When most Americans think about the health system, they tend to focus on the diagnosis of disease and medical treatment. But the health of Americans is largely determined by other factors, including human biology, personal risk behaviors, and hazards on the job and in the environment. One important measure of health is the extent to which early deaths are prevented. Various estimates suggest that only about 10 percent of all early deaths in this country can be prevented by medical treatment. By contrast, population-wide public health approaches have the potential to help prevent 70 percent of these deaths, through measures that target underlying risks, such as tobacco, drug, and alcohol use; diet and sedentary lifestyles; and environmental factors (3).
Over the past 200 years, major advances in the health and longevity of the American people have resulted from public health interventions designed to reduce or eliminate significant threats to the health of communities. Examples include the creation of safe water and sewage disposal systems, the control of disease-bearing insects and rodents, immunization of the population, the identification and rapid control of disease outbreaks, and the establishment and enforcement of safe food processing and handling practices. In an era of global drug-resistant diseases, complex environmental exposures, and new insight into the ways that genetics and lifestyle choices contribute to disease and disability, the public health mission -- to identify and address community health problems -- becomes more difficult and more critical.
In spite of the importance of population-based public health services, years of neglect are compromising the capability of many communities in the United States to provide them. Most providers and consumers think of the public health system only in terms of providing medical services to the poor. Few have a clear understanding of the population-based (i.e., nonclinical) functions that national, state, and local public health agencies perform or how these functions support them. Realizing the potential of population-based interventions to protect and improve health requires that policymakers and the public have a clearer understanding of who is involved in public health, what they do, and the benefits that result from their actions. Only then can the types of resources that public health needs -- including information technology -- be appreciated and addressed.
Because public health focuses on promoting healthy people in healthy communities, those with important roles to play encompass not only public health agencies at various levels, but also a broad range of individuals; health professionals and institutions; and public and private organizations. Working together, these parties prevent epidemics and the spread of disease, protect against environmental hazards, prevent injuries, promote and encourage healthy behaviors and mental health, respond to disasters and assist communities in recovery, and assure the quality and accessibility of health services. To accomplish these ends, the public health community needs to carry out the following essential services (4):
- monitor health status to identify community health problems;
- diagnose and investigate health problems and health hazards in the community;
- inform, educate, and empower people about health issues;
- mobilize community partnerships to identify and solve health problems;
- develop policies and plans that support individual and community health efforts;
- enforce laws and regulations that protect health and ensure safety;
- link people to needed personal health services and assure the provision of health care when otherwise unavailable;
- assure a competent public health and personal health care workforce;
- evaluate the effectiveness, accessibility, and quality of personal and population-based health services; and
- conduct research to identify new insights and innovative solutions to health problems.
As the health care system increasingly shifts towards a population-based focus, the interests of public health and the health care sector are beginning to converge. With the growth of managed-care plans responsible for defined populations of enrollees, and the emergence of health plan "report cards", the health care system is becoming a more suitable vehicle for achieving certain public health objectives (such as the delivery of clinical preventive services). With payments based on capitation, health plans have an incentive to care about population health because they benefit financially to the extent that either they or the public health system keep their enrollees healthy. And with managed-care plans taking over the care of vulnerable populations, such as Medicaid beneficiaries, public health agencies are becoming responsible for assuring that the enrollees of these plans receive appropriate services. As both the interests and populations-of-interest in these two sectors converge, there is a real opportunity to integrate health promotion and disease prevention into health care delivery. To move in this direction, health care organizations and the public health community will need to coordinate not only their roles and responsibilities, but also their information systems.