDS INFLUENCING THE NATION'S HEALTH
This report examines some reasons for the nation's current health status and proposes measures and actors that will help improve and continually assure the nation's health in the future. As noted, there is a need to transform social norms and strengthen the potential for more effective partnerships within a public health system to ensure that they will promote and protect population health. A number of factors create both opportuni ties and threats as we work to reach this goal. These include (1) population growth and demographic change (a population growing larger, older, and more racially and ethnically diverse, with a higher incidence of chronic disease); (2) unprecedented technological and scientific advances that create new channels for information and communication, as well as novel ways of preventing and treating disease; and (3) the geopolitical and economic challenge of globalization, including international terrorism (Brownson and Kreuter, 1997; Levy, 1998; Koplan and Fleming, 2000; McKinlay and Marceau, 2000). Some of these factors offer unprecedented opportunities for global and national health improvement, whereas others pose threats that make it more difficult to achieve the best conditions necessary for the nation's health.
The U.S. population will become much grayer in the twenty-first century, and strengthening community and individual capacities and resources to support good health at all ages will be essential. As the Baby Boom generation ages into retirement, the proportion of the U.S. population over age 65 is projected to reach 13.3 percent by 2010 and 18.5 percent by 2025 (Bureau of the Census, 1996; Campbell, 1997). In 21 states, the elderly population is expected to at least double between 1995 and 2025 (Campbell, 1997). The nation has also seen a doubling of the number of centenarians, from 30,000 to 60,000, over the past several years (Portnoi, 1999).
The graying of America doubtlessly will be accompanied by some changes in the population's needs for health care, long-term care, and other services. This trend especially underscores the importance of services and social supports to promote healthy aging. Although care needs for the elderly have declined somewhat in recent years, there are concerns about society's ability to respond effectively to the needs of this demographic group (Wolf, 2001). An aging population will require effective means of chronic disease prevention and management to help older people maintain the best possible levels of health and function. Although some health problems may be inevitable because of biologic and genetic factors, research is pointing to new opportunities for promoting health at older ages (Fried, 2000). For example, community-based interventions to support behavioral changes such as increases in physical activity and good nutrition may partially reverse some health damage and may help prevent the occurrence of additional problems (Andrews, 2001). Furthermore, earlier investments in health promotion and disease prevention could produce benefits at younger ages, before irreparable damage has occurred and before the chances for healthful, functional aging are reduced (Khaw, 1997; Andrews, 2001). Also, public policy could expand the social, economic, and lifestyle options avail able to aging populations (Jacobzone, 2000). Aging healthfully promises not only psychosocial benefits and the ability to remain functional and independent for as long as possible but may also result in medical cost savings (Reed et al., 1998).
The increasing number of elderly Americans will also draw increased attention to the need (shared by many others, including children and city dwellers) for adequate housing, safe and appropriate urban design, and for easily accessible transportation systems that allow for the continuation of both subsistence activities like grocery shopping and social interactions like participation in senior citizens' groups (NRC, 2001). Moreover, it has already given rise to a well-defined political constituency (e.g., through organizations like the American Association of Retired Persons [AARP]) and can be expected to influence the medical and population-level health research agendas (NRC, 2001).
The United States is also becoming more racially and ethnically diverse through both immigration and natural growth (Day, 1996). The proportion of the population accounted for by Hispanics, African Americans, Asian Americans and Pacific Islanders, and Native Americans is expected to rise from 28 percent in 2000 to 32 percent by 2010 (IFTF, 2000). Although diversity enriches American culture and strengthens America's democracy, it also challenges the systems that traditionally have provided for the health and welfare of American society. For example, minority groups are underrepresented among the population of health care professionals, and many health care workers are not sufficiently skilled in the delivery of culturally competent care. Additionally, the health system itself (as the broader sociocultural environment in which it is embedded) is characterized by complex undercurrents of pervasive inequities and institutional racism, which lead to stereotypes, biases, and uncertainties that result in unequal treatment of racial and ethnic minority patients (IOM, 2002). New immigrant groups also bring their own perceptions about the role of government, the meaning of community, and the definition of health and illness; and these must be considered in creating better ways to achieve a healthy nation.
Continuing disparities in health status and the outcomes of health care demonstrate the need for a greater effort to ensure equitable access to and services from the health care delivery system for people of different backgrounds (IOM, 2002). With an increasingly diverse population, the nation will need a more highly developed knowledge base concerning the social determinants of health and a continuing reassessment and improved understanding of the ways in which social, cultural, and ecological factors shape health behaviors and influence health status (IFTF, 2000).
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