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I. Introduction Of the broad range of governmental responsi- bilities in public health, perhaps none is more fundamental than the obligation to provide perspective and direction to guide health pro- grams along a productive course-the agenda- setting function. Its importance stems from the ability of nationally identified goals to motivate and recruit the commitment of local and private resources.] Fulfilling this responsibility, the U.S. Public Health Service and other public and private organizations around the country through the Healthy People 2000 process are about to embark on a course aimed at achieving ambitious national health goals by the year 2000. This effort builds on the nation's decade-long initiative to meet a series of health promotion/disease prevention objectives established in the late 1970s aimed at making the United States a nation of healthy people, regardless of age, race, or socioeco- nomic status, by 1990. These goals are national in scope, and the suc- cesses that have been achieved also must be credited to a national-not solely a federal or governmental- effort. In establishing a new set of health objectives for the year 2000, it is clear that the cooperation and commitment of every segment of the public and pri- vate sectors are needed. Only through concerted, focused efforts, made by large numbers of caring, concerned individuals and organizations, can this become a nation of truly healthy people. As a first step in this process, the views of Americans from all sectors about what the goals should be are summa- rized in this report. HISTORY AND PURPOSE OF THE OBJECTIVES Because of the fundamental public health accomplish- ments of earlier generations, today's national health agenda focuses increasingly on health promotion and disease prevention. This new direction was made possible by massive public health and sanitation reforms after the turn of the century that dramatically reduced infectious diseases. In the 1930s the intro- duction of effective vaccines and antibiotics further improved health status. More recent improvements in clinical care can be tied to revolutionary advances in medical research and medical technology. Although disease prevention has always been a major responsibility of the Public Health Service (PHS), in the late 1970s the PHS recommitted its efforts to health promotion and disease prevention in response to Title XVII of the Public Health Senace Act, which directed the Secretary of Health and Human Services to establish national goals for health promotion and disease prevention. The PHS respond- ed in 1979 by publishing Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention.2 The report presented a set of general goals for reducing preventable death and injury in different age groups by 1990. In 1980 the PHS took the process a step further by identifying a set of 226 quantitative health promotion and disease prevention objectives for 1990 in Promot- ing Health/Preventing Disease: Objectives for the Na- tion.3 The publication followed extensive reviews of the knowledge base and expert opinion in each area. The objectives were expressed as quantitative measures, for example, reducing the national rate of infant mortality to no more than 9 out of 1,000 live births by 1990. (In 1978 the infant mortality rate was 12 per 1,000 live births.) Additional objectives ad- dressed the special needs of minorities, one stating that by 1990, no county and no racial or ethnic group should have an infant mortality rate in excess of 12 deaths per 1,000 live births. (In 1978 the rate for Blacks was 23 per 1,000 live births.) The range of endpoints encompassed by the objectives included improved health status, reduced risk factors, increased public and professional awareness, improved services and protection, and improved surveillance and evalua- tion systems. During the 1980s, these objectives for improving clinical preventive services, health protection, and health promotion provided a common strategy and a frame of reference that sparked new initiatives by state and local governments and community organiza- tions and increased interagency cooperation in the federal government. Perhaps most important, they provided a sense of unity for the disparate profes- sional activities, both public and private, that con- tribute so much to the health of the country. Be- cause the health objectives set precise numerical targets and provided baseline data for measuring Introduction 1

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progress, they have served to track improvements and to spotlight problem areas in the nation's health status. National response to the 1990 Objectives has confirmed the usefulness of the objectives approach. By 1985, the United States was on the way to meeting about half of the 1990 Objectives, and the country has seen major reductions in the amount of illness and death in specified categories for infants, children, and adults.4 The success of the 1990 Objectives demonstrates vividly that a well-formulated set of national health promotion and disease prevention objectives can increase interagency and intergovernmental coopera- tion and can provide a lasting health promotion/ disease prevention strategy that will continue to capture public interest over time. Health promotion and disease prevention deserve a massive, interdisc~pli- nary effort from government and the private sector. In the course of developing new objectives to be achieved by the year 2000, suggestions were offered about how to make the process maximally effective. As Jerrold Michael, Dean of the School of Public Health of the University of Hawaii, says, Objectives are only meaningful when they reflect and are relevant to a vision that we have of the kind of society we want." The conditions necessary to achieve these ob- jectives are important, especially competence in the health professions and informed supportive leadership in the com- munity. Achievement of health objectives is not in the hands of the health professions alone. The resources of health, education, economic development, and human services must become connected to and interwoven with health objec- tives. (~149) A group of state health officers, all of whom have worked to implement the 1990 Objectives within their states, summed up their view of the national objec- tives in this way. First, they felt that the objectives should be national, not just federal. Although the federal government is providing leadership and a process for developing the objectives, federal, state, and local government officials; industry; educational institutions; and private, nonprofit organizations must "take ownership" of the objectives and play a role in implementing them. Second, they felt that the objec- tives process must allow for local/regional variations in which communities can outline and address their independent needs within the national framework. Third, they said that the objectives should be tied to 2 Healthy People 2000: Citizens Chart the Course a process of implementation so that states and communities can implement national goals at the local level. Finally, they felt that establishing and achieving national health objectives is a process that will require the commitment of resources from all levels of government-not just the federal government-as well as from private sources. Lawmaking bodies, from the Congress to individual city councils, must be encouraged to accept the idea of national objectives and support the objectives by appropriating funds. Resources from industry and nonprofit organizations must be identified and mobilized. (#750) The private sector agrees. According to Paul Entmacher, who represented the Business Roundtable: The public sector should take the primary leadership role in establishing health objectives and providing surveillance over the nation's health, but the Business Roundtable endorses the concept of ongoing, nonpartisan, appro- priate, public-private collaboration in setting and measuring the nation's health objectives. We naturally wish to contribute mainly to those objectives that could affect the employers and employees in the business community in the United States in the year 2000. There is a fundamental commonality, however, between the eventual national objectives and the nation's private sector work force because as citizens and taxpayers they either are or ought to be vitally concerned about the health of their environment. (#465) HEARINGS AND TESTIMONY To develop a framework for cooperation and action by the diverse groups that play important roles in improving the nation's health, the Public Health Service and the Institute of Medicine (IOM) held hearings in seven cities across the country in early 1988. The purpose of the hearings was to solicit testimony from a broad range of individuals and community organizations about appropriate and attainable national health promotion and disease prevention objectives for the year 2000. The hearings provided a forum for groups and individuals to propose precise quantitative objectives for maintaining health and reducing death, disease, and disability; interventions to meet these objectives; and surveillance programs to assess preventive needs and efforts. The hearings also provided an oppor

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tunity to build upon the nation's earlier prevention program, the 1990 Objectives for the Nation, first presented by the Surgeon General in 1980. An outgrowth of the hearings was the promotion of widespread interest and involvement in the agenda- setting process in general, as well as a commitment on the part of virtually all testifiers to help develop and implement the Year 2000 Health Objectives specifically. The PHS and the IOM also have convened a Year 2000 Health Objectives Consortium Qf more than 300 national professional and voluntary organizations and state and territorial health departments to help guide the hearing process. These organizations held their own special hearings on the objectives, submitted official written testimony, and helped review the draft objectives. Equally important, these groups (listed in the appendix) will provide leadership in all sectors and at all levels in implementing the Year 2000 Health Objectives. The IOM and the PHS used a two-prong strategy to organize the hearings. First, local cosponsors were identified in each of the cities, including schools of public health and departments of community medi- cine, state health departments, and local voluntary and professional organizations. All of the local cospon- sors were asked to suggest speakers from the geogra- phical area of the hearing. Second, consortium mem- ber organizations were asked to suggest speakers for each of the regional hearings. Day-and-a-half-long regional hearings were held in seven cities Birmingham, Los Angeles, Houston, Seattle, Denver, Detroit, and New York-between January and March 1988. A total of almost 1,000 participants registered for the hearings, including representatives of the sponsoring organizations, repre- sentatives of consortium groups and other interested local and national organizations, public health offi- cials, college and university faculty and students, and others. Speakers at the hearings represented the wide variety of organizations that work to promote health, including public and private health care organizations; public health agencies at federal, state, and local levels; employers; schools; insurers; community organizations; and minority groups. Almost 100 national and local organizations suggested speakers. Each hearing provided time for brief invited testi- mony, followed by an open session for comments from the floor. In all, 318 people testified at regional hearings. In addition, many individuals who were not able to attend the hearings submitted written testi- mony. In total more than 800 individuals and organizations submitted testimony. At each of the seven regional hearings, a panel received the testimony on behalf of the Public Health Service and questioned the speakers to help claritr their points of view and recommendations. The panels included representatives of the PHS central office (Washington or Atlanta), the PHS regional office, the Association of State and Territorial Health Officers, the IOM, and other private sector groups. Questions for Testifiers In preparing their testimony, testifiers were asked to address the following questions: 1. What targets for disease prevention and health promotion should be identified for achievement by the year 2000 that were not identified in the 1990 Objec- tives? What measures do you propose for improving health status or reducing risk factors? What measures do you propose for achieving the outcomes selected? 2. Which, if any, of the 1990 targets for preven- tion might be dropped in the Year 2000 Health Objectives? 3. In reviewing the 1990 Objectives in your arrays) of interest, what revisions do you suggest in the quantitative measures proposed, both in health outcomes and in prevention/promotion approaches such as professional education, information services, technology, research, and evaluation? 4. What data are available for tracking the quan- titative measures you propose? What suggestions can you make for closing gaps in such data? 5. In discussing the burden of illness and the cost to societr of identified target areas, what are your suggestions to improve measures of these costs? Because their oral presentations were brief, speakers were encouraged to supplement their remarks with written testimony. They also were asked to include documentation and specific references to the literature on each subject area. Scope of the Testimony The testifiers addressed nearly every aspect of health promotion and disease prevention but, as might be expected, their testimony was not evenly distributed across topics, nor was it proportional to the relative magnitude of various health problems. Although most of the testimony focused on objectives them- seIves, many speakers addressed the needs of special Introduction 3

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populations and crosscutting areas such as implement- ing the objectives and financing health promotion and disease prevention programs. Approximately one-third of the speakers testified primarily about the need to develop preventive services targeted against specific diseases and problems such as cancer, heart disease and stroke, infant mortality, unintended pregnancies (especially among adolescents), AIDS, infectious and sexually transmitted diseases, oral health problems, and other chronic conditions. Chronic diseases also were dis- cussed frequently in testimony that focused on health promotion strategies. More than one-fourth of those who testified stressed health promotion issues, including behavior modification and health education. Speakers asked for strengthened programs dealing with smoking and smokeless tobacco use, alcohol and drug abuse, nutrition, physical fitness, and mental health. About one in four speakers addressed the special needs of components of the population. Some ad- dressed the needs of racial and ethnic minorities such as Blacks, Hispanics, and Native Americans. Others focused on the needs of population age groups, espe- cially the elderly and adolescents, as well as the disabled. Many stressed the special needs of the poor and homeless. The speakers who addressed these issues generally agreed that more objectives should be targeted specifically toward these groups than had been for 1990. Approximately one in five witnesses testified about health problems and solutions associated with the physical and social environment. Some wrote or spoke about efforts to clean up the air, the water, and the food supply, and to improve the disposal of hazardous waste. Others addressed intentional and unintentional violence, often stemming from alcohol or drug abuse and family problems. Many speakers addressed the need for improved workplace safety and disease prevention measures. Many witnesses identified areas in which resources were lacking, including (1) data, especially for states and smaller areas, and for minorities; (2) information about successful prevention strategies; (3) personnel resources; and above all, (4) financial resources for preventive services and health promotion programs. Speakers also addressed technical issues, including developing and implementing national objectives at the state and local levels as well as the need to reduce the number of objectives and have them reflect national priorities. Witnesses answered the questions given to them in 4 Healthy People 2000: Citizens Chart the Course advance, but most speakers did not address all of the questions. Some 450 testifiers recommended specific health promotion and disease prevention programs, and one-third of these gave some information on their efficacy. A similar number suggested objectives to be considered, at least in a generic form, and more than half of these witnesses proposed specific, quantitative values that they thought were achievable by the year 2000. After the hearings and the submission of all written testimony, the process began that would summarize more than 800 pieces of testimony into a form that could be used by 21 PHS working groups to develop actual objectives. First, each piece of testimony was categorized according to topic, target group, and delivery setting addressed. Then each individual piece of testimony was summarized. In addition, papers were developed synthesizing the testimony that was given on 18 individual topics, 4 target populations, and 4 imple- mentation issues that cut across all topic areas. Finally, all of the objectives proposed by the witnesses were compiled and matched to the relevant topics. Completed summary material was then sent to the appropriate PHS working groups. Members of the working groups also had the opportunity to read the complete body of testimony or refer to it for clarification of a particular point. PURPOSE AND STRUCTURE OF THIS REPORT This report has two purposes: First, it provides important information for those drafting objectives at all levels. The report does not relate every statement made in the testimony, but instead highlights major themes, puts the testimony in context, and spells out the implications of this testimony for setting objectives. All of the testimony has been distributed to the groups writing the national objectives, and this report serves as a guide to that material. Groups drafting objectives for states or local areas, or for other organizations, should also find the structure created by this report and the material summarized here useful. Second, it serves as the record of a unique process in which over 1,000 concerned health professionals and laymen from all regions of the country contributed their knowledge and experience to the building of national objectives for health promotion and disease prevention. Those present at the regional hearings were uniformly impressed with the level of commitment that the participants exhibited to the

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objectives-setting process and to the activities that the objectives address. To build broader commitment to the Year 2000 Health Objectives, this report recognizes the contributions these individuals made and documents their efforts. Although the report has been checked for factual accuracy and completeness, it is primarily the work of the individuals who submitted testimony. It does not attempt or purport to fully discuss the topics in terms of data, or of programming, evaluation, and policy issues. Rather, it is designed to document the hearings and to present highlights in a form that is useful to those attempting to adapt and implement the objectives at the state, national, or local level. The oputions expressed in this report are those of the testifiers, not the Institute of Medicine or its parent organization, the National Academy of Sciences. Tes- timony cited and quoted in the text is referenced with a number in parentheses, and a list at the end of each chapter gives the name and affiliation of the testifiers (as of the date of their testimony). When testimony was received in writing from one of the consortium organizations, the statement is attributed to the organization rather than to the individual who sub- mitted it. This report is input to the Healthy People 2000 process, but it is not the final word. The Year 2000 Health Objectives themselves will be published by the Public Health Senace in September 1990. Structure of This Document Because both the testifiers and the readers of this report approach health promotion and disease prevention activities from different perspectives, a number of organizing principles have been used for the report. First, following this introduction, the report contains two chapters that address crosscutting issues relating to the development of objectives or their implementation. Chapter 2 discusses the process of developing national, state, and local objectives and is based on experience with the 1990 Objectives around the country. Chapter 3 focuses on implementing the objectives at the state and local levels, including the need for surveillance and information resources. The chapters on the structure and format of the objectives and the process of determining their content will be useful to those developing similar objectives for states, local areas, and other segments of the population. The chapter on implementation, surveillance, and information resources addresses the steps necessary to implement the objectives at all levels. Second, the report contains four chapters that address special health promotion and disease preven- tion needs and opportunities in particular components of the population. These include children and adoles- cents, older adults, people with disabilities, and racial or ethnic minorities. These groups deserve special attention (1) because their problems are especially severe; (2) because individualized, culturally specific approaches are sometimes required to address these problems; and (3) because the only way to make a substantial difference for the entire population is to target groups whose problems are particularly severe. Third, the report summarizes the large amount of testimony that was received on health promotion and disease prevention in special settings, especially in the health care system, in schools, at the worksite, and in the community. Chapters address the potential for health promotion and disease prevention activities in the four settings, the barriers to these activities in medical and nonmedical settings, and the means to overcome them. Principles of health education appro- priate for all settings are also discussed. The remainder of the material is organized accord- ing to the substantive priority areas for which national objectives will be formulated. There are 18 such chapters, organized into three groups. 'rhe first group addresses behavioral risk factors and problems: tobacco use, alcohol and drug abuse, nutrition, physical fitness, and mental health issues. The second group discusses health problems related to the physi- cat and social environment: unintentional injuries, violence and abusive behavior, environmental health, and occupational safety and health issues. The third group focuses on approaches to preventing specific diseases and health problems: human immunodefi- ciency virus (HIV) infection, sexually transmitted diseases, infectious diseases, maternal and infant health problems, adolescent pregnancy, heart disease and stroke, cancer, other chronic and disabling conditions, and oral health problems. The following three groupings correspond roughly to the three categories that have come to represent health promotion and disease prevention activities and the national objectives. 1. Health promotion activities seek to facilitate community and individual measures to foster life- styles that maintain and enhance the state of health and well-being. 2. Health protection activities target population groups and foster changes in the environment con- ducive to improved health and well-being. Health Introduction

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protection activities include changes in the physical environment as well as changes in the social environ- ment brought about through legislation and govern- ment regulation. 3. Preventive health services are targeted toward individuals to prevent the occurrence of specific di- seases and disorders. These interventions are usually REFERENCES 1. McGinnis JM: Setting nationwide objectives in disease prevention and health promotion. The United States experience. Oxford Textbook of Public Health. Edited by WW Holland, R Detels, G Knox. Oxford: Oxford University Press, 1985 earned out in health care settings. Many of the health problems addressed by the objectives, however, require a range of health promo- tion, health protection, and preventive senace measures, and do not fall cleanly into one of these categories. Nevertheless, the categories are helpful in organizing discussion and efforts, and appear in venous ways throughout this report. 2. U.S. Department of Health, Education and Welfare: Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention (DHEW Publication No. [PHS] 79-55071), 1979 3. U.S. Department of Health and Human Services: Promoting Health/Preventing Disease: Objectives for the Nation. Washington, D.C.: U.S. Government Printing Office, 1980 4. U.S. Department of Health and Human Services: The 1990 Objectives for the Nation: A Midcourse Review. Washington, D.C.: U.S. Government Printing Office, November 1986 TESTIFIERS CITED IN CHAPTER 1 149 Michael, Jerrold; University of Hawaii School of Public Health 465 Entmacher, Paul; Metropolitan Life Insurance Company 750 Richland, Jud; Association of State and Territorial Health Officials 6 Healthy People 2000: Citizens Char the Course