The Future of the Public's Health in the 21st Century by Committee on Assuring the Health of the Public in the 21st Century

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Copyright © 2003 National Academy of Sciences
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ISBN: 978-0-309-08622-6

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.

AREAS OF ACTION AND CHANGE

To address the present and future challenges faced by the nation's public health system-including potential actors in the private and nonprofit sectors-this report proposes six areas of action and change to be undertaken by all who work to assure population health. These areas include

1. Adopting a population health approach that considers the multiple determinants of health;

2. Strengthening the governmental public health infrastructure, which forms the backbone of the public health system;

3. Building a new generation of intersectoral partnerships that also draw on the perspectives and resources of diverse communities and actively engage them in health action;

4. Developing systems of accountability to assure the quality and availability of public health services;

5. Making evidence the foundation of decision making and the measure of success; and

6. Enhancing and facilitating communication within the public health system (e.g., among all levels of the governmental public health infrastructure and between public health professionals and community members).

FINDINGS AND RECOMMENDATIONS

Governmental Public Health Infrastructure

Finding: Public health law at the federal, state, and local levels is often outdated and internally inconsistent. This leads to inefficiency and a lack of coordination and may even pose a danger in a crisis requiring an immediate and effective public health response. Pioneering work at the national level has gone into developing models and guidance to assist states in reforming their public health laws as appropriate for their unique legal structures and public health preparedness needs, but a more comprehensive effort is needed.

1. The Secretary of the Department of Health and Human Services (DHHS), in consultation with states, should appoint a national commission to develop a framework and recommendations for state public health law reform. In particular, the national commission would review all existing public health law as well as the Turning Point Model State Public Health Act and the Model State Emergency Health Powers Act; provide guidance and technical assistance to help states reform their laws to meet modern scientific and legal standards; and help foster greater consistency within and among states, especially in their approach to different health threats (Chapter 3).

Finding: The public health workforce must have appropriate education and training to perform its role. Today, a majority of governmental public health workers have little or no training in public health. Enhancing the knowledge and skills of governmental public health workers and nongovernmental workers who perform public health functions is necessary to ensure that essential public health services are competently delivered. Assessing and strengthening competence will help to ensure workforce preparedness, nurture leadership, and assure the quality of public health services.

2. All federal, state, and local governmental public health agencies should develop strategies to ensure that public health workers who are involved in the provision of essential public health services demonstrate mastery of the core public health competencies appropriate to their jobs. The Council on Linkages between Academia and Public Health Practice should also encourage the competency development of public health professionals working in public health system roles in for-profit and nongovernmental entities (Chapter 3).

3. Congress should designate funds for the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) to periodically assess the preparedness of the public health workforce, to document the training necessary to meet basic competency expectations, and to advise on the funding necessary to provide such training (Chapter 3).

4. Leadership training, support, and development should be a high priority for governmental public health agencies and other organizations in the public health system and for schools of public health that supply the public health infrastructure with its professionals and leaders (Chapter 3).

5. A formal national dialogue should be initiated to address the issue of public health workforce credentialing. The Secretary of DHHS should appoint a national commission on public health workforce credentialing to lead this dialogue. The commission should be charged to determine if a credentialing system would further the goal of creating a competent workforce and, if applicable, the manner and time frame for implementation by governmental public health agencies at all levels. The dialogue should include representatives from federal, state, and local public health agencies, academia, and public health professional organizations who can represent and discuss the various perspectives on the workforce credentialing debate (Chapter 3).

Finding: Developments in communication and information technologies present both opportunities and challenges to attaining the vision of healthy people in healthy communities. Harnessing the potential of these technologies will enable public health officials to collect and disseminate information more efficiently, improve the effectiveness of public health interventions, and enable the public to understand what services should be provided, and thus what they have the right to expect from their public officials.

6. All partners within the public health system should place special emphasis on communication as a critical core competency of public health practice. Governmental public health agencies at all levels should use existing and emerging tools (including information technologies) for effective management of public health information and for internal and external communication. To be effective, such communication must be culturally appropriate and suitable to the literacy levels of the individuals in the communities they serve (Chapter 3).

Finding: Existing information networks make it difficult, and sometimes impossible, for governmental public health agencies to exchange information and communicate effectively with the health care delivery system for the purposes of surveillance, reporting, and appropriately responding to threats to the public's health. Clear communication and enhanced information gathering, processing, and dissemination mechanisms will increase the accountability and effectiveness of governmental public health agencies and other public health system actors. Individuals and communities may also benefit by being able to contribute and collect information directly relevant to them.

7. The Secretary of DHHS should provide leadership to facilitate the development and implementation of the National Health Information Infrastructure (NHII). Implementation of NHII should take into account, where possible, the findings and recommendations of the National Committee on Vital and Health Statistics (NCVHS) working group on NHII. Congress should consider options for funding the development and deployment of NHII (e.g., in support of clinical care, health information for the public, and public health practice and research) through payment changes, tax credits, subsidized loans, or grants (Chapter 3).

Finding: At this time, DHHS lacks a system for conducting regular assessments of the adequacy and capacity of the governmental public health infrastructure. Such assessments are urgently needed to keep Congress and the public informed and would play an important role in supporting a regular process of assessment and evaluation at state and local public health agency levels.

8. DHHS should be accountable for assessing the state of the nation's governmental public health infrastructure and its capacity to provide the essential public health services to every community and for reporting that assessment annually to Congress and the nation. The assessment should include a thorough evaluation of federal, state, and local funding for the nation's governmental public health infrastructure and should be conducted in collaboration with state and local officials. The assessment should identify strengths and gaps and serve as the basis for plans to develop a funding and technical assistance plan to assure sustainability. The public availability of these reports will enable state and local public health agencies to use them for continual self-assessment and evaluation (Chapter 3).

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