Medical science continues to advance, but that alone is not sufficient to improve the public's health. What must be done to apply our knowledge in ways that benefit the most people.
Research to understand the psychological and emotional processes of aging is essential to creating a society in which the elderly can thrive. The 20th century witnessed two profound changes in regions of the world where people are well educated and science and technology flourish: Life expectancy nearly doubled, and fertility rates fell dramatically. As a result, individuals and populations are aging.
The nature and extent of the illegal drug problems in the United States have fundamentally changed during the past two decades; now policy needs to change as well. The United States will soon surpass the half-million mark for drug prisoners, which is more than 10 times as many as in 1980. It is an extraordinary number, more than Western Europe locks up for all criminal offenses combined and more than the pre-Katrina population of New Orleans. How effective is this level of imprisonment in controlling drug problems? Could we get by with, say, just a quarter million locked up for drug violations?
Federal research, economic incentives for industry, and a more responsive regulatory regime will all be necessary to produce a timely and widely available vaccine. Vaccination to prevent viral and bacterial diseases is modern medicine’s most cost-effective intervention. Were a vaccine to be available quickly after the onset of the widely predicted pandemic from an H5N1 strain of avian influenza, it might save scores of millions of lives worldwide. But that option is not feasible.
The U.S. health care system must pay more attention to providing quality care to people with mental problems or substance-use conditions. Each year, more than 33 million U.S. residents receive health care for mental problems and/or for conditions resulting from the use of alcohol, illegal drugs, or prescription medications. The total comprises approximately 20% of working-age adults, a nearly identical portion of adolescents, and 6% of children. Millions more people need care but for various reasons do not receive treatment. For example, although more than 3 million people aged 12 or older received treatment in 2003 for alcohol or drug use, more than six times that number—9% of this age group—reported abusing or being physiologically dependent on alcohol, illicit drugs, prescription drugs, or a combination of these.
Government needs to ensure that genetic tests provide useful medical information and that the test results are reliable. Currently, the government exercises only limited oversight of the analytic validity of genetic tests (whether they accurately identify a particular mutation) and virtually no oversight of the clinical validity of genetic tests (whether they provide information relevant to health and disease in a patient). To the extent that oversight exists, it is distributed among several agencies, with little interagency coordination. As a result, no clear regulatory mechanism exists to guide the transition of tests from research to clinical practice, or to ensure that tests offered to patients are analytically or clinically valid. In order to protect consumers, and to help advance the potential benefits offered by genetic testing, government action is urgently needed.
Public health officials have been quick to adopt this new tool for identifying emerging problems, but research is needed to assess its effectiveness. Heightened awareness of the risks of bioterrorism since 9/11 coupled with a growing concern about naturally emerging and reemerging diseases such as West Nile, severe acute respiratory syndrome (SARS), and pandemic influenza have led public health policymakers to realize the need for early warning systems. The sooner health officials know about an attack or a natural disease outbreak, the sooner they can treat those who have already been exposed to the pathogen to minimize the health consequences, vaccinate some or all of the population to prevent further infection, and identify and isolate cases to prevent further transmission. Early warning systems are especially important for bioterrorism because, unlike other forms of terrorism, it may not be clear that an attack has taken place until people start becoming ill. Moreover, if terrorism is the cause, early detection might also help to identify the perpetrators.
Potential benefits depend on linking genetic and environmental data in designing research, developing applications, and forging public policies. Breakthroughs in biology are changing our world. Just as chemistry and physics had broad ramifications in the preceding centuries, the New Biology unleashed by the Human Genome Project and associated developments will send ripples through many aspects of 21stcentury life and will be influential in improving the health of the public. The public health sciences will be essential for interpreting the health significance of genetic variation and the gene/environment interactions at the core of most diseases and biological phenomena. The combination of genomics and public health sciences will be critical to achieve the vision of predictive, personalized, preventive health care and community health services (Table 1).
The nation must act now, or it will watch its children grow into adults with excessive levels of diabetes, heart disease, cancer, and other weight-related ailments. After improving dramatically during the past century, the health of children and youth in the United States now faces a dangerous setback: an epidemic of obesity. It is occurring in boys and girls in every state, in younger children and adolescents, across all socioeconomic strata, and among all ethnic groups. Traditionally, most people have considered weight to be a personal statistic, of concern only to themselves or, on occasion, to their physicians. Both science and statistics, however, argue that this view must change. As researchers learn ever more about the health risks of obesity, the rise in the prevalence of obesity in children—and in adults as well—is increasingly becoming a major concern to society at large and hence a public health problem demanding national attention.
A broad vision of population health is the most effective path to improved health for individuals. The fall 2004 decision by NBC to introduce a new TV program dramatizing the fight against emerging disease threats might be taken as a sign of rising glamour for the public health professions. Modeled on the successful format of ratings winners such as ER and CSI, the series Medical Investigation features a cast of young, dashing, and sometimes overbearing personalities devoted to saving lives and unraveling mysteries, all while spouting a steady stream of technical jargon as they combat threats ranging from “Blue Man” syndrome to Legionnaire’s disease.
The National Campaign to Prevent Teen Pregnancy was organized in 1996 by a diverse group of individuals who had concluded that the problem of teen pregnancy was not receiving the intense national focus that it deserved; that too few Americans understood the central role that teen pregnancy plays in child poverty, out-of-wedlock childbearing, and welfare dependence; and that there was merit in raising the profile of this problem and in pushing hard for solutions. At its first meeting, the National Campaign’s board defined the organization’s mission: to improve the well-being of children, youth, and families by reducing teen pregnancy. The board also set a numerical goal for the nation and the National Campaign: to reduce the rate of teen pregnancy by onethird between 1996 and 2005.
The legal system provides many tools to promote public health, but it includes necessary limits to protect individual rights. Public health law is experiencing a renaissance. Once fashionable during the Industrial and Progressive eras, the ideals of population health began to wither in the late 20th century. In their place came a sharpened focus on personal and economic freedom. Political attention shifted from population health to individual health and from public health programs to private medicine. Signs of revitalization of the field of public health law can be seen in diverse national and global contexts. The Centers for Disease Control and Prevention (CDC) created a center of excellence in public health law—the Center for Law & the Public’s Health (www.publichealthlaw.net)—and other nations have followed suit. In the aftermath of September 11 and the anthrax attacks, the CDC requested the drafting of the Model State Emergency Health Powers Act, now adopted in whole or in part by 37 states. A consortium of state and federal partners then drafted the “Turning Point” Model Public Health Act, which outlines a modern mission, core functions, and essential services for public health agencies. At the global level, the World Health Organization (WHO) is revising the International Health Regulations and preparing a WHO Model Public Health Act to Advance the Millennium Development Goals.
Today’s system for developing and approving drugs is fundamentally flawed. Fixing it will require new technological tools and new regulatory approaches. The pharmaceutical industry is one of the most successful components of the U.S. economy. In recent years, however, critics have increasingly blamed the industry for setting prices too high, for earning too much profit, and for developing more “me too” drugs than truly innovative therapies. High prices have led private citizens, organizations, municipalities, and states to purchase prescription drugs from Canada, and they have prompted Congress to consider legalizing the reimportation of drugs, a serious threat to the future viability of the industry.
Building in-country research capacity is critical to staving off epidemics and finding long-term solutions to critical health needs. International initiatives to combat diseases have proliferated, in some cases dramatically, during the past decade. For example, world spending on HIV/AIDS has increased from 0 million in 1996 to about billion in 2003. President Bush’s Emergency Plan for AIDS Relief alone has promised to deliver billion during the next five years to combat the epidemic.
The axing of a key data collection program is a major setback for effective policymaking. Not knowing about the actual patterns of illicit drug abuse and drug distribution cripples policymaking. As the subtitle of a National Academies report put it four years ago, "What We Don't Know Keeps Hurting Us." (Currently, we don't even know whether the total dollar volume of illicit drug sales is going up or down from one year to the next.) It hurts more when the most cost-effective data collection programs are killed, as happened recently to the Arrestee Drug Abuse Monitoring (ADAM) program of the National Institute of Justice (NIJ).
All countries must adopt uniform and enforceable public health standards to stop the spread of infectious disease. In June 2003, some 80 people in three Midwestern states were stricken with monkeypox. Until then, the disease--a sometimes fatal viral infection related to smallpox--had never been seen outside Central and West Africa. In the United States, the virus is believed to have spread to humans from pet prairie dogs, which in turn were likely infected by a giant Gambian rat held by a Chicago exotic pet dealer. So far, no one has died. But if the outbreak is confirmed to be an inadvertent byproduct of trade, then it is yet another warning sign of the growing international exchange of viruses.
The past two decades have seen major economic changes in the health care system in the United States, but no solution has been found for the basic problem of cost control. Per-capita medical expenditures increased at an inflation-corrected rate of about 5 to 7 percent per year during most of this period, with health care costs consuming an ever-growing fraction of the gross national product. The rate of increase slowed a little for several years during the 1990s, with the spread of managed care programs. But the rate is now increasing more rapidly than ever, and control of medical costs has reemerged as a major national imperative. Failure to solve this problem has resulted in most of the other critical defects in the health care system.
We now know a great deal about the factors that allow novel infections to originate and spread. Major outbreaks during the past decade, including those of hantavirus pulmonary syndrome, Ebola, hemolytic uremic syndrome, West Nile, and (currently) severe acute respiratory syndrome (SARS), all followed the same pattern.
Thomas Jefferson was unequivocal: "Without health, there is no happiness. An attention to health, then, should take the place of every other object." During the past two decades, the association of health and quality of life has been underscored by developments that not only have meant better health for individuals but also have positioned the United States on the doorstep of transformational change in notions of good health and how it is determined. It has become clear that health is not just a matter of biology and medical care, but of behavior, of environment, and of social conditions. Along with these insights have come important new opportunities and priorities.
Much has happened during the past decade that has affected the quality of education received by underrepresented minority groups (African Americans, Alaska Natives, American Indians, Mexican Americans, and Puerto Ricans). Educational progress has been made on several fronts for these groups, even while significant increases in their numbers and diversity have occurred. Challenges remain in several areas, however. In addition, efforts are underway to undermine the progress that has taken place.
The late 1980s were not good times for New York's Harlem or the other disadvantaged urban communities in the United States. Two linked epidemics, one posed by the human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/ AIDS) and the other by crack/cocaine, had shredded the already tattered social structure of these communities and threatened to destroy a generation of children.
Fifteen years ago, the research agenda delineated in these pages regarding the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) stressed the importance of a diverse and robust scientific portfolio. It included basic studies of the molecular biology, natural history, epidemiology, and pathogenesis of HIV, as well as applied research to develop therapies for HIV-infected individuals and effective ways of preventing transmission of the virus.
Forecasting the future of health care and health policy is an imperfect science. Among the predictions made in the mid-1980s were that there would be a physician surplus, a growing number of elderly people, an increase in the number of people in managed care plans, restructured health benefits, new technologies, more for-profit health care delivery, rising health care costs, and a restrained federal government role. All of these issues--with the exception of a physician surplus, which is still being debated--turned out to have an impact on health policy. Several of these will continue to challenge policymakers during the next decade, and new or reemerging issues will also pose challenges.
As a result of the growth and aging of the U.S. population, more Americans died of cancer in 1999 than in any previous year. Yet mere numbers do not by any means reflect the true state of our war against cancer. I have long argued that cancer statistics can be quite misleading and that only an age-adjusted mortality rate--one that takes into account the growth and aging of the population--allows for fair comparisons between different populations and different years.
More systemic protection is needed to guard against the deliberate or inadvertent creation of advanced disease agents. Remarkable advances are underway in the biological sciences. One can credibly imagine the eradication of a number of known diseases, but also the deliberate or inadvertent creation of new disease agents that are dramatically more dangerous than those that currently exist. Depending on how the same basic knowledge is applied, millions of lives might be enhanced, saved, degraded, or lost.
Demand for high-quality care will increase only when consumers have better information about child care and stronger economic incentives to purchase excellent care. Child care in the United States is, by many standards, in poor shape. Commonly heard complaints include that today's system of child care endangers the well-being of children, causes financial hardship and stress for families, makes it next-to-impossible for low-income families to work their way off welfare, causes substantial productivity losses to employers, and prevents many mothers from maintaining productive careers in the labor force.
Sensible regulation and effective use of information technology are essential to reaping the benefits of this scientific revolution. Biomedical research is being fundamentally transformed by developments in genomics and informatics, and this transformation will lead inevitably to a revolution in medical practice. Neither academic research institutions nor society at large have adapted adequately to the new environment. If we are to effectively manage the transition to a new era of biomedical research and medical practice, academia, industry, and government will have to develop new types of partnership.
Better deployment of the government's food safety resources is essential to minimizing the growing risks from foodborne illnesses. Controversy over genetically modified foods has helped put food safety in the headlines, but that issue, like others we read about--mad cow disease, Listeria and Salmonella outbreaks, chemical contamination--needs to be understood and addressed in the broader context of how we protect consumers from all foodborne hazards. This broader perspective is obscured, however, by the fragmented and in many ways outdated legal and organizational framework for food safety in the United States. Food safety law is a patchwork of many enactments that, all told, lack a coherent, science-based mandate for regulators and that split food jurisdiction among a dozen or more agencies, most prominently the Food and Drug Administration (FDA), the Department of Agriculture (USDA), and the Environmental Protection Agency (EPA).
Greater progress will be made against drug abuse when our strategies reflect the full complexities of the latest scientific understanding. The United States is stuck in its drug abuse metaphors and in polarized arguments about them. Everyone has an opinion. One side insists that we must control supply, the other that we must reduce demand. People see addiction as either a disease or as a failure of will. None of this bumpersticker analysis moves us forward. The truth is that we will make progress in dealing with drug issues only when our national discourse and our strategies are as complex and comprehensive as the problem itself.
Advances in genetics highlight the individual, but medicine should be directing its attention to the community. In 1957, the year I entered college, the American Medical Association issued its "Principles of Medical Ethics." Section 10 stated "The honored ideals of the medical profession imply that the responsibility of the physician extends not only to the individual, but also to society, and these responsibilities deserve his interest and participation in activities that have the purpose of improving both the health and the well-being of the individual and the community [my italics]." Improving the health and well-being of the individual remains an honored ideal of the medical profession, and one that has also served as the guiding principle behind government funding of basic biomedical research. Improving the health of the community, however, has always depended on the shifting fortunes of the very notion of community in our deeply individualistic society, and it remains, in many ways, an ideal more easily articulated than put into practice.
The United States flubbed its chance to eliminate TB in the 1960s; it shouldn't let that happen again. It is said that opportunity knocks only once, but when it comes to the opportunity to eliminate tuberculosis (TB) in the United States, we have been given a second chance. If the country now fails to seize this moment, the losses in terms of both health and economics are certain to be great.
Reform is needed, but the program's core principles and essential components must be preserved. The aging of the U.S. population will generate many challenges in the years ahead, but none more dramatic than the costs of providing health care services for older Americans. Largely because of advances in medicine and technology, spending on both the old and the young has grown at a rate faster than spending on other goods and services. Combining a population that will increasingly be over the age of 65 with health care costs that will probably continue to rise over time is certain to mean an increasing share of national resources devoted to this group. In order to meet this challenge, the nation must plan how to share that burden and adapt Medicare to meet new demands.
As the elderly population grows more numerous and more active, the public and private sectors will have to develop specialized products and services. It happens every seven seconds: Another baby boomer turns 50 years old. As they have done in other facets of American life, the 75 million people born between 1946 and 1964 are about to permanently change society again. The sheer number of people that will be living longer and be more active than in previous generations will alter the face of aging forever.
The main policy goal should be to minimize the aggregate societal damage associated with drug use. "Fanaticism," says Santayana, "consists of redoubling your efforts when you have lost sight of your aim." An old Alcoholics Anonymous adage defines insanity as "continuing to do the same thing and expecting to get a different result." Between them, these two aphorisms define the condition of U.S. drug policy and the public debate about it.
Tackling the core problem of addiction could curb criminal behavior and ease the burden on government budgets. During the past 15 years, concerns about crime and violence have prompted increased law enforcement, prosecution, and punishment. But although the "get tough" approach may have contributed to recent reductions in crime, there are limits to its ability to enhance the public's safety and general well-being in the long run. The reason is that it does little to address drug and alcohol abuse and addiction. Although these problems have had a fundamental impact on the criminal behavior of 80 percent of inmates, only one in six of those who need substance abuse treatment receives it while in prison, and far fewer receive comprehensive intensive treatment with aftercare. As a result, our prison doors open to release tens of thousands of untreated or inadequately treated offenders back into the community every year. Most will return to a life of drug and alcohol use and crime, typically committing as many as 100 offenses annually.
Teenage pregnancy grabs the headlines, but most unintended and unwanted pregnancies occur among adults. In the past year, new national efforts have been launched that are aimed at reducing the large numbers of unintended pregnancies among U.S. teenagers. Yet even if these efforts are dramatically successful, they will make only a dent in the problem of unintended pregnancy, because about three-fourths of the 3.1 million unintended pregnancies in the United States each year occur among adults. Indeed, more than half of the 4.5 million pregnancies among women 20 years of age or older are unintended.