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From the Editor

The Pursuit Of Public Health: How Serious Is Society?

This sorry state of affairs is hardly a new phenomenon. The Institute of Medicine’s Committee on the Future of Public Health spelled it out in vivid fashion in an important 1988 study of the public health enterprise. With new public health threats on the horizon post-9/11, Congress and the Bush administration have a historic opportunity to improve this neglected system. But this is more than a challenge for government. It also poses a question for society: Are we willing to invest the necessary resources to bolster a depleted public health system and create conditions that promote healthy populations?

Given this challenge, and the greater emphasis that Health Affairs itself is placing on public health matters, we are devoting this issue to the future of the public health enterprise. Many of the papers that follow, including those of Edward Baker and Jeffrey Koplan, Christine Gebbie, John Lumpkin, and Bernard Turnock, lend insight to policymakers for developing the necessary infrastructural prerequisites not only for responding to emerging threats, like bioterrorism, but also for improving population health indicators. Other papers, such as those by Senator Frist and Ilona Kickbusch, speak to the vision that must guide structural reform efforts both domestically and globally. We wish to acknowledge the important role that Eileen Salinsky, a senior research associate at George Washington University’s National Health Policy Forum, played in helping to shape the issue and also in serving as one of our peer reviewers.

We were joined in this thematic effort by the Robert Wood Johnson Foundation (RWJF), the largest private philanthropy that devotes its grant making exclusively to health-related projects. The RWJF is itself an interesting case study in how best to allocate resources in relation to medical need and the public’s health. At its founding (1973), the mission of the RWJF was simply stated: to improve the health and health care of all Americans. But over the next two decades the foundation awarded grants that promoted medical care and reflected a strong belief that expanding insurance coverage should be the nation’s top health policy priority. During this period the RWJF’s grant making favored health care over health by an overwhelming 95:5, a ratio that is similar to that of the combined private and public investment in personal health services. But as a robust economy more than tripled the foundation’s assets (and thus its annual payout) and a new president, Steven Schroeder, took over the helm in 1992 with a different outlook, the RWJF began to enlarge its focus, moving in a more sustained fashion into the realm of public health. The foundation created national programs that sought to curb personal behavior that is detrimental to an individual’s health, focusing particularly on substance abuse and tobacco control. In 1998, as a consequence of the deemed success of these programs and the expansion of its resources, the foundation’s board approved a reorganization, establishing its health programs as an equal partner with health care for the first time. Schroeder said in an interview (p. 244) that he regarded his efforts to shift RWJF grant making that favored health care over health to a 50:50 balance as his most important accomplishment in the twelve years he held the post. "When you look at the determinants of health and what it will take to make our country healthier, we could have an ICU on every block and still not get there. Yet most foundation and government funding is targeted at providing medical care rather than advancing the public’s health in more consequential ways." Two senior vice-presidents now preside over the two divisions: J. Michael McGinnis over health and Risa J. Lavizzo-Mourey over health care. Lavizzo-Mourey was recently named to succeed Schroeder as the RWJF’s chief executive officer when he retires 31 December 2002.

Beyond the RWJF, other foundations, including the Annie E. Casey Foundation, the California Wellness Foundation, the Conrad Hilton Foundation, the Henry J. Kaiser Family Foundation, the Kansas Health Foundation, the W.K. Kellogg Foundation, and the Pew Charitable Trusts, have all made recent grants in improving the public’s health. In the end, though, given the magnitude of resources required, how rapidly and successfully the public health system is upgraded and the health of the public improved will depend on the larger investments, in leadership and resources, made by our federal, state, and local governments.

John K. Iglehart

Founding Editor

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