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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
Representative terms from entire chapter:
disease prevention
