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John Last defines public health in his dictionary of epidemiology as, “Efforts organized by society to protect, promote, and restore the people's health. It is the combination of science, skills and beliefs that is directed to the maintenance and improvement of the health of all the people through collective or social actions.”1 These efforts organized by society are focused on “creating conditions in which people can be healthy”—the mission of public health as defined by the Institute of Medicine (IOM) in its 1988 Report on the Future of Public Health,2 and confirmed in the IOM's 2003 report, The Future of the Public's Health in the 21st Century.3
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The value of public health is unquestionable. Its prevention efforts are responsible for 25 years of the nearly 30 year improvement in life expectancy at birth in the United States over the past century. This is based on evidence that only about 5 years of the 30 year improvement are the result of medical care.4 Public health approaches carry significant potential for future contributions as well, since almost half of deaths in the United States are premature and result from preventable causes.5
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Public health is practiced in a variety of settings and agencies, and by a variety of professionals. The work of many community-based organizations or major not-for-profit voluntary organizations can certainly be characterized as the practice of public health. Their programs fit Last's definition and are consistent with the mission statement articulated by the IOM. However, when we think of public health activities, we most often envision the constellation of activities of governmental public health agencies at the federal, state, and particularly, local levels. This is especially true since it is only official public health agencies that have statutory responsibility for the health status of the populations they serve. Legal authority for this responsibility is based on a variety of federal, state, and local ordinances, including the granting of police powers.
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A PUBLIC HEALTH RENAISSANCE?
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It can be argued that public health in the United States is in the midst of a “renaissance” in several ways. The last several decades have seen a great deal of effort focused on defining the role of public health within the context of the health problems and health services existing in this country. There have also been significant changes in the way public health services are practiced and evaluated in a number of settings. Improvements in financial support and organizational structure for public health services have been less evident.
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A Philosophic Renaissance
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The pace of change in understanding the place and role of public health in the United States has accelerated dramatically in recent years. Stimulated by the disturbing findings in the 1988 IOM report (public health system in disarray, no coherent vision or mission, disconnection from its academic base, ...