KEY TERMS

Affordable Care Act (ACA)

Biotechnology

Health Insurance Portability and Accountability Act (HIPAA)

Healthy People 2020

Human Genome Project

Managed care organizations (MCOs)

Public Health Information Network (PHIN)

The United States in the 20th century saw great progress in public health. As a field of practice, public health has advanced in knowledge and methodology. Biomedical scientists have identified many of the organisms that cause infectious diseases and have developed methods to control them. Epidemiologists have recognized risk factors that lead to many chronic diseases, information that can be used to reduce people’s risk of illness. Efforts to clean up the environment have resulted in air and water that are much safer than they were a half-century ago. Intensive health education efforts have even persuaded Americans to improve some health-related behaviors, leading to reductions in tobacco use and drunk driving. The ability to assess the state of the public’s health and to evaluate the impact of medical and public health interventions has also advanced dramatically because of vast stores of health-related data and computer software capable of analyzing them. These achievements have greatly improved the health of Americans. The average lifespan has increased by 30 years since 1900 (when it was 47), and 25 of those years are attributed to improvements in public health.¹

In 1999, the Centers for Disease Control and Prevention (CDC) published a “top ten” list of great public health achievements of the 20th century.¹ These accomplishments were chosen for the positive impact they have had and will continue to have in reducing deaths, illnesses, and disabilities in the United States. Following is the CDC’s list (not in order of importance).

• Routine use of vaccination has resulted in a dramatic reduction in infectious diseases, including the eradication of smallpox; the elimination of polio in the Americas; and control of measles, rubella, tetanus, diphtheria, and a number of other infectious diseases in the United States and other parts of the world.

• Improvements in motor vehicle safety have contributed to large reductions in motor vehicle-related deaths. This has been achieved through engineering efforts to make vehicles and highways safer and through success in persuading people to adopt healthier behaviors, such as using seat belts, child safety seats, and motorcycle helmets, and to not drink and drive.

• Safer workplaces have resulted in a dramatic reduction in fatal occupational injuries—down 90 percent since 1933—and illness. This achievement results from improvements in safety in mines and in the manufacturing, construction, and transportation industries.

• Control of infectious diseases has been achieved by (in addition to vaccination) improved sanitation, cleaner water, safer food, the discovery of antibiotic drugs, and methods of epidemiologic surveillance and follow-up.

• A decline in deaths from heart disease and stroke has resulted from the identification of risk factors and people’s significant success in changing their behavior to reduce cholesterol levels and to stop smoking. Secondary prevention methods, such as early detection and treatment of high blood pressure, also contribute to the lower number of deaths.

• Safer and healthier foods have almost eliminated major nutritional deficiency diseases such as rickets, goiter, and pellagra in the United States. Microbial contamination of food has been reduced, and nutritional supplementation and labeling have made possible a healthier diet.

• Healthier mothers and babies are the result of better hygiene and nutrition; availability of antibiotics; greater access to health care, including prenatal care; and technologic advances in medicine. Since 1900, there has been a 90 percent reduction in the infant mortality rate and a 99 percent reduction in the maternal mortality rate.

• Access to family planning and contraceptive services has contributed to healthier mothers and babies through smaller family size and longer intervals between the birth of children; increased opportunities for preconception counseling and screening; and improved control of sexually transmitted diseases.

• Fluoridation of drinking water has reduced tooth decay in children by 40 percent to 70 percent, and tooth loss in adults has been reduced by 40 percent to 50 percent.

• Recognition of tobacco use as a health hazard and subsequent public health antismoking campaigns have helped to prevent people from beginning to smoke, have promoted quitting, and have reduced exposure to environmental (second-hand) tobacco smoke. The resulting decrease in the prevalence of smoking among adults has prevented millions of smoking-related deaths.

Challenges for the 21st Century

In the early 21st century, public health faces many challenges, both old and new. There are renewed threats from infectious diseases, such as AIDS, antibiotic resistance, and foodborne pathogens. The global economy has increased Americans’ vulnerability to many of the health threats faced by residents of less developed nations, brought about by international travel and by imported agricultural products. Paradoxically, past successes have led to new threats, such as climate change caused by overpopulation and economic development, and rising costs of medical care for the aging population. The challenge of understanding and altering human behavior—the factor that now contributes most substantially to premature mortality—remains to be confronted by the public health practitioners of the 21st century. The decline in cigarette smoking has slowed; rates of alcohol and illicit drug use among adolescents are largely unchanged over the past decades; physical inactivity and unhealthy diets contribute to the increasing prevalence of obesity among Americans; and injury is still a major cause of death.²

Ironically, the successes of public health in the 20th century led to cutbacks in resources and support for preventive activities. During the second half of the century, the medical approach—curing health problems rather than preventing them—gained acceptance. Public health’s many achievements, including those described above, were taken for granted while rapidly increasing resources were devoted to medical care. This problem was recognized in the Institute of Medicine’s (IOM’) 1988 report, The Future of Public Health.³ This report prompted public health agencies, policy makers, and academic institutions to initiate a national discussion on the role of public health and the steps necessary to strengthen its capacity to fulfill its role. Attempts were made to coordinate public health efforts at various levels of government, to develop public–private partnerships in communities, and to undertake strategic planning aimed at achieving defined goals and objectives. The IOM undertook a new analysis in 2003 to follow up on the 1988 report and made recommendations for enhancing understanding of public health and developing a framework for assuring the public’s health in the new century.⁴

The events of fall 2001, particularly the bioterrorist attacks using anthrax, brought new attention to the American public health system and revealed the weaknesses in the public health infrastructure—workforce, information systems, laboratories, and other organizational capacity—which was suffering from neglect. It became clear to policy makers and the public that the public health system is the front line of defense in protecting the population from bioterrorism and other threats. Concerns about preparedness led to a flow of federal funds into public health agencies and activities. These funds have helped state and local agencies to begin strengthening their capacity to respond to public health challenges; however, public health officials are concerned as to whether the efforts can be sustained. Budget deficits at the federal and state levels threaten to derail the upgrades just when their importance is being recognized. The IOM’s report, The Future of the Public’s Health in the 21st Century, was published in 2003 and includes lessons learned from the 2001 attacks.⁴

The 2003 report stated that, “the public health system that was in disarray in 1988 remains in disarray today.”^4(p.100) It noted that the United States was not meeting its potential in the area of population health, in part because of the nation’s emphasis on (1) medical care rather than preventive services and (2) biomedical research rather than prevention research. It also noted the serious and persistent disparities in health status among various population groups, according to race and ethnicity, gender, and socioeconomic status. The report recommended that the public health workforce needs better education and training, that changes are needed in public health laws to bring them up-to-date and to ensure better coordination among states and territories, and that advances in information technology should be used more effectively to provide adequate surveillance and communication. Although the resources to rectify some of the deficiencies have been provided in the wake of 9/11, the IOM report stressed the need for these efforts to be sustained for the long term.

In 2009, the IOM again considered the state of public health in the United States and produced a report called For the Public’s Health: Investing in a Healthier Future, concluding that the health system’s failure to develop and deliver effective prevention strategies continues to take a toll on the economy and society. Public health departments should be the backbone of the health system, the report said, but they need adequate funding to do so. The report recommended that all public health agencies develop a minimum package of public health services that all health departments should deliver, and that Congress should authorize a dedicated, stable, and long-term financing structure to generate the revenue required to deliver this minimum package of services. As a source of this revenue, the report suggested a tax on all healthcare transactions.⁵

Strategic Planning for Public Health

With so many different agencies at so many different political and organizational levels involved in implementing public health’s mission, it became apparent some time ago that there was a need for planning and coordination. Beginning in 1979, the U.S. Public Health Service adopted “management by objectives,” a process that was becoming increasingly widespread in the private sector. This technique requires that managers jointly define a set of measurable goals, use these goals as a guide to their actions, and regularly measure progress toward achieving them. The management-by-objectives approach is especially useful in decentralized organizations, where many different actors must coordinate their efforts, and thus is well suited to the needs of the public health system.⁶

To develop goals for the year 1990, the Public Health Service enlisted a broad range of participants from both within and outside of government to specify a set of health status objectives. The national goals, published as Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention,⁷ set targets for reducing mortality rates in different age groups, with specific objectives designed to meet each target. For example, to achieve the goal of a 25 percent death rate reduction for ages 25 through 64, progress had to be made in reducing the prevalence of cigarette smoking, high blood cholesterol, and high blood pressure among adults. Any state, community, or research group that applied for federal funds for a public health program had to justify its request by showing how its project would contribute to achieving one or more of the Healthy People goals. When the results of the first planning cycle were tallied in 1990, the numerical mortality goals were met for three of the four age groups: infants, children, and adults aged 25 through 64. Only targets for adolescents and young adults were not met, because of continued high rates of fatal motor vehicle injuries, homicides, and suicides.⁶

The Healthy People planning process encourages states and local communities to use the national objectives as a basis for developing objectives of their own. One problem that became obvious during the first decade of the program was a lack of data systems that could track progress, especially at the local level.

In 1987, the Public Health Service began the process of setting objectives for the following decade. Healthy People 2000, a 692-page book sets three overall goals, with over 300 measurable objectives divided into 22 priority areas.⁸ As in the previous Healthy People publication, these objectives set targets for individual behavioral change, environmental and regulatory protections, and access to preventive health services. Healthy People 2000 also addressed the problem of inadequate data, which had hindered evaluation of progress toward the 1990 objectives. Implementing, tracking, and reporting on the goals and objectives involved many agencies of the federal government, as well as hundreds of state agencies, national organizations, academic institutions, and business groups. Most states developed their own year 2000 objectives. The individual states’ objectives either paralleled or modified the national objectives to suit the states’ own needs and priorities.

In 2001, a final review was published that evaluated the nation’s progress in meeting the Healthy People 2000 objectives.⁹ Progress was achieved on over 60 percent of the objectives. Targets were met in reducing deaths from coronary heart disease and cancer, reducing AIDS incidence, and reducing homicide, suicide, and firearm-related deaths. Tobacco-related mortality targets were met. Goals for infant mortality and the number of children with elevated blood lead levels were nearly met. There was progress toward reducing health disparities. However, for 15 percent of the Healthy People 2000 objectives, the nation moved away from the report’s targets. Notably, these included the prevalence of overweight and obesity, especially among adolescents, an ominous sign for the future health of Americans.

Healthy People 2010, launched in January 2000, set public health goals and objectives even higher.¹⁰ Healthy People 2010 had two overall goals:

1. Increase quality and years of healthy life.

2. Eliminate health disparities.

These were similar to the goals of Healthy People 2000, except that the first goal placed a new focus on quality of life, and the second goal no longer set different targets for racial and ethnic minorities, aiming to ensure that all groups in the United States will be equally healthy.

Healthy People 2010 was organized into 28 focus areas, many of which were the same as the priority areas in Healthy People 2000. In addition, a set of 10 leading health indicators, were chosen as areas of special focus. These indicators, which included such behavioral factors as physical activity and responsible sexual behavior, as well as environmental quality and access to health care, were based on their ability to motivate action, the availability of data to measure their progress, and their relevance as broad public health issues.

A final review of Healthy People 2010 was published in 2011, assessing progress in achieving the objectives in each of the 28 focus areas, as well as a summary of progress for the leading health indicators and the two goals. Also, for each objective, the review summarized disparities by race and ethnicity, sex, education level, income, geographic location, and disability status whenever data was available.¹⁰

For eight of the focus areas, more than 75 percent of the objectives moved toward, met, or exceeded their 2010 targets. These areas included health communication, heart disease and stroke, immunization and infectious diseases, occupational safety and health, and tobacco use. For five of the focus areas, more than 30 percent of the objectives could not be assessed because of lack of data. Two focus areas—arthritis, osteoporosis, and chronic back conditions, and nutrition and overweight—moved toward or achieved less than 25 percent of their targets.

In assessing the first goal of Healthy People 2010—quality and years of healthy life—years of life continue to improve, especially in the older population, but measures of quality yielded mixed results. There were slight improvements in “years in good or better health” and “expected years free of activity limitations.” However, “expected years free of selected chronic conditions” declined. The second goal, eliminating health disparities, did not show evidence of systematic improvement. Status on the objectives was improving for most populations, but the differences among the groups were generally not declining.¹¹

As 2010 approached, the public health community mobilized to launch the process for Healthy People 2020. There were four overarching goals:

• Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.

• Achieve health equity, eliminate disparities, and improve the health of all groups.

• Create social and physical environments that promote good health for all.

• Promote quality of life, health development, and health behaviors across all life stages.

Final 2020 goals and objectives were released in December 2010.¹² Healthy People 2020 has replaced the traditional print publication with an interactive website, http://www.healthypeople.gov. There are 42 topic areas, with more than 1200 objectives. A set of 26 leading health indicators was chosen as high priority health issues. The website allows ongoing tracking of progress toward meeting the targets. The Healthy People 2020 topic areas are listed in Box 31-1.

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