The Ultimate Measures of Health

Assessing public health progress involves measuring what is important. Until now, such measurements have largely entailed disease surveillance or special reports that summarize disease trends, presented by race/ethnicity or some other variable.1–3 Such efforts have advanced critical understanding of our disease status as a nation. But individual health ultimately reflects not just the singular influence of biology, but also the complex constellation of many other dimensions. Future assessment efforts must begin to measure and track those social determinants4,5 so that we can measure what is ultimate, not merely what is important. Health arises not just from a doctor's office, but also from our homes, jobs, schools, communities, and places of worship—in short, where we live, labor, learn, play, and pray.5–9 All of these conditions determine whether we can fully be healthy, defined by the World Health Organization as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”10 While some Americans meet this standard, far too many fall short. Disturbingly, many cannot reach their full potential because of unnatural causes linked to economic, social, or environmental disadvantage.11 Such situations limit opportunities for good health choices. Addressing these health disparities requires first a better understanding of measures representing social, economic, educational, environmental, policy-oriented, cultural, and even spiritual dimensions of health. Recently, the Institute of Medicine (IOM) report For the Public's Health: The Role of Measurement in Action and Accountability reaffirmed the urgency of addressing the underlying factors that contribute to poor health, not just disease outcome data.6 The IOM recommended changes in the process, tools, and approaches used to gather information about social and environmental determinants, including a standardized core set of health outcome indicators and indicators of community health. Such improved data collection and measurement frameworks will help assess and provide clear accountability needed from both government and multisector partners responsible for understanding, monitoring, and improving population health. Also, the recently unveiled goals and objectives of Healthy People 2020 for the first time have identified the social determinants as one of its 42 topic areas.7 In joining time-honored topic areas such as tobacco use and immunization, social determinants outcomes over the next decade move us closer to assessing the foundations of health, not just disease. While the precise metrics are still under discussion, areas under consideration include those related to education, employment, income, housing, family and social support, community safety, and characteristics of the built environment. Such measures have already received some attention from the County Health Rankings,12 a collaboration of the Robert Wood Johnson Foundation (RWJF) and the University of Wisconsin Population Health Institute, as well as from the most recent IOM report on the Leading Health Indicators.13 Changing what we measure can lead to new directions in how we act. Indeed, the time-honored core public health function of assessment catalyzes two others: assurance and policy.14 In 21st century public health, we understand that health is too important to be left to the health sector alone. Indeed, we need a broad social determinants approach—that is, health in all policies—that involves a multisector approach and collaboration with a host of nontraditional partners. Doing so will allow more people a true opportunity for better health choices—and help make the healthy choice the easier choice. Recently, the U.S. Department of Health and Human Services (HHS) has stressed such a multidisciplinary approach through its HHS Action Plan to Reduce Racial and Ethnic Health Disparities.15 By capitalizing on community-based prevention approaches and other opportunities to transform health care embedded in the Affordable Care Act,16 the HHS Action Plan offers an opportunity to eliminate disparities and improve public health quality in its broadest sense.17 We also need to communicate the social determinants of health, a term still largely confined to academic circles, in ways that better resonate with the general public. RWJF has committed to finding a common language that expands national views about where health starts, not just where diseases end.18 RWJF suggests messages such as “your neighborhood or job shouldn't be hazardous to your health,” and, “all Americans should have the opportunity to make the choices that allow them to live a long, healthy life, regardless of income, education, or ethnic background.” In short, we are all interdependent and interconnected, and we all have promises to keep. The classic 1988 IOM report The Future of Public Health defines the essence of our field as “fulfilling society's interest in assuring conditions in which people can be healthy.”14 Beginning to assess and address those conditions through a social determinants approach opens the door to innovative ways of improving public health. Measuring what is ultimate, as well as what is important, will surely move our country closer to the day when every person has the opportunity to reach his or her highest attainable standard of health.