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Conclusion Future of Public Health C. William Keck, F. Douglas Scutchfield, and James W. Holsinger Jr. It should be clear to readers that both the health of the public and the discipline and practice of public health in the United States are evolving rapidly. Measures of health status have, with some important exceptions, shown steady improvement since the beginning of the twentieth century. The practice of public health, broadly defined, is responsible for the majority of those gains. However, the contributions of public health have been largely unappreciated by the general public, and both the practice and the discipline have been overshadowed by the attention lavished on institutions and practitioners that provide personal medical care. The last several decades, however, have witnessed a growing awareness both inside and outside the public health profession that achieving a higher level of community health will require more emphasis on health promotion and disease prevention and public policy initiatives that provide incentives to improve health outcomes. Important elements in creating this awareness and the accompanying movement for policy change have been the philosophic renaissance occurring in the public health profession since the late 1980s and the work of researchers that has made it clear that the improved application of preventive services and a community-based approach to affect the social determinants of health have the potential to improve health status. This is easier said than done, of course. Realizing this potential will require more resources for providing preventive services, improving the organization and delivery of individual and community preventive services, broadening the public health agenda to include the social determinants of health, melding medicine and public health in meaningful ways, and expanding research into public health services and systems. The Patient Protection and Affordable Care Act of 2010 (ACA) is supportive of these efforts; its provisions include incentives 252   Keck, Scutchfield, and Holsinger to improve the application of health promotion and disease prevention activities , large investments in public health practice, and support for the training of preventive medicine specialists, among other initiatives.1 This concluding chapter reviews these elements, with particular attention paid to the systems changes that must occur in both public health and clinical medicine if citizens of the United States are to benefit from the knowledge we have and are developing about maintaining health. It also describes the particular challenges facing local health departments as they confront these new realities. Evolution of the Public’s Health Health in the industrialized world has shown remarkable progress over the past 100 years. Gains in life expectancy and general health status in the United States have been part of this trend. In 1900 life expectancy at birth in the United States for all persons stood at 47.3 years (46.3 for men and 48.3 for women); by 2007 life expectancy for all persons had risen to 77.9 years (75.4 for men and 80.4 for women).2 The infant mortality rate in 1900 was almost 100 infant deaths per 1,000 live births; by 2006 that number had dropped to 6.7.3, 4 Similarly , death rates for all causes for all persons per 100,000 population declined from 1,719.0 in 1900 to 760.2 in 2007.5–7 Many attribute these gains to the advances in clinical medicine that are so compellingly chronicled in the lay media . The fact is, however, that only about five of the approximately thirty years gained in life expectancy are the result of clinical curative interventions.8 Despite this good news, there is gathering evidence that all is not as well as it could be or should be in terms of U.S. health status. Even though it spends more than any other country on health care and has made significant gains in health over time, the United States currently ranks poorly on measures of health compared with the rest of the industrialized world, and it is losing ground. At the turn of the last century, when the World Health Organization ranked the effectiveness of the world’s health systems, the United States was thirty-seventh—at the bottom of the industrialized nations.9 The 2008 Robert Wood Johnson Foundation report Overcoming Obstacles to Health notes that the United States has slipped in both infant mortality rates—dropping from eighteenth in the world in 1980 to twenty-fifth in 2002—and life expectancy rates—dropping from fourteenth to twenty-third.10 In addition, there are huge disparities in health among various U...

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