Question

Suppose a community is trying to decide on the size of a parks and recreation department. The community has 5 individuals, denoted by A, B, C, D, and E. To pay for the department, each individual will be taxed $20 for each worker the department employs. The individuals have the following (inverse) demands for a parks and recreation department of size L:

pA = 70 − 10L

pB = 60 − 10L

pC = 30 − 10L

pD = 20 − 10L

pE = 20 − 10L

a. If majority rule determines the equilibrium size of the parks and recreation department, what level will the community choose?

b. If a social planner could choose the equilibrium size of the parks and recreation department, what level would be chosen?

c. Suppose that new communities can be formed and individuals are allowed to “vote with their feet”. How many communities would be formed, and who would move to each community?

Answer 1

Social characteristics of individuals are closely related to health. Among the most important findings to emerge from public health research over recent years is the extent to which characteristics of areas exert independent effects on health. This ecological⁴ approach has been rediscovered and is now embedded in a multilevel framework. The major idea is that characteristics of places—neighborhoods, schools, work sites, and even nations— carry with them health risks for the individuals who live in those environments. The health risk conferred by these places is above and beyond the risk that individuals carry with them. Thus, we might view characteristics of physical environments (e.g., parks and buildings) as well as social environments (e.g., levels of inequality and civic trust) as truly properties of places, not individuals. In this section, the committee reviews evidence related to two aspects of places—economic inequality and social capital— that are assessed at an ecological level to examine their effects on health. These findings are relatively new and undoubtedly will be refined with further research. Economic inequality may exert an effect on health in addition to the effect of individual income on health. Such an effect may be particularly robust for people in the United States who are at the lower ends of the distribution.

For most people, thinking about health and health care is a very personal issue. Assuring the health of the public, however, goes beyond focusing on the health status of individuals; it requires a population health approach. As noted in Chapter 1, America's health status does not match the nation's substantial health investments. The work of assuring the nation's health also faces dramatic change, systemic problems, and challenging societal norms and influences. Given these issues, the committee believes that it is necessary to transform national health policy, which traditionally has been grounded in a concern for personal health services and biomedical research that benefits the individual. Such repositioning will affirm and expand existing commitments to reflect a broader perspective. Approaching health from a population perspective commits the nation to understanding and acting on the full array of factors that affect health.

To best address the social, economic, and cultural environments at national, state, and local levels, the nation's efforts must involve more than just the traditional sectors—the governmental public health agencies and the health care delivery system. As has been outlined in the preceding pages, what is needed is the creation of an effective intersectoral public health system. Furthermore, the efforts of the public health system must be supported by political will—which comes from elected officials who commit resources and influence based on evidence—and by “healthy” public policy—which comes from governmental agencies that consider health effects in developing agriculture, education, commerce, labor, transportation, and foreign policy.

This chapter describes the rationale behind a transformed approach to addressing population health problems. This approach identifies key determinants of the nation's health and presents evidence for their consideration in developing effective national strategies to assure population health and support the development of a public health system that blends the strengths and resources of diverse sectors and partners (IOM, 1997).