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Objective To assess national pandemic preparedness and response plans from a health system perspective to determine the extent to which implementation strategies that support health system performance have been included. Methods We systematically mapped pandemic preparedness and response implementation strategies that improve resilience to pandemics onto the Health System Performance Assessment Framework for Universal Health Coverage. Using this framework, we conducted a document analysis of 14 publicly available national influenza pandemic preparedness plans, submitted to the European Centre for Disease Prevention and Control, to assess how well health system functions are accounted for in each plan. Findings Implementation strategies found in national influenza pandemic preparedness plans do not systematically consider all health system functions. Instead, they mostly focus on specific aspects of governance. In contrast, little to no mention is made of implementation strategies that aim to strengthen health financing. There was also a lack of implementation strategies to strengthen the health workforce, ensure availability of medical equipment and infrastructure, govern the generation of resources and ensure delivery of public health services. Conclusion While national influenza pandemic preparedness plans often include provisions to support health system governance, implementation strategies that support other health system functions, namely, resource generation, service delivery, and in particular, financing, are given less attention. These oversights in key planning documents may undermine health system resilience when public health emergencies occur. Objectif Evaluer les plans nationaux de preparation et de reaction aux pandemies du point de vue du systeme de sante afin de determiner le niveau d'inclusion des strategies de mise en oeuvre qui soutiennent la performance du systeme de sante. Methodes Nous avons systematiquement identifie les strategies de mise en oeuvre de la preparation et de la reaction aux pandemies qui ameliorent la resilience dans le cadre devaluation de la performance des systemes de sante pour la couverture sanitaire universelle. Ce cadre nous a servi de base pour proceder a une analyse documentaire de 14 plans nationaux de preparation a une pandemie de grippe accessibles au public. Ces plans ont ete soumis au Centre europeen de prevention et de controle des maladies, afin devaluer la prise en compte des fonctions des systemes de sante dans chaque plan. Resultats Les strategies de mise en oeuvre figurant dans les plans nationaux de preparation aux pandemies de grippe ne prennent pas systematiquement en compte toutes les fonctions des systemes de sante. Elles se concentrent plutot sur des aspects specifiques de la gouvernance. En revanche, les strategies de mise en oeuvre visant a renforcer le financement de la sante ne sont que peu, voire pas, mentionnees. Les strategies de mise en oeuvre visant a renforcer les effectifs du personnel de sante, a garantir la disponibilite des equipements medicaux et des infrastructures, a regir la generation de ressources et a assurer la prestation de services de sante publique font egalement defaut. Conclusion Si les plans nationaux de preparation aux pandemies de grippe comprennent souvent des dispositions visant a soutenir la gouvernance des systemes de sante, les strategies de mise en oeuvre qui soutiennent d'autres fonctions des systemes de sante, notamment la generation de ressources, la prestation de services et, en particulier, le financement, beneficient d'une attention moindre. Ces lacunes dans des documents de planification cles sont de nature a nuire a la resilience du systeme de sante en cas de situation d'urgence liee a la sante publique. Objetivo Evaluar los planes nacionales de preparacion y respuesta ante una pandemia desde la perspectiva del sistema sanitario para determinar en que medida se han incluido estrategias de implementacion que apoyen el rendimiento del sistema sanitario. Metodos Se trazo un mapa sistematico de las estrategias de preparacion y respuesta ante pandemias que mejoran su resiliencia en el Marco de Evaluacion del Rendimiento del Sistema Sanitario para la Cobertura Sanitaria Universal. A partir de este marco, se realizo un analisis documental de 14 planes nacionales de preparacion ante una pandemia de gripe y de acceso publico, presentados al Centro Europeo para la Prevencion y el Control de las Enfermedades, con el fin de evaluar en que medida se tienen en cuenta las funciones del sistema sanitario en cada plan. Resultados Las estrategias de implementacion que se encuentran en los planes nacionales de preparacion ante una pandemia de gripe no consideran sistematicamente todas las funciones del sistema sanitario. En su lugar, se centran sobre todo en aspectos especificos de la gobernanza. Por otro lado, apenas se mencionan las estrategias de aplicacion destinadas a reforzar la financiacion sanitaria. Tambien faltan estrategias de implementacion para reforzar el personal sanitario, garantizar la disponibilidad de equipos medicos e infraestructuras, gobernar la generacion de recursos y garantizar la prestacion de servicios sanitarios publicos. Conclusion Aunque los planes nacionales de preparacion ante una pandemia de gripe suelen incluir disposiciones para apoyar la gobernanza del sistema sanitario, se presta menos atencion a las estrategias de implementacion que apoyan otras funciones del sistema sanitario, en concreto, la generacion de recursos, la prestacion de servicios y, en particular, la financiacion. Estos descuidos en documentos de planificacion clave pueden debilitar la resiliencia del sistema sanitario cuando se producen emergencias de salud publica., Introduction The coronavirus disease 2019 (COVID-19) pandemic profoundly affected health systems as well as economies and societies more broadly. (1,2) As countries grappled with increasing numbers of COVID-19 cases, many [...]

Black women in the United States continue to face multilayered forms of anti-Black gendered oppression leading to severe health disparities and inequities that have a dire impact on their well-being. This paper recognizes the urgency to attend to Black women's health and healing in the pursuit of creating health equity. The authors call for the creation of sacred spaces for Black women to participate in embodied and community-engaged healing, grounded in a gender justice that is inextricably tied to racial justice. This research is inspired by the long, rich line of Black American women activist-healers that have called for the radical healing of Black women. Therefore, the authors root their work in an ethical health justice ethos, honoring the humanity of Black women through a recognition of their sacredness, guided by the principles of justice, truth-telling, love, and respect that emphasizes that Black women's lives matter. Using an interdisciplinary approach, the authors braid together healing narratives from the fields of Public Health, Black Psychology, Africana Studies, and Gender, Women's, and Sexuality Studies. Underscoring the importance of Black women reclaiming their radical healing, this paper at the same time underlines resisting anti-Black gendered racism and interlocking forms of oppression. The authors emphasize gender and racial justice while endorsing collectivistic orientations, grounded in an African-centered worldview, that support Black women's embodied and community-engaged healing. As a result, the authors also draw from healing narratives in their fields that include cultural paradigms, socially engaged spirituality, and generational and gendered wisdom. Connecting historical to present-day medical/mental health encounters, the authors underscore inhumane, racist, and sexist pseudoscience, medical treatment, and research experiments on Black women's bodies. The authors also address social injustices, isolation, and (dis)ease while foregrounding gender and racial justice in the creation of health equity for Black women. Keywords: Black Womanism, Black Feminism, Public health, Black Psychology, Black women, Healing, Health justice, Introduction Rarely, if ever, are any of us healed in isolation. Healing is an act of communion. ~bell hooks, All About Love Due to the current backlash of anti-Black gendered [...]

I am a second-year Epidemic Intelligence Service (EIS) officer assigned to the Centers for Disease Control and Prevention's (CDC's) National Environmental Public Health Tracking Program (Tracking Program). EIS officers, commonly [...]

Objectives. We sought to examine the utilization and impact of enabling services, such as interpretation and eligibility assistance, among underserved Asian American, Native Hawaiian, and other Pacific Islander (AANHOPI) patients served at 4 community health centers. Methods. For this project, we developed a uniform model for collecting data on enabling services and implemented it across 4 health centers that served primarily AANHOPI patients. We also examined differences in patient characteristics between users and nonusers of enabling services. Results. Health center patients used many enabling services, with eligibility assistance being the most used service. In addition, compared with nonusers, users of enabling services were more likely to be older, female, AANHOPI, and uninsured (P Conclusions. For underserved AANHOPI patients at community health centers, enabling services are critical for access to appropriate care. We were the first to examine uniform data on enabling services across multiple health centers serving underserved AANHOPI patients. More data on enabling services and evaluation are needed to develop interventions to improve the quality of care for underserved AANHOPI patients. (Am J Public Health. 2010;100:2199-2205. doi: 10.2105/AJPH.2009.172270)

Objectives. We sought to examine the extent to which children in the child welfare system receive mental health care consistent with national standards. Methods. We used data from 4 waves (3 years of follow-up) of the National Survey of Child and Adolescent Well-Being, the nation's first longitudinal study of children in the child welfare system, and the Area Resource File to examine rates of screening, assessment, and referral to mental health services among 3802 youths presenting to child welfare agencies. Weighted population-averaged logistic regression models were used to identify variables associated with standards-consistent care. Results. Only half of all children in the sample received care consistent with any 1 national standard, and less than one tenth received care consistent with all of them. Older children, those exhibiting externalizing behaviors, and those placed in foster care had, on average, higher odds of receiving care consistent with national standards. Conclusions. Adverse consequences of childhood disadvantage cannot be reduced unless greater collaboration occurs between child welfare and mental health agencies. Current changes to Medicaid regulations that weaken entitlements to screening and assessment may also worsen mental health disparities among these vulnerable children. (Am J Public Health. 2010;100:742-749. doi: 10.2105/AJPH.2008.151472)

Reducing and eliminating disparities in health is a matter of life and death. Each year in the United States, thousands of individuals die unnecessarily from easily preventable diseases and conditions. It is critical that we approach this problem from a broad public health perspective, attacking all of the determinants of health: access to care, behavior, social and physical environments, and overriding policies of universal access to care, physical education in schools, and restricted exposure to toxic substances. We describe the historical background for recognizing and addressing disparities in health, various factors that contribute to disparities, how the public health approach addresses such challenges, and two successful programs that apply the public health approach to reducing disparities in health. Public health leaders must advocate for public health solutions to eliminate disparities in health.

Nuclear weapons pose a particularly destructive threat. Prevention of the proliferation and use of nuclear weapons is urgently important to public health. 'Horizontal' proliferation refers to nation-states or nonstate entities that do not have, but are acquiring, nuclear weapons or developing the capability and materials for producing them. 'Vertical' proliferation refers to nation-states that do possess nuclear weapons and are increasing their stockpiles of these weapons, improving the technical sophistication or reliability of their weapons, or developing new weapons. Because nation-states or other entities that wish to use or threaten to use nuclear weapons need methods for delivering those weapons, proliferation of delivery mechanisms must also be prevented. Controlling proliferation--and ultimately abolishing nuclear weapons--involves national governments, intergovernmental organizations, nongovernmental and professional organizations, and society at large. (Am J Public Health. 2007;97:1589-1594. doi:10.2105/AJPH.2006. 100602)

Disruption caused by decades of war and civil strife in Afghanistan has led many international and national nongovernmental organizations (NGOs) to assume responsibility for the delivery of health services through contracts with donor agencies. Recently the Afghan Government has pursued the policy of contracting for a basic package of health services (BPHS) supported by funds from three major donors--the World Bank, the United States Agency for International Development (USAID) and the European Commission. With the gradual strengthening of the public health ministry, options for the future include pursuing the contracting option or increasing public provision of health services. Should contracting with NGOs be pursued, a clear strategy is required that includes developing accreditation instruments, better contracting mechanisms and a system for monitoring and evaluating the entire process. Should the government opt for an increasing role, problems to be solved include securing the transition to public provision, obtaining guarantees that appropriate financing will be provided and reconfiguration of the public health delivery system. Large-scale contracting with the private for-profit sector cannot be recommended at this stage, although this option could be explored via subcontracting by larger NGOs or small-scale trial contracts initiated by the public health ministry. Irrespective of the option chosen, an important challenge remaining is the recalcitrant problem of high out-of-pocket payments. Sustainable delivery of health services in Afghanistan can only be achieved with a clear national strategy in which all stakeholders have roles to play in the financing, regulation and delivery of services. La desorganisation provoquee par des decennies de conflits armes et de guerre civile en Afghanistan a conduit de nombreuses organisations non gouvernementales (ONG)internationales et nationales a assumer la delivrance de prestations de sante par le biais de contrats avec les agences donatrices. Recemment, le gouvernement afghan a prolonge cette politique contractuelle par un ensemble de prestations de sante de base, beneficiant du soutien financier des trois principaux donateurs :la Banque mondiale, l'AID des Etats-Unis d'Amerique (USAID) et la Commission europeenne. A mesure que le ministere de la sante publique se renforce, on peut envisager de poursuivre l'option contractuelle ou de developper la prestation de services de sante par le secteur public. Si l'on continue de passer des contrats avec des ONG, il faudra disposer d'une strategie claire, prevoyant la mise au point d'instruments d'accreditation, de meilleurs mecanismes contractuels et d'un systeme de suivi et d'evaluation du processus dans son ensemble. Si les pouvoirs publics optent pour un accroissement de leur role, il faudra assurer la transition vers une delivrance par le secteur public des prestations, obtenir des garanties quant a la disponibilite de fonds suffisants et reconfigurer de maniere appropriee le systeme public de prestations de sante. Nous ne recommandons pas a ce stade de passer de grands contrats a visees lucratives avec le secteur prive, bien qu'il soit possible d'envisager cette option en sous-traitant aupres d'ONG plus importantes ou en passant de petits contrats pilote a l'initiative du ministere de la sante. Quelle que soit l'option choisie, il reste a resoudre le probleme epineux du paiement des prestations par l'usager. La delivrance durable de prestations de sante n'est possible en Afghanistan que si l'on definit une strategie claire dans laquelle toutes les parties prenantes ont un role a jouer dans le financement, la reglementation et la delivrance des prestations. Las perturbaciones causadas por decadas de guerra y contiendas civiles en el Afganistan han llevado a muchas organizaciones no gubernamentales (ONG) internacionales y nacionales a asumir la responsabilidad de proveer los servicios de salud mediante la concertacion de contratos con organismos donantes. Recientemente el Gobierno del Afganistan ha aplicado la politica de contratar un paquete basico de servicios de salud con el respaldo de los fondos facilitados por tres importantes donantes, a saber, el Banco Mundial, la Agencia de los Estados Unidos para el Desarrollo Internacional y la Comision Europea. Con el gradual fortalecimiento del Ministerio de Salud Publica, las opciones con miras al futuro son el mantenimiento de la politica de subcontratacion o la ampliacion de la prestacion publica de servicios de salud. Si se opta por los contratos con ONG, se requiere una estrategia clara que abarque el desarrollo de instrumentos de acreditacion, mejores mecanismos de contratacion y un sistema de seguimiento y evaluacion de todo el proceso. Si el gobierno decide desempenar un papel mas importante, habra que resolver problemas como la necesidad de asegurar la transicion a la prestacion publica de servicios, la obtencion de garantias de que se contara con la suficiente financiacion y la reconfiguracion del sistema de prestacion de servicios de salud publica. La subcontratacion a gran escala con el sector privado con fines de lucro no es una opcion recomendable en esta etapa, aunque se podria explorar esa posibilidad subcontratando servicios a grandes ONG u organizando ensayos a escala reducida desde el Ministerio de Salud Publica. Con independencia de la opcion elegida, un problema arduo que se resiste es la elevada cuantia de los pagos directos. Para que la prestacion de servicios de salud en el Afganistan sea sostenible, habra que adoptar una estrategia nacional clara en la que todos los interesados directos tengan funciones que desempenar en materia de financiacion, reglamentacion y prestacion de servicios., Introduction Decades of war and civil strife have adversely affected the delivery of health services to the population of Afghanistan. Until recently, the network of public service delivery had been [...]

Objective: Access to an affordable, nutritious food supply is an important determinant of population health. Healthy food basket surveys have been used across Australia as a tool to monitor food cost, quality and variety. The release of the revised Nutrient Reference Values, together with local interest in food security, highlighted the need to develop a Victorian Healthy Food Basket to reflect the food access issues of the Victorian population. Method: The development took place at Monash University, Victoria, in December 2006. Demographic and food purchasing data were used to define the family types and foods in the healthy basket, respectively. The revised Nutrient Reference Values were used to benchmark the nutritional adequacy of the basket. Results: A Victorian Healthy Food Basket consisting of 44 core and non-core foods was developed. The quantities of the 44 items in the basket were modified to meet the nutritional needs of four different family types most common in Victoria and those most vulnerable to food insecurity: two adults and two children; a single mother and two children; a single adult male; and a single elderly female. Conclusion: Victoria has a local tool to monitor healthy food cost and accessibility that meets at least 85% of all individual nutrient requirements and at least 95% of all energy requirements for four family types for a fortnight. Implications: The Victorian Healthy Food Basket provides an additional tool to monitor the cost and access to healthy food in Victoria. Key words: Nutrition requirements; food analysis; healthy food; family characteristics.

The area under the receiver operating characteristic curve (AUC) is a popular summary measure of the efficacy of a medical diagnostic test to discriminate between healthy ad diseased subjects. A frequently encountered problem in studies that evaluate a new diagnostic test is that not all patients undergo disease verification because the verification test is expensive, invasive, or both. Furthermore, the decision to send patients to verification often depends on the new test and on other predictors of true disease status. In such cases, usual estimators of the AUC based on verified patients only are biased. In this article we develop estimators of the AUC of markers measured on any scale that adjust for selection to verification. These estimators adjust for measured patient covariates ad diagnostic test results and also for an assumed degree of residual selection bias. They can then be used in a sensitivity analysis to examine how the AUC estimates change when different plausible degrees of residual association are assumed. As with other missing-data problems, due to the curse of dimensionality, a model for disease or a model for selection is needed to obtain well-behaved estimators of the AUC when the marker and/or the measured covariates are continuous. We describe a doubly robust estimator that has the attractive feature of being consistent and asymptotically normal if either the disease or the selection model (but not necessarily both) is correct. KEY WORDS: Diagnostic test; Marker; Nonignorable; Sensitivity; Sensitivity analysis; Specificity.

Bioethics' traditional focus on clinical relationships and exotic technologies has led the field away from population health, health disparities, and issues of justice. The result: a myopic view that misses [...]

Distribution of health aid and public health and heterogeneity aspects associated with this are evaluated.

Objectives. Although a growing body of evidence demonstrates that availability and quality of essential public health services vary widely across communities, relatively little is known about the factors that give rise to these variations. We examined the association of institutional, financial, and community characteristics of local public health delivery systems and the performance of essential services. Methods. Performance measures were collected from local public health systems in 7 states and combined with secondary data sources. Multivariate, linear, and nonlinear regression models were used to estimate associations between system characteristics and the performance of essential services. Results. Performance varied significantly with the size, financial resources, and organizational structure of local public health systems, with some public health services appearing more sensitive to these characteristics than others. Staffing levels and community characteristics also appeared to be related to the performance of selected services. Conclusions. Reconfiguring the organization and financing of public health systems in some communities--such as through consolidation and enhanced intergovernmental coordination--may hold promise for improving the performance of essential services.

We propose cumulative meta-analysis as the procedure of completing a new meta-analysis at each successive wave in a research database. Two facets of cumulative knowledge are considered: the first, sufficiency, refers to whether the meta-analytic database adequately demonstrates that a public health intervention works. The second, stability, refers to the shifts over time in the accruing evidence about whether a public health intervention works. We used a hypothetical data set to develop the indicators of sufficiency and stability, and then applied them to existing, published datasets. Our discussion centers on the implications of the use of this procedure in evaluating public health interventions.

The innovative practice that resulted from the Ottawa Charter challenges public health knowledge about programming and evaluation. Specifically, there is a need to formulate program theory that embraces social determinants of health and local actors' mobilization for social change. Likewise, it is imperative to develop a theory of evaluation that fosters reflexive understanding of public health programs engaged in social change. We believe advances in contemporary social theory that are founded on a critique of modernity and that articulate a coherent theory of practice should be considered when addressing these critical challenges.

Objective: To compare rates of self-reported use of health services between rural, remote and urban South Australians. Methods: Secondary data analysis from a population-based survey to assess health and well-being, conducted in South Australia in 2000. In all, 2,454 adults were randomly selected and interviewed using the computer-assisted telephone interview (CATI) system. We analysed health service use by Accessibility and Remoteness Index of Australia (ARIA) category. Results: There was no statistically significant difference in the median number of uses of the four types of health services studied across ARIA categories. Significantly fewer residents of highly accessible areas reported never using primary care services (14.4% vs. 22.2% in very remote areas), and significantly more reported high use ([greater than or equal to] 6 visits. 29.3% vs. 21.5%). Fewer residents of remote areas reported never attending hospital (65.6% vs. 73.8% in highly accessible areas). Frequency of use of mental health services was not statistically significantly different across ARIA categories. Very remote residents were more likely to spend at least one night in a public hospital (15.8%) than were residents of other areas (e.g. 5.9% for highly accessible areas). Conclusion: The self-reported frequency of use of a range of health services in South Australia was broadly similar across ARIA categories. However, use of primary care services was higher among residents of highly accessible areas and public hospital use increased with increasing remoteness. There is no evidence for systematic rural disadvantage in terms of self-reported health service utilisation in this State. (Aust N Z J Public Health 2004; 28: 426-32)

Objective: To assess the implementation of the Australian core functions of public health in rural Western Australia. Methods: Cross-sectional surveys (n=26) and semi-structured key informant interviews (n=64) with public health practitioners throughout each of the eight rural health regions in Western Australia. A scoring system was utilised to categorise responses that were frequently part of current practice (score=2), sometimes undertaken (score=1) and rare or not undertaken at all (score=0). Results: Functions with reasonably good coverage (mean score [3.sup.1.0]) included: preventing and controlling communicable and non-communicable diseases; promoting and supporting healthy lifestyles; planning, funding, managing and evaluating health gain; ensuring safe and healthy environments; and contributing to healthy growth and development through all life stages. Lower levels of coverage were found for: assessing health needs; developing healthy public policy and fiscal measures; strengthening communities; and improving health for Aboriginal people and other vulnerable groups. Conclusions: There are limitations in the capacity of the rural public health workforce in Western Australia to implement the core public health functions. While some areas were defined as being adequately addressed, gaps in implementation appeared across all nine functions. Implications: The Australian core functions can be utilised to broadly assess current public health practice, however further development of the functions and their measurement, plus methods to align accountability measures for current public health practice with the core functions, are required. (Aust N Z J Public Health 2004; 28:418-25)

From its origins, when public health was integral to societies' social structures, through the sanitary movement and contagion eras, when it evolved as a separate discipline, to the 'new public health' era, when health promotion projects like Healthy Cities appear to be steering the discipline back to society's social structure, public health seems to have come full circle. It is this observation that has led some to ask, 'What's new about the 'new public health'?' This article addresses the question by highlighting what is new about the health promotion era--including adapted components of previous eras that have been incorporated into its core activities--and its suitability in addressing established and emerging public health threats. (Am J Public Health. 2004;94:705-709)

Objective To gauge the effects of operating the Bamako Initiative in Kongoussi district, Burkina Faso. Methods Qualitative and quasi-experimental quantitative methodologies were used. Findings Following the introduction of fees-for-services in July 1997, the number of consultations for curative care fell over a period of three years by n average of 15.4% at "case" health centres but increased by 30.5% at "control" health centres. Moreover, although the operational results for essential drugs depots were not known, expenditure increased on average 2.7 times more than income and did not keep pace with the decline in the utilization of services. Persons in charge of the management committees had difficulties in releasing funds to ensure access to care for the poor. Conclusion The introduction of fees-for-services had an adverse effect on service utilization. The study district is in a position to bear the financial cost of taking care of the poor and the community is able to identify such people. Incentives must be introduced by the state and be swiftly applied so that the communities agree to a more equitable system and thereby allow access to care for those excluded from services because they are unable to pay. Keywords Fee-for-service plans; Health services accessibility/economics; Health services/economics; Primary health care; Essential drugs/economics; Drugs, Generic/economics; Operations research; Burkina Faso (source: MeSH, NLM). Mots cles Plan remboursement a l'acte; Accessibilite service sante/economie; Services sante/economie; Programme soins courants; Medicaments essentiels/economie; Produits generiques/economie; Recherche operationnelle; Burkina Faso (source: MeSH, BIREME). Palabras clave Planes de aranceles por servicios; Accesibilidad a los servicios de salud/economia; Servicios de salud/economia; Atencion primaria de salud; Medicamentos esenciales/economia; Medicamentos genericos/economia; Investigacion operativa; Burkina Faso (fuente: DeCS, BIREME)., Introduction In the early 1980s, community-based funding was one of the mechanisms used to implement the policy of primary health care. Following the health reforms of the 1980s, however, the [...]

An internationally influential model of population health was developed in Canada in the 1990s, shifting the research agenda beyond health care to the social and economic determinants of health. While agreeing that health has important social determinants, the authors believe that this model has serious shortcomings; they critique the model by focusing on its hidden assumptions. Assumptions about how knowledge is produced and an implicit interest group perspective exclude the sociopolitical and class contexts that shape interest group power and citizen health. Overly rationalist assumptions about change understate the role of agency. The authors review the policy and practice implications of the Canadian population health model and point to alternative ways of viewing the determinants of health. (Am J Public Health. 2003;93:392-396)

The origin of the population health approach is an historic debate over the relationship between economic growth and human health. In Britain and France, the Industrial Revolution disrupted population health and stimulated pioneering epidemiological studies, informing the early preventive public health movement. A century-long process of political adjustment between the forces of liberal democracy and propertied interests ensued. The 20th-century welfare states resulted as complex political mechanisms for converting economic growth into enhanced population health. However, the rise of a 'neoliberal' agenda, denigrating the role of government, has once again brought to the fore the importance of prevention and a population health approach to map and publicize the health impacts of this new phase of 'global' economic growth.

The September 11, 2001, attack on the World Trade Center had profound effects on the well-being of New York City. The authors describe and assess the strengths and weaknesses of the city's response to the public health, environmental/ occupational health, and mental health dimensions of the attack in the first 6 months after the event. They also examine the impact on the city's health care and social service system. The authors suggest lessons that can inform the development of a post-September 11th agenda for strengthening urban health infrastructures. (Am J Public Health. 2003;93:400-406)

Population health is a relatively new term that has not yet been precisely defined. Is it a concept of health or a field of study of health determinants? We propose that the definition be 'the health outcomes of a group of individuals, including the distribution of such outcomes within the group,' and we argue that the field of population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two. We present a rationale for this definition and note its differentiation from public health, health promotion, and social epidemiology. We invite critiques and discussion that may lead to some consensus on this emerging concept. (Am J Public Health. 2003;93: 380-383)

Violence is a public health problem that can be understood and changed. Research over the past 2 decades has demonstrated that violence can be prevented and that, in some cases, prevention programs are more cost-effective than other policy options such as incarceration. The United States has much to contribute to--and stands to gain much from--global efforts to prevent violence. A new World Health Organization Initiative presents an opportunity for the United States to work with other nations to find cost-effective ways of preventing violence and reducing its enormous costs.

The author examines available evidence on the effects of exposure to joblessness on emotional well-being according to race and sex. The impact of racism on general health outcomes also is considered, particularly racism in the specific form of wage discrimination. Perceptions of racism and measured exposures to racism may be distinct triggers for adverse health outcomes. Whether the effects of racism are best evaluated on the basis of self-classification or social classification of racial identity is unclear. Some research sorts between the effects of race and socioeconomic status on health. The development of a new longitudinal database will facilitate more accurate identification of connections between racism and negative health effects.

The authors invoke a population health perspective to assess the distribution of environmental hazards according to race/ethnicity, social class, age, gender, and sexuality and the implications of these hazards for health. The unequal burden of environmental hazards borne by African American, Native American, Latino, and Asian American/Pacific Islander communities and their relationship to well-documented racial/ethnic disparities in health have not been critically examined across all population groups, regions of the United States, and ages. The determinants of existing environmental inequities also require critical research attention. To ensure inclusiveness and fill important gaps, scientific evidence is needed on the health effects of the built environment as well as the natural environment, cities and suburbs as well as rural areas, and indoor as well as outdoor pollutants.

The authors review the available empirical evidence from population-based studies of the association between perceptions of racial/ethnic discrimination and health. This research indicates that discrimination is associated with multiple indicators of poorer physical and, especially, mental health status. However, the extant research does not adequately address whether and how exposure to discrimination leads to increased risk of disease. Gaps in the literature include limitations linked to measurement of discrimination, research designs, and inattention to the way in which the association between discrimination and health unfolds over the life course. Research on stress points to important directions for the future assessment of discrimination and the testing of the underlying processes and mechanisms by which discrimination can lead to changes in health.

Research on racism as a harmful determinant of population health is in its infancy. Explicitly naming a long-standing problem long recognized by those affected, this work has the potential to galvanize inquiry and action, much as the 1962 publication of the Kempe et al. scientific article on the 'battered child syndrome' dramatically increased attention to--and prompted new research on--the myriad consequences of child abuse, a known yet neglected social phenomenon. To further work on connections between racism and health, the author addresses 3 interrelated issues: (1)links between racism, biology, and health; (2) methodological controversies over how to study the impact of racism on health; and (3) debates over whether racism or class underlies racial/ethnic disparities in health.