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THE NATION'S HEALTH GOALS: SOCIAL CHANGE, PROBLEMS AND OPPORTUNITIES * MICHAEL A. STOTO, PH.D. Study Director National Health Objectives for the Year 2000 Institute of Medicine National Academy of Sciences Washington, D.C.
of national health objectives for the year 2000. The objectives will represent a national consensus on priorities for health promotion and disease prevention to guide public and private policy during the 1990s. Developing these objectives is a massive effort, involves a cast of thousands, and has been underway for almost two years. I am glad to let you know about our progress and to have the opportunity to get you involved in the development of the objectives. The rationale for the objectives reflects the increasing prominence of health promotion and disease prevention on the national health agenda. This new direction was made possible by fundamental medical and public health accomplishments of earlier generations: public health and sanitation reforms at the turn of the century, effective vaccines and antibiotics during the 1930s, and more recent improvements in clinical preventive services. Furthermore, these medical and public health developments coincide with a growing popular interest in improving overall health, beyond mere freedom from disease. The importance of the objectives stems from the ability of nationally identified goals to motivate and to recruit commitment of local and private resources. The Year 2000 Health Objectives project is a cooperative effort of the federal government, state, and local governments, professional and voluntary organizations (including those whose primary focus is other than health), other private sector organizations and individuals in these organizations, academia, and elsewhere. The lead organization is the Office of Disease Prevention and Health Promotion in the office of the Assistant Secretary M/[Y TOPIC IS THE DEVELOPMENT
*Presented in a panel, Today's Economic, Social, and Political Climate, as part of the Annual Health Conference, The Changing Agenda for Health Care in America: Balancing Need and Commitment, held by the Committee on Medicine in Society of the New York Academy of Medicine May 9 and 10, 1989. Address for reprint requests: Institute of Medicine, 2101 Constitution Avenue NW, Washington, D.C. 20418
Bull. N.Y. Acad. Med.
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for Health. The Institute of Medicine, which I represent, leads the effort to coordinate the work of all the nonfederal organizations involved. To set the stage for the development of the new national objectives, the Public Health Service and the Institute of Medicine last year sponsored seven regional hearings (including one here in New York City) and 10 more specialized hearings around the country, and took testimony from almost 800 individuals and organizations. Participants came from all walks of life, public and private. They included both health professionals and lay men and women, representatives of professional organizations, voluntary groups and private companies, and both academicians and practitioners. Racial and ethnic minority groups and all areas of the country were represented. Testifiers spoke about their hopes and plans, about the issues they would like to see addressed on a national level, and about the problems and successes that they see at the local level. Overall, this testimony presents a uniquely rich and detailed compilation of views about improving health in the United States. Its major strength is that it portrays the views of the people on the firing line in health promotion and disease prevention. While not everything proposed by these testifiers meets the standards that a scientific organization would apply to information for setting national policies, the testimony provides valuable "intelligence" about the thinking and the resources available to both the generals and the foot soldiers in the battle for the health of Americans. I shall use most of my time this morning on what these witnesses said about two major issues: the development and implementation of national objectives and the need for better access to health promotion and disease prevention in medical settings. Much more was said about specific health promotion activities and preventive services, but this material is too lengthy to even try to summarize in a brief time. I shall finish with a brief report on the current status of the objective development process.
Objectives Process and Implementation The process of setting national health objectives began a decade ago with the publication of a set of overall goals for five broad age groups in Healthy People, the first Surgeon General's report on health promotion and disease prevention.1 For example, one goal was: "To continue to improve infant health, and, by 1990, to reduce infant mortality by at least 35 percent, to fewer than nine deaths per 1,000 live births." The next year the Public Health Service published 226 specific, quantitative objectives addressing health outcomes and the reduction of associated risk factors, public and professional awareness of health promotion and disVol. 66, No. 1, January-February 1990
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ease prevention issues, the provision of preventive services and health protections, and surveillance systems to assess progress.2 For instance, one of the objectives was: "By 1990, low birth weight babies (2,500 grams and under) should constitute no more than five percent of all live births." Overall, the 1990 Objectives have been successful. In a 1985 progress review, about half of the objectives were either already achieved or on track to be accomplished by 1990, and only about one quarter seemed unlikely to be achieved. There were no data, however, to assess progress toward the rest of the objectives.3 More important, by last year all but one of the U. S. states and territories had established or begun to establish objectives of their own.4
STRUCTURE AND Focus OF THE OBJECTIVES The 226 objectives for 1990 were divided into three broad functional groups: Health promotion activities that seek to facilitate community and individual measures to foster lifestyles that maintain and enhance the state of health and well-being. Health protection activities that target population groups and foster changes in their environments conducive to improved health and well-being. Health protection activities include changes both in the physical environment and in the social environment brought about through technical means and through legislation and government regulation. Preventive health services that are targeted toward individuals to prevent specific diseases and disorders. These interventions are usually carried out in medical settings. Although many testifiers accepted this framework and commented on specific issues, a few felt that national objectives focused exclusively on health matters were in danger of missing the underlying causes of illness. For example, Mr. Jule Sugarman, secretary of the Washington State Department of Social and Health Services, said that "As broad as these objectives are and will be, they are not broad enough to assure the preservation of health. The World Health Organization is asking its member nations to consider in its health policies the impact on health of education, housing, business, agriculture and the other sectors of society. We in this nation need to give more public attention to these intersectorial impacts on health." In a similar vein, the American Public Health Association suggested that "many health problems could be ameliorated by improved social conditions, including employment, housing, nutrition, and greater access to health care." Many witnesses suggested that national objectives include special objectives grouped by and targeted to various demographic, racial, ethnic, and Bull. N.Y. Acad. Med.
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other subpopulations. Potential groups suggested include: the old and young, racial and ethic minorities, the poor and the homeless, and various kinds of workers. The basic rationale is that separate "component objectives" are necessary to identify groups most in need of intervention and to target programs, especially programs designed for their needs, to them. A number of public and private sector witnesses expressed their support for setting clear priorities among the objectives. For instance, Dr. Bernard Turnock, Director of the Illinois Department of Public Health, said: "Having clearly visible and repeatedly articulated priorities and broadly defining these priorities into categories is critically important. It allows all potential participants to better understand their role in addressing a collective health problem and serves to catalyze inclusion and participation over exclusion and avoidance. It focuses our efforts on the health outcomes and on the persons affected or potentially affected by the problems, rather than on the health care delivery system as so many of our past and current so-called health priorities have done. It establishes a focal point for integration and systemization of diverse efforts -including some even outside the traditional notion of health strategies - and provides a rallying point for seeking and securing new and expanded resources." IMPLEMENTING THE OBJECTIVES AT STATE AND LOCAL LEVELS
Realization of national objectives depends, in large measure, on the extent to which national, regional, state, and local organizations -both public and private -use and adapt them to better understand and to act on the health concerns of the groups and communities they serve. Since the publication of the 1990 Objectives for the Nation, many states, counties, and cities have developed their own objectives based on the national model, and state and local health officers testified at length about successes and failures. Testifiers made it clear that translating national objectives into an action plan for the nation must involve every one of the building blocks of the nation's public health system -the state and local health departments and districts. It must also involve the efforts of the private sector, including both businesses and professional and voluntary organizations. The American Public Health Association, among other testifiers, put in a strong call for public participation in the objectives process: "There is a need to involve the general public in health promotion and disease prevention, in order to enable individuals to determine for themselves the means to achieve optimal health. Methods should be developed to increase consumer participaVol. 66, No. 1, January-February 1990
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tion and expand the roles of health consumers in achieving the objectives for the nation." In addition to individuals, public participation involves communities and community organizations. For instance, Dr. Woodrow Myers, Indiana State Health Commissioner, reported that "We must do more work within our communities to revive their ability to identify and address their own health needs, to look for local solutions to local problems." The business community also has a role to play in implementing the Year 2000 Health Objectives. For instance, Dr. Paul Entmacher of Metropolitan Life and the Business Round Table said: "As corporate citizens and as major taxpayers, the country's major companies have a shared interest in the health of the nation. We recognize that the public sector should take the primary leadership role in establishing health objectives and providing surveillance over the nation's health, but the Business Round Table endorses the concept of ongoing, nonpartisan, appropriate, public-private collaboration in setting and measuring the nation's health objectives." Many witnesses said that involvement of these diverse groups -state and local health departments, business and the broader public -calls for strong federal leadership in implementing as well as determining the objectives. Their suggestions ranged from providing research results and technical assistance in implementing the objectives to the financing of state and local activities. Finally, many witnesses addressed the need for better surveillance systems to assess progress toward the objectives, both at the national and at the state and local level. For instance, Dr. Cecil Sheps, representing the American Public Health Association, said: "The data collection and analysis system is crucial, not only in identifying the nature and scale of problems in achieving the objectives but also in evaluating the implementation activities with a view to utilizing the most effective program to achieve the objectives." ACCESS TO PREVENTIVE SERVICES
Despite this strong call for community participation, many testifiers emphasized that the medical system is critical to the implementation of the Year 2000 Health Objectives. There are severe problems with access to preventive health care in the United States, and health professionals have an unfulfilled potential role in preventing disease and promoting the health of the American
population. Dr. Milton Roemer of the University of California at Los Angeles said: "Many, if not all, of the priorities on the national agenda can be substantially influenced by access to professional health care. To cite just a few examples, Bull. N.Y. Acad. Med.
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the detection of and intervention against hypertension and cancer, immunization against preventable infectious diseases, control of obesity, or the preventive management of depression require the services of physicians or other skilled health personnel. Yet some 35 to 40 million Americans do not have economic access to doctors through voluntary health insurance, Medicare, or Medicaid. Access to professional care may have very broad impacts on health promotion. Education and advice from a doctor can affect life-style- smoking, alcohol use, contraception, exercise, diet, stress -more effectively than the most skilled messages of mass media. Prevention is more effective if it is integrated with the delivery of medical care." Some, such as Dr. Roemer, saw the problem as access to medical care in general. Others focused their remarks on preventive services, per se. Problems of access to preventive services, as with health services more generally, are especially severe among the poor and the homeless. This population is large enough and includes enough of America's most vulnerable citizens to warrant particular concern in the Year 2000 Health Objectives, testifiers said. For instance, Dr. Stephen Joseph, the New York City Commissioner of Health, said: "The health problems of New York inevitably reflect the conditions of poverty in which too many families live. Confronting these environments means confronting the failures of our formal and informal education systems, chronic unemployability, the too-frequent drift into a lifetime of crime and drugs, the collapse of the nuclear family, and a worsening housing crisis." The problems that minorities face in access to health care are severe and complex, as many witnesses noted. They are caused not only by socioeconomic factors, but by different cultural attitudes and beliefs about health and medicine. Millions of Americans, especially blacks, wrote Dr. Daniel Blumenthal of the Morehouse School of Medicine, lack adequate access to quality health services. Reasons include: lack of insurance, and even "adequate" insurance does not cover preventive services; living in rural or innercity areas that are poorly served by physicians; and the shortage of minority physicians. Blumenthal reports that, for instance, although 12% of the U.S. population is black, fewer than 3 % of U.S. physicians are black. Furthermore, Dr. Osman Ahmed of Meharry Medical College said that "Blacks are known to delay in seeking health care within the traditional health care system, preferring to rely upon family, friends, and even spiritualists and healers during periods of economic and emotional stress." Dr. Ahmed suggested that unique value systems, together with medical care expenses, have prevented blacks from utilizing the health care system: "Since different loci of control are operating in Blacks, different health promotion strategies should be used to reach them." Vol. 66, No. 1, January-February 1990
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Other minority groups have similar difficulties with access to health care. "Hispanics, in particular Puerto Ricans, continue to have poorer health status, and excess morbidity and mortality compared to the majority population," according to Dr. Eric Munoz of the Long Island Jewish Medical Center. Munoz suggested that this disparity is due in part to less access to health care and preventive services in particular. HEALTH PROMOTION AND DISEASE PREVENTION IN MEDICAL SETTINGS
Implementation of national objectives for health promotion and disease prevention in medical settings depends on the participation of physicians, other health professionals, and the organizations in which they work. The testifiers had many recommendations as to how to make better use of health professionals in disease prevention and health promotion programs, including changes in training programs, payment and reimbursement systems, and stronger recruitment. A number of witnesses called on physicians to play a much stronger role in health promotion and disease prevention than they currently do. For instance, Dr. John Logsdon reported on a series of studies funded by the insurance industry under the banner of Project INSURE, which he directs. These studies have shown that: physicians are interested in clinical prevention, and they will effectively provide preventive services, including patient education, if they receive practice-based training and the financial barriers to preventive care are removed; such interventions can be effective in changing risk behaviors; and their costs can be controlled. According to the American Academy of Family Physicians, "Physicians in primary care can have a positive, cost-effective impact on health behaviors in very cost effective ways. For example, the simple offering by a general practitioner of advice to stop smoking to patients who come to the doctor for some reason other than smoking, results in a 5 percent quit rate at the end of one year. " To take advantage of the opportunities presented by physicians, the American Academy of Family Physicians called for insurance coverage of proved preventive services; systems for health-risk assessment and longitudinal tracking of screening examinations and health behaviors; improvement of the medical school curriculum; and research on preventive interventions. Other witnesses discussed the roles that a wide range of health professionals can play in implementing the health promotion and disease prevention Bull. N.Y. Acad. Med.
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objectives. The professional groups include pharmacists, nurses, midwives, public health professionals, and allied health professionals. In many cases, these groups are oriented to disease prevention and health promotion and effective at it, and minimal changes in training and funding patterns will have important effects. As a number of testifiers pointed out, nurses and allied health professionals are in positions to provide one-on-one patient education regarding life-styles and habits that will prevent illness. The policies of the health care organizations also have an important effect on access to preventive services. The general feeling was that hospitals, community health centers, and health maintenance organizations are interested in providing more preventive services, but funding patterns inhibit their ability to do so. For instance, Dr. Jack Owen of the American Hospital Association reported: "As chronic disease has replaced acute infectious disease as the major cause of morbidity and mortality, as the locus of care has shifted to the outpatient setting, and as the research base for broadly defined health promotion/disease prevention services has solidified, hospitals across the United States have become major providers of health promotion services and active partners with other local organizations in addressing community health problems." However, Dr. Owen reported that changes in hospital care -there are now more outpatient services, shorter inpatient stays, and more care of chronic illness than acute illness -have meant that hospitals have less opportunity to offer health education to patients. In addition, personnel shortages, especially in nursing, and inadequate financial resources may prevent health care professionals from being able to offer the wide range of educational efforts called for in the 1990 Objectives, such as counseling in safety belt use, nutrition education, physical fitness regimens, and stress and coping skills. Given the lack of progress toward some key objectives and the lack of access to private health insurance, Dr. Owen said "It is perhaps time to elevate financing for preventive services to the status of an objective if risk reduction and health status objectives are to be achieved for all populations." Dr. David Sobel of the Kaiser Permanente Medical Group in California reported that Health Maintenance Organizations (HMOs) offer special advantages for the efficient delivery of preventive and health promotion services: financial incentives to the organization for the implementation of cost-effective services, economies of scale in the delivery of health education services, and centralized medical records to help evaluate these initiatives. Dr. Sobel Vol. 66, No. 1, January-February 1990
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points out, however, that HMOs need to find ways to make sure that individual physicians, as well as the HMO as a whole, have incentives to provide preventive services. FINANCING HEALTH PROMOTION AND DISEASE PREVENTION
Many testifiers agreed that financing health promotion and disease prevention programs was an obstacle to overcome in implementing the national objectives. Some saw the problem in the context of a larger concern about overall health expenditures in the United States, and proposed changes in Medicare and Medicaid or in already existing federal grant programs. Most of those who testified on these issues, however, proposed major changes in the financing of health care, including a national health insurance policy. Some witnesses suggested that existing federal funding programs could do more to finance health promotion and disease prevention programs and to improve the access to health care more generally. In particular, testifiers addressed the possibilities of changing Medicare reimbursement policies for preventive services, increasing the Medicaid coverage to include more people and more services, and better coordinating block and categorical grant programs with the national objectives. The Health Policy Agenda for the American People, a collaborative effort of nearly 200 health, health-related, business, government, and consumer groups to impact health sector change, is developing recommendations to improve the current insurance system. The Health Policy Agenda has developed a "basic benefits package" to serve as the basis for private health insurance plans and for public programs that finance health care. Other witnesses, however, say that without major changes in the current system, which excludes many and provides little preventive care for those who are covered, it will be difficult to make progress on the Year 2000 Health Objectives. While some witnesses see a national health system or at least a national health insurance system as the only answer, others proposed changes to the existing private insurance system. For instance, Dr. Derrick Jelliffe of the University of California at Los Angeles said: "Until the country has some form of national health insurance coverage or other national health system enabling preventive and curative health services to be available to all economic levels in the country, the rest of the deliberations on the objectives border on the farcical. Unless one is careful, a potpourri of fragmented programs of limited extent and coverage may emerge in the usual sort of way. There is no way that the country can Bull. N.Y. Acad. Med.
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move from being a second-class nation as far as health services are concerned until national health coverage has been achieved." In some cases, the resources for health promotion and disease prevention programs are already available, but poorly coordinated. With regard to adolescent health problems, for instance, Drs. Claire Brindis and Philip Lee, of the University of California at San Francisco, wrote that "categorical programs that have followed traditional patterns and focused on a single aspect of an issue-family planning, drug abuse, counseling-have had limited success. " Only a small portion of the adolescent population has responded to this categorical, medical-model approach, they say. Instead, "communities need to work towards comprehensive and coordinated services -the collocation of health education, social, and job-related services, and combined funding from public and private sources. " Many testifiers called for better training to achieve the potential that health professionals, and especially physicians, offer for implementing the objectives. One issue is the need for more specialists in preventive medicine. Other witnesses called for better integration of the knowledge and skills needed for health promotion and disease prevention in the basic education of all health
professionals. Other witnesses, however, felt that the problem is not a shortage of health professionals overall, but rather their distribution. Many inner cities and rural areas have few physicians and other health professionals; furthermore, according to the witnesses, the main federal program for addressing this problem, the National Health Service Corps, is insufficient. The problems of underserved areas often intersect with the lack of access for minority populations. A number of testifiers suggested that one solution to this joint problem could be found in training more minority health professionals at all levels. Dr. Frederick Adams, Commissioner of the Connecticut Department of Health Services, said: "Ultimately, achievement of the nation's health objectives will depend not only on clearly articulated measures, but also on the availability of appropriately trained personnel who are representative of the communities served, and who recognize the fact that health is the outcome of many complex factors, involving individual, institutional and community behavior patterns. " CURRENT STATUS
That is a brief summary of what some of the testifiers said about the objectives process and health promotion and disease prevention in medical Vol. 66, No. 1, January-February 1990
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settings. Other witnesses, of course, addressed specific behaviors relevant to health, the social and physical environment, specific prevention services, and the problems experienced by particular population subgroups. Taken together, the testimony is a rich historical record of a wide range of public and professional views about health promotion and disease prevention at the time of the development of the Year 2000 Health Objectives. The Public Health Service has taken this testimony under advisement, has convened 21 separate working groups led by different PHS agencies, and is currently finishing up the first draft of the objectives for the year 2000. The handout I distributed lists the current areas in which there will be objectives. The PHS plans to distribute the draft objectives for public comment next month. The development of the Year 2000 Health Objectives has been an open process from the start. Thousands of individuals have been involved in presenting testimony and in drafting and reviewing objectives. We hope that this broad participation will lead to a deeper commitment to implementing the objectives when they become available next year. Please become a part of the process by reviewing and commenting on the objectives this summer. REFERENCES
1980. 1. U.S. Department of Health, Education, and Welfare: Healthy People: The Sur- 3. U.S. Department of Health and Human Services: The 1990 Health Objectives for geon General's Report on Health Promothe Nation: A Midcourse Review. Washtion and Disease Prevention. ington, D.C., Govt. Print. Off., 1986. Washington, D.C., Govt. Print. Off., 4. Public Health Foundation: Status Report: 1979. State Progress on 1990 Health Objectives 2. U.S. Department of Health and Human for the Nation. Washington, D.C, Public Services: Promoting Health/Preventing Health Foundation, 1988. Disease-Objectives for the Nation. Washington, D.C., Govt. Print. Off.,
Bull. N.Y. Acad. Med.
THE NATION'S HEALTH GOALS: SOCIAL CHANGE, PROBLEMS AND OPPORTUNITIES * MICHAEL A. STOTO, PH.D. Study Director National Health Objectives for the Year 2000 Institute of Medicine National Academy of Sciences Washington, D.C.
of national health objectives for the year 2000. The objectives will represent a national consensus on priorities for health promotion and disease prevention to guide public and private policy during the 1990s. Developing these objectives is a massive effort, involves a cast of thousands, and has been underway for almost two years. I am glad to let you know about our progress and to have the opportunity to get you involved in the development of the objectives. The rationale for the objectives reflects the increasing prominence of health promotion and disease prevention on the national health agenda. This new direction was made possible by fundamental medical and public health accomplishments of earlier generations: public health and sanitation reforms at the turn of the century, effective vaccines and antibiotics during the 1930s, and more recent improvements in clinical preventive services. Furthermore, these medical and public health developments coincide with a growing popular interest in improving overall health, beyond mere freedom from disease. The importance of the objectives stems from the ability of nationally identified goals to motivate and to recruit commitment of local and private resources. The Year 2000 Health Objectives project is a cooperative effort of the federal government, state, and local governments, professional and voluntary organizations (including those whose primary focus is other than health), other private sector organizations and individuals in these organizations, academia, and elsewhere. The lead organization is the Office of Disease Prevention and Health Promotion in the office of the Assistant Secretary M/[Y TOPIC IS THE DEVELOPMENT
*Presented in a panel, Today's Economic, Social, and Political Climate, as part of the Annual Health Conference, The Changing Agenda for Health Care in America: Balancing Need and Commitment, held by the Committee on Medicine in Society of the New York Academy of Medicine May 9 and 10, 1989. Address for reprint requests: Institute of Medicine, 2101 Constitution Avenue NW, Washington, D.C. 20418
Bull. N.Y. Acad. Med.
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for Health. The Institute of Medicine, which I represent, leads the effort to coordinate the work of all the nonfederal organizations involved. To set the stage for the development of the new national objectives, the Public Health Service and the Institute of Medicine last year sponsored seven regional hearings (including one here in New York City) and 10 more specialized hearings around the country, and took testimony from almost 800 individuals and organizations. Participants came from all walks of life, public and private. They included both health professionals and lay men and women, representatives of professional organizations, voluntary groups and private companies, and both academicians and practitioners. Racial and ethnic minority groups and all areas of the country were represented. Testifiers spoke about their hopes and plans, about the issues they would like to see addressed on a national level, and about the problems and successes that they see at the local level. Overall, this testimony presents a uniquely rich and detailed compilation of views about improving health in the United States. Its major strength is that it portrays the views of the people on the firing line in health promotion and disease prevention. While not everything proposed by these testifiers meets the standards that a scientific organization would apply to information for setting national policies, the testimony provides valuable "intelligence" about the thinking and the resources available to both the generals and the foot soldiers in the battle for the health of Americans. I shall use most of my time this morning on what these witnesses said about two major issues: the development and implementation of national objectives and the need for better access to health promotion and disease prevention in medical settings. Much more was said about specific health promotion activities and preventive services, but this material is too lengthy to even try to summarize in a brief time. I shall finish with a brief report on the current status of the objective development process.
Objectives Process and Implementation The process of setting national health objectives began a decade ago with the publication of a set of overall goals for five broad age groups in Healthy People, the first Surgeon General's report on health promotion and disease prevention.1 For example, one goal was: "To continue to improve infant health, and, by 1990, to reduce infant mortality by at least 35 percent, to fewer than nine deaths per 1,000 live births." The next year the Public Health Service published 226 specific, quantitative objectives addressing health outcomes and the reduction of associated risk factors, public and professional awareness of health promotion and disVol. 66, No. 1, January-February 1990
20
M.A. STOTO
ease prevention issues, the provision of preventive services and health protections, and surveillance systems to assess progress.2 For instance, one of the objectives was: "By 1990, low birth weight babies (2,500 grams and under) should constitute no more than five percent of all live births." Overall, the 1990 Objectives have been successful. In a 1985 progress review, about half of the objectives were either already achieved or on track to be accomplished by 1990, and only about one quarter seemed unlikely to be achieved. There were no data, however, to assess progress toward the rest of the objectives.3 More important, by last year all but one of the U. S. states and territories had established or begun to establish objectives of their own.4
STRUCTURE AND Focus OF THE OBJECTIVES The 226 objectives for 1990 were divided into three broad functional groups: Health promotion activities that seek to facilitate community and individual measures to foster lifestyles that maintain and enhance the state of health and well-being. Health protection activities that target population groups and foster changes in their environments conducive to improved health and well-being. Health protection activities include changes both in the physical environment and in the social environment brought about through technical means and through legislation and government regulation. Preventive health services that are targeted toward individuals to prevent specific diseases and disorders. These interventions are usually carried out in medical settings. Although many testifiers accepted this framework and commented on specific issues, a few felt that national objectives focused exclusively on health matters were in danger of missing the underlying causes of illness. For example, Mr. Jule Sugarman, secretary of the Washington State Department of Social and Health Services, said that "As broad as these objectives are and will be, they are not broad enough to assure the preservation of health. The World Health Organization is asking its member nations to consider in its health policies the impact on health of education, housing, business, agriculture and the other sectors of society. We in this nation need to give more public attention to these intersectorial impacts on health." In a similar vein, the American Public Health Association suggested that "many health problems could be ameliorated by improved social conditions, including employment, housing, nutrition, and greater access to health care." Many witnesses suggested that national objectives include special objectives grouped by and targeted to various demographic, racial, ethnic, and Bull. N.Y. Acad. Med.
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THE NATION'S
21 21
other subpopulations. Potential groups suggested include: the old and young, racial and ethic minorities, the poor and the homeless, and various kinds of workers. The basic rationale is that separate "component objectives" are necessary to identify groups most in need of intervention and to target programs, especially programs designed for their needs, to them. A number of public and private sector witnesses expressed their support for setting clear priorities among the objectives. For instance, Dr. Bernard Turnock, Director of the Illinois Department of Public Health, said: "Having clearly visible and repeatedly articulated priorities and broadly defining these priorities into categories is critically important. It allows all potential participants to better understand their role in addressing a collective health problem and serves to catalyze inclusion and participation over exclusion and avoidance. It focuses our efforts on the health outcomes and on the persons affected or potentially affected by the problems, rather than on the health care delivery system as so many of our past and current so-called health priorities have done. It establishes a focal point for integration and systemization of diverse efforts -including some even outside the traditional notion of health strategies - and provides a rallying point for seeking and securing new and expanded resources." IMPLEMENTING THE OBJECTIVES AT STATE AND LOCAL LEVELS
Realization of national objectives depends, in large measure, on the extent to which national, regional, state, and local organizations -both public and private -use and adapt them to better understand and to act on the health concerns of the groups and communities they serve. Since the publication of the 1990 Objectives for the Nation, many states, counties, and cities have developed their own objectives based on the national model, and state and local health officers testified at length about successes and failures. Testifiers made it clear that translating national objectives into an action plan for the nation must involve every one of the building blocks of the nation's public health system -the state and local health departments and districts. It must also involve the efforts of the private sector, including both businesses and professional and voluntary organizations. The American Public Health Association, among other testifiers, put in a strong call for public participation in the objectives process: "There is a need to involve the general public in health promotion and disease prevention, in order to enable individuals to determine for themselves the means to achieve optimal health. Methods should be developed to increase consumer participaVol. 66, No. 1, January-February 1990
22
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tion and expand the roles of health consumers in achieving the objectives for the nation." In addition to individuals, public participation involves communities and community organizations. For instance, Dr. Woodrow Myers, Indiana State Health Commissioner, reported that "We must do more work within our communities to revive their ability to identify and address their own health needs, to look for local solutions to local problems." The business community also has a role to play in implementing the Year 2000 Health Objectives. For instance, Dr. Paul Entmacher of Metropolitan Life and the Business Round Table said: "As corporate citizens and as major taxpayers, the country's major companies have a shared interest in the health of the nation. We recognize that the public sector should take the primary leadership role in establishing health objectives and providing surveillance over the nation's health, but the Business Round Table endorses the concept of ongoing, nonpartisan, appropriate, public-private collaboration in setting and measuring the nation's health objectives." Many witnesses said that involvement of these diverse groups -state and local health departments, business and the broader public -calls for strong federal leadership in implementing as well as determining the objectives. Their suggestions ranged from providing research results and technical assistance in implementing the objectives to the financing of state and local activities. Finally, many witnesses addressed the need for better surveillance systems to assess progress toward the objectives, both at the national and at the state and local level. For instance, Dr. Cecil Sheps, representing the American Public Health Association, said: "The data collection and analysis system is crucial, not only in identifying the nature and scale of problems in achieving the objectives but also in evaluating the implementation activities with a view to utilizing the most effective program to achieve the objectives." ACCESS TO PREVENTIVE SERVICES
Despite this strong call for community participation, many testifiers emphasized that the medical system is critical to the implementation of the Year 2000 Health Objectives. There are severe problems with access to preventive health care in the United States, and health professionals have an unfulfilled potential role in preventing disease and promoting the health of the American
population. Dr. Milton Roemer of the University of California at Los Angeles said: "Many, if not all, of the priorities on the national agenda can be substantially influenced by access to professional health care. To cite just a few examples, Bull. N.Y. Acad. Med.
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THE
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the detection of and intervention against hypertension and cancer, immunization against preventable infectious diseases, control of obesity, or the preventive management of depression require the services of physicians or other skilled health personnel. Yet some 35 to 40 million Americans do not have economic access to doctors through voluntary health insurance, Medicare, or Medicaid. Access to professional care may have very broad impacts on health promotion. Education and advice from a doctor can affect life-style- smoking, alcohol use, contraception, exercise, diet, stress -more effectively than the most skilled messages of mass media. Prevention is more effective if it is integrated with the delivery of medical care." Some, such as Dr. Roemer, saw the problem as access to medical care in general. Others focused their remarks on preventive services, per se. Problems of access to preventive services, as with health services more generally, are especially severe among the poor and the homeless. This population is large enough and includes enough of America's most vulnerable citizens to warrant particular concern in the Year 2000 Health Objectives, testifiers said. For instance, Dr. Stephen Joseph, the New York City Commissioner of Health, said: "The health problems of New York inevitably reflect the conditions of poverty in which too many families live. Confronting these environments means confronting the failures of our formal and informal education systems, chronic unemployability, the too-frequent drift into a lifetime of crime and drugs, the collapse of the nuclear family, and a worsening housing crisis." The problems that minorities face in access to health care are severe and complex, as many witnesses noted. They are caused not only by socioeconomic factors, but by different cultural attitudes and beliefs about health and medicine. Millions of Americans, especially blacks, wrote Dr. Daniel Blumenthal of the Morehouse School of Medicine, lack adequate access to quality health services. Reasons include: lack of insurance, and even "adequate" insurance does not cover preventive services; living in rural or innercity areas that are poorly served by physicians; and the shortage of minority physicians. Blumenthal reports that, for instance, although 12% of the U.S. population is black, fewer than 3 % of U.S. physicians are black. Furthermore, Dr. Osman Ahmed of Meharry Medical College said that "Blacks are known to delay in seeking health care within the traditional health care system, preferring to rely upon family, friends, and even spiritualists and healers during periods of economic and emotional stress." Dr. Ahmed suggested that unique value systems, together with medical care expenses, have prevented blacks from utilizing the health care system: "Since different loci of control are operating in Blacks, different health promotion strategies should be used to reach them." Vol. 66, No. 1, January-February 1990
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Other minority groups have similar difficulties with access to health care. "Hispanics, in particular Puerto Ricans, continue to have poorer health status, and excess morbidity and mortality compared to the majority population," according to Dr. Eric Munoz of the Long Island Jewish Medical Center. Munoz suggested that this disparity is due in part to less access to health care and preventive services in particular. HEALTH PROMOTION AND DISEASE PREVENTION IN MEDICAL SETTINGS
Implementation of national objectives for health promotion and disease prevention in medical settings depends on the participation of physicians, other health professionals, and the organizations in which they work. The testifiers had many recommendations as to how to make better use of health professionals in disease prevention and health promotion programs, including changes in training programs, payment and reimbursement systems, and stronger recruitment. A number of witnesses called on physicians to play a much stronger role in health promotion and disease prevention than they currently do. For instance, Dr. John Logsdon reported on a series of studies funded by the insurance industry under the banner of Project INSURE, which he directs. These studies have shown that: physicians are interested in clinical prevention, and they will effectively provide preventive services, including patient education, if they receive practice-based training and the financial barriers to preventive care are removed; such interventions can be effective in changing risk behaviors; and their costs can be controlled. According to the American Academy of Family Physicians, "Physicians in primary care can have a positive, cost-effective impact on health behaviors in very cost effective ways. For example, the simple offering by a general practitioner of advice to stop smoking to patients who come to the doctor for some reason other than smoking, results in a 5 percent quit rate at the end of one year. " To take advantage of the opportunities presented by physicians, the American Academy of Family Physicians called for insurance coverage of proved preventive services; systems for health-risk assessment and longitudinal tracking of screening examinations and health behaviors; improvement of the medical school curriculum; and research on preventive interventions. Other witnesses discussed the roles that a wide range of health professionals can play in implementing the health promotion and disease prevention Bull. N.Y. Acad. Med.
THE NATlON'S HEALTH GOALS GOALS
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objectives. The professional groups include pharmacists, nurses, midwives, public health professionals, and allied health professionals. In many cases, these groups are oriented to disease prevention and health promotion and effective at it, and minimal changes in training and funding patterns will have important effects. As a number of testifiers pointed out, nurses and allied health professionals are in positions to provide one-on-one patient education regarding life-styles and habits that will prevent illness. The policies of the health care organizations also have an important effect on access to preventive services. The general feeling was that hospitals, community health centers, and health maintenance organizations are interested in providing more preventive services, but funding patterns inhibit their ability to do so. For instance, Dr. Jack Owen of the American Hospital Association reported: "As chronic disease has replaced acute infectious disease as the major cause of morbidity and mortality, as the locus of care has shifted to the outpatient setting, and as the research base for broadly defined health promotion/disease prevention services has solidified, hospitals across the United States have become major providers of health promotion services and active partners with other local organizations in addressing community health problems." However, Dr. Owen reported that changes in hospital care -there are now more outpatient services, shorter inpatient stays, and more care of chronic illness than acute illness -have meant that hospitals have less opportunity to offer health education to patients. In addition, personnel shortages, especially in nursing, and inadequate financial resources may prevent health care professionals from being able to offer the wide range of educational efforts called for in the 1990 Objectives, such as counseling in safety belt use, nutrition education, physical fitness regimens, and stress and coping skills. Given the lack of progress toward some key objectives and the lack of access to private health insurance, Dr. Owen said "It is perhaps time to elevate financing for preventive services to the status of an objective if risk reduction and health status objectives are to be achieved for all populations." Dr. David Sobel of the Kaiser Permanente Medical Group in California reported that Health Maintenance Organizations (HMOs) offer special advantages for the efficient delivery of preventive and health promotion services: financial incentives to the organization for the implementation of cost-effective services, economies of scale in the delivery of health education services, and centralized medical records to help evaluate these initiatives. Dr. Sobel Vol. 66, No. 1, January-February 1990
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points out, however, that HMOs need to find ways to make sure that individual physicians, as well as the HMO as a whole, have incentives to provide preventive services. FINANCING HEALTH PROMOTION AND DISEASE PREVENTION
Many testifiers agreed that financing health promotion and disease prevention programs was an obstacle to overcome in implementing the national objectives. Some saw the problem in the context of a larger concern about overall health expenditures in the United States, and proposed changes in Medicare and Medicaid or in already existing federal grant programs. Most of those who testified on these issues, however, proposed major changes in the financing of health care, including a national health insurance policy. Some witnesses suggested that existing federal funding programs could do more to finance health promotion and disease prevention programs and to improve the access to health care more generally. In particular, testifiers addressed the possibilities of changing Medicare reimbursement policies for preventive services, increasing the Medicaid coverage to include more people and more services, and better coordinating block and categorical grant programs with the national objectives. The Health Policy Agenda for the American People, a collaborative effort of nearly 200 health, health-related, business, government, and consumer groups to impact health sector change, is developing recommendations to improve the current insurance system. The Health Policy Agenda has developed a "basic benefits package" to serve as the basis for private health insurance plans and for public programs that finance health care. Other witnesses, however, say that without major changes in the current system, which excludes many and provides little preventive care for those who are covered, it will be difficult to make progress on the Year 2000 Health Objectives. While some witnesses see a national health system or at least a national health insurance system as the only answer, others proposed changes to the existing private insurance system. For instance, Dr. Derrick Jelliffe of the University of California at Los Angeles said: "Until the country has some form of national health insurance coverage or other national health system enabling preventive and curative health services to be available to all economic levels in the country, the rest of the deliberations on the objectives border on the farcical. Unless one is careful, a potpourri of fragmented programs of limited extent and coverage may emerge in the usual sort of way. There is no way that the country can Bull. N.Y. Acad. Med.
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move from being a second-class nation as far as health services are concerned until national health coverage has been achieved." In some cases, the resources for health promotion and disease prevention programs are already available, but poorly coordinated. With regard to adolescent health problems, for instance, Drs. Claire Brindis and Philip Lee, of the University of California at San Francisco, wrote that "categorical programs that have followed traditional patterns and focused on a single aspect of an issue-family planning, drug abuse, counseling-have had limited success. " Only a small portion of the adolescent population has responded to this categorical, medical-model approach, they say. Instead, "communities need to work towards comprehensive and coordinated services -the collocation of health education, social, and job-related services, and combined funding from public and private sources. " Many testifiers called for better training to achieve the potential that health professionals, and especially physicians, offer for implementing the objectives. One issue is the need for more specialists in preventive medicine. Other witnesses called for better integration of the knowledge and skills needed for health promotion and disease prevention in the basic education of all health
professionals. Other witnesses, however, felt that the problem is not a shortage of health professionals overall, but rather their distribution. Many inner cities and rural areas have few physicians and other health professionals; furthermore, according to the witnesses, the main federal program for addressing this problem, the National Health Service Corps, is insufficient. The problems of underserved areas often intersect with the lack of access for minority populations. A number of testifiers suggested that one solution to this joint problem could be found in training more minority health professionals at all levels. Dr. Frederick Adams, Commissioner of the Connecticut Department of Health Services, said: "Ultimately, achievement of the nation's health objectives will depend not only on clearly articulated measures, but also on the availability of appropriately trained personnel who are representative of the communities served, and who recognize the fact that health is the outcome of many complex factors, involving individual, institutional and community behavior patterns. " CURRENT STATUS
That is a brief summary of what some of the testifiers said about the objectives process and health promotion and disease prevention in medical Vol. 66, No. 1, January-February 1990
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settings. Other witnesses, of course, addressed specific behaviors relevant to health, the social and physical environment, specific prevention services, and the problems experienced by particular population subgroups. Taken together, the testimony is a rich historical record of a wide range of public and professional views about health promotion and disease prevention at the time of the development of the Year 2000 Health Objectives. The Public Health Service has taken this testimony under advisement, has convened 21 separate working groups led by different PHS agencies, and is currently finishing up the first draft of the objectives for the year 2000. The handout I distributed lists the current areas in which there will be objectives. The PHS plans to distribute the draft objectives for public comment next month. The development of the Year 2000 Health Objectives has been an open process from the start. Thousands of individuals have been involved in presenting testimony and in drafting and reviewing objectives. We hope that this broad participation will lead to a deeper commitment to implementing the objectives when they become available next year. Please become a part of the process by reviewing and commenting on the objectives this summer. REFERENCES
1980. 1. U.S. Department of Health, Education, and Welfare: Healthy People: The Sur- 3. U.S. Department of Health and Human Services: The 1990 Health Objectives for geon General's Report on Health Promothe Nation: A Midcourse Review. Washtion and Disease Prevention. ington, D.C., Govt. Print. Off., 1986. Washington, D.C., Govt. Print. Off., 4. Public Health Foundation: Status Report: 1979. State Progress on 1990 Health Objectives 2. U.S. Department of Health and Human for the Nation. Washington, D.C, Public Services: Promoting Health/Preventing Health Foundation, 1988. Disease-Objectives for the Nation. Washington, D.C., Govt. Print. Off.,
Bull. N.Y. Acad. Med.
