Traditionally, health goals have been framed as reductions in the occurrence of disease, disability, injury, and death rates. Although these measures are critical, they represent only negative outcomes that we all hope to avoid or delay as long as possible. These measures are no longer adequate. We have to determine, investigate, track, and act on those aspects of health that are becoming increasingly influential as ways in which U.S. residents think about health. People’s thoughts about health, often framed as aspirations, come from the contexts of their lives. We must develop measures that enable us to assess health as defined by WHO in 1946.14
To this end, the Centers for Disease Control and Prevention (CDC) has proposed specific goals for improving health so that in the future, the health of U.S. residents is improved measurably.37
Moreover, those improvements will be perceived by people to directly affect their ability to achieve the full quality of life to which they aspire. These goals have motivated CDC both to invest in research on measures of burden and to investigate the public health use of nontraditional measures of health such as social capital38
and assess the feasibility of the development of appropriate metrics of disease burden in these areas.39
For infants and toddlers, the critical concerns are related to growth, cognitive and physical development, and preventable death. At present, childhood goals focus on learning, healthy connections to family, developing friendships and social skills, continued appropriate growth and development, and preventable death. Health for adolescents should be reflected by healthy weight, appropriate levels of physical activity, strong and healthy social connections to family, peers, school, or community organizations, and healthy behavioral choices (e.g., drug, alcohol, and tobacco abstinence). For younger adults, measures of full participation and satisfaction both with work and with family life are needed. For older adults, measures are needed for activity, independence, and satisfactory social leisure activities.
The effect of social relationships and cohesion on health is important in nearly all life stages at both the individual and community levels. Measuring these social relationships and their impact on health is challenging.40
Likewise, measurement is needed of environmental and behavioral protective factors in populations. For example, progress on health status could be monitored by measuring the proportion of U.S. residents: (1
) living in cohesive communities designed to make healthful living easier, safer, and enjoyable; (2
) working in settings free from hazardous exposures and safety risks and that also promote healthy choices; and (3
) sending their children to schools where education about health, including physical education and food services, encourages the formation of healthy behaviors.
Measurement of disease burden is informative but falls short of the needs in public health. Assessment of programs and tracking accountability will not only require use of multiple measures of burden, but also practical and useful measures of both essential public health services and positive health attributes and well-being.41
Useful tools for public health must be readily available, easy to use, and consistent across time and place. As a result, we must balance the need for increasing amounts of data with the ability of those in health to process those data in an effective and timely manner.
If the United States accepts the vision of health articulated by WHO in 1946 and is committed to the achievement of optimal health for its citizens, it must develop and use the tools that will measure progress toward that burden. The process of developing these tools requires agreement with partners in state and local public health as well as international collaborators such as WHO on both metrics and data standards. Development of effective tools also requires research and evaluation that will engage partners not only in government but also academia and the private sector. The CDC is committed to this new approach to measuring health, but the agency cannot act alone and will seek collaboration in this effort.
In the 20th century, tremendous advances were made in the health of the U.S. population. Today, we not only propose a better use of measures of burden, but also argue for a shift toward measures of health—the state of physical, mental, and social well-being articulated by WHO in 1946. The science necessary to direct such a shift has not emerged, and the societal will to foster that science has lagged.
Even if scientific developments were well developed and political will were supportive, public health practitioners would need to arrive at consensus on the essential set of population health measures. Such a consensus process might involve demonstrating the science underlying potential measures, illustrating their utility in developed and developing countries, assessing their utility in measuring disparities in health, and incorporating the perspectives of various stakeholders. This would involve building on existing partnerships (e.g., as exist today among WHO and partner nations) as well as development of new partners. With the framework proposed in this article, the health community can focus prevention and control efforts more precisely and measure the impact of those efforts more accurately. It is incumbent on the medical and public health communities to provide joint leadership and make the expansion and use of appropriate measures of the public’s health a societal priority.