Secretary's Council on Health Promotion and Disease Prevention Objectives for 2010

DR. RICHMOND: Thank you. First, just let me say that I think it's been interesting to observe the institutionalization of this process. We went through the first iteration in 1979, and of course we then established goals for a 10-year period for 1990. We had the iteration then, and I think it's very significant that this process is now beginning, so that goals can be set for the year 2010.

The context in which we developed the goals was an interesting one. I think there was the general feeling that we could talk about health promotion and disease prevention in quantitative terms largely around the infectious diseases at that time. The history of epidemiology in this country, the history of morbidity and mortality patterns certainly over the earlier decades of this century indicated that we could do much, that the advances in the natural sciences and their applications had enabled us to do a lot in terms of the reduction of the infectious diseases.

I, as a pediatrician, could reflect on the fact that when I trained in pediatrics just prior to World War II, that I had spent--and I reconstructed the time allocations--that I had spent 50 percent of my training time looking after children who had diseases, acute infectious diseases that today's medical students, if they're trained in the United States, would never see. So that was a remarkable transformation.

But then, something was beginning to happen that we really hadn't been fully aware of. The late Walsh McDermott was inclined to say, while no one was looking certain things sneaked up on us. One of the things that became very dramatic was that, subsequent to the publication of the first Surgeon General's Report on Smoking and Health in 1964, we began to see something that no one had anticipated, and that is in the non-infectious diseases we began to see rather significant process. As we know, there's been a reduction of 40 percent in heart disease and 60 percent in mortality from stroke. So things had begun to happen in disorders that we regarded as multifactorial and we had to take cognizance of that.

We felt that the time had come then to really orient the Public Health Service and the nation toward trying to establish goals and to see whether we could achieve those goals. Historically, in reflecting on that period, it's appropriate to note that this wasn't entirely well accepted. There was a lot of resistance on the part of professionals, both in and out of the Public Health Service, concerning doing this. Of course, the great anxiety was that we could establish goals and never meet them. I used to deal with that anxiety by saying it is better to have loved and lost than never to have loved. So we did succeed in mobilizing the Public Health Service.

I think what we learned, first of all, was that in this process we could indeed establish goals, and secondly, it was important to have those goals be quantifiable. So it was, I think, an extremely interesting exercise that we went through in terms of really developing consensus among the experts that these goals could be quantified. Also related to this was the issue of the scientific base for the establishment of these goals. At that time, we had the great good fortune to be able to enlist the help of David Hamburg, who was then the President of the Institute of Medicine, and his colleague Dr. Elena Nightangale to develop the scientific documentation for the goals.

So we had this two-pronged approach to publication. One, Healthy People for the public at large, and for professionals broadly, and this back-up document called Background Papers, which the Institute of Medicine under Dr. Nightangale's leadership very effectively pulled together for us. It was really quite remarkable to see what the response was.

I think I was most struck by the responses that we got from professors of preventive medicine around the country, who probably would have been the greatest skeptics. I received glowing letters from a number of them saying well, finally somebody has dared to quantify these goals and put them down on paper, and in our teaching we can now use this. I think that one shouldn't underestimate the importance of the documents that have been generated in the various iterations for the teaching of public health professionals, because I don't think it's possible for students, no matter what their major emphasis is in their student days, to get through a school of public health these days without being familiar with Healthy People and the goals.

I think it's also important to recognize--and the Deputy Secretary touched on this in his comments--the impact internationally in going into the World Health Assembly and meeting ministers from all over the world. They were very impressed, and of course all of them tried in one way or another to emulate the process. So, in the course of the institutionalization, of course the presence of these documents in the libraries around the world and their availability to students, I think, has been extremely important.

I think that we also shouldn't minimize the impacts that the reports have had on State and local health departments. The State health officers, the city and county health officers await each iteration with considerable interest and always look at it in terms of what can we do to take from this the establishment of the counterparts to the national goals.

Some of the progress that we've made as a consequence in health status in this country, of course, has been really quite remarkable. The improvement in immunization rates, while we never really quite complete the job, has been considerable. I've been very impressed in looking at what's happened to the infant mortality rates over the years. We've come down steadily. And again--it was mentioned earlier--I think it's fair to say that in many political jurisdictions in the country now, our rates are as good as those of the countries we've always tried to emulate, those that have had the very best records in the world. So, we're really moving toward not alone catching up, but really maintaining some leadership in that area as well.

I would perhaps limit my remarks mainly to these comments which are more historical. I do have some comments to make about where I think we ought to be going. I might suggest that I think we ought to take special note what the fallout from the genome project might be as we look to the year 2010. That project will probably have been completed by then and what we might learn from it.

I think we've got to take a whole fresh approach to reformulating the goals in terms of the elderly population. I think that, again, the progress in this area has been so significant that I think we really need to think about how we can reformulate the goals. We sort of backed into that problem back in 1979, not really knowing quite what to do with morbidity and mortality, so we relied on functional status, which I think for the time was an appropriate way to go, but I think we can be concrete.

Again, as a pediatrician and person who has been interested in early child development for decades, I would suggest that perhaps the greatest loss of human potential that we are observing in this country is the developmental declines that we see, particularly in the very low income populations in this country in young children, a matter that was the object of a White House Conference that the Secretary and I were at last Thursday. So that it's a problem that's attained visibility, because there are no mortality indicators for this problem. We're talking about a loss of a potential, particularly learning potential, and it's not measurable in quite the same way that mortality can be measured, but I think it's a sufficient national problem. We ought to think of how we can do this.

Then, I think, in terms of health habits and how health habits move in fortunate or unfortunate directions, and particularly in pre-adolescent and adolescent populations, that is something that merits a good deal of attention.

In concluding my comments, I would just say that I'm very impressed with the materials that have already been developed, and I'm particularly impressed by the numbers of people who have been involved. I think that, particularly, the draft summary of the Consortium focus groups I found to be extremely useful. I thought I had a lot of suggestions to make, beyond what I've given you, but they're all in here, virtually. So I found it an extremely useful document because it pulls together, I think, most of the problems that we have to face as we contemplate this next iteration of Healthy People. So I'm very pleased to be here to participate in this effort.

DR. BOUFFORD: Thank you very much, and we will, just to reiterate--this afternoon is not really for you to be sitting and listening to presentations. Each of the presentations will be quite brief and we will try to use that opportunity to allow us all to get into the discussion of the kinds of issues that you're flagging for us, Dr. Richmond, at the end of your comments. Dr. DuVal.

DR. DUVAL: Yes, in deference to your agenda, I will limit my comments to just saying, number one, that I was here and in my tenure in the Department antedated the arrival of Healthy People and the Surgeon General's Report. But on the other hand, in the late 1980s, as Julie has already referred to, the Institute of Medicine was contacted by the Department to undertake two or three, I think, fairly important missions, one of which culminated in some of the scientific background for the objectives that were adopted, and Dr. Richmond has already referred to that.

The other was to conduct national public hearings in, I think, six or eight cities across the United States, San Francisco, Denver, New York and so forth. I was asked by the Institute of Medicine to oversee the entire area of the development of the public comments and chaired most of the meetings around the United States, took the necessary comments from the public and together at the end of this, two or three of us collated them into a document which was then advanced to the Department for distribution to the agencies. Out of that came the actual and specific objectives.

That was a very good exercise, and I note that, in your material that was forwarded to us, you also basically posed the question, should we at all consider again going back to the public for any input, and go a different route, and I will comment on that a little later. I do have some views about that, but it was a successful enterprise, and I'm glad that we did it. It was a very fine learning experience.

I would also add as a closing comment that, like Julie, I feel very keenly that the interest expressed for instance by the number of people in this room who have other claims on their time and are willing, even if not commanded, to be here shows, however, that this is now an institutionalized process in which there's a relatively high order of interest. I'm supportive of that.

I would also add, finally, that the preparation of the materials shows an awful lot of thoughtful work, and I was, for one, very pleased to have an opportunity to review them before I got here. Thank you.

DR. BOUFFORD: Dr. Windom.

DR. WINDOM: When I was here 10 years ago in 1986, Dr. DuVal made it very easy, as he mentioned. We were following up on what Dr. Richmond had instituted. Any time you have a program underway, it's much easier to improve upon it than to start over again. So Dr. DuVal certainly helped out in that area too, as I did around the country.

I think it was important at that time to meet with representatives of the divergent and many health agencies and voluntary groups and so forth that we have in the nation that are interested in this and have an opportunity, maybe limited, but at that time, to express themselves. I think those are important meetings for input.

Of course, the main thing that took so much of my time was--I came in just 2 years after the virus was discovered of AIDS, and consequently we had a major educational effort. That took so much of our time then, focusing on--we all had thought infectious diseases had been eradicated. As Dr. Richmond indicated, we were satisfied that antibiotics had cured everything and immunizations had and so we could relax. But we had a bold awakening when HIV appeared.

So education and working on prevention was really a very major effort. Out of the frustration of education not getting anywhere or information not being assimilated, we undertook the effort to send out 110 million pamphlets to 110 million homes, which was close to each and every mailbox in the country. The reason behind that was my frustration was that people kept saying they didn't know what was going on in AIDS. We said, well, did you get it in the mail; we sent it to you. But even so, as you know, it turned out to be that many people either got it, didn't look at it, or forgot about it.

So, consequently, that problem was breaking a barrier that still exists, not just in HIV, but in all forms of health. I think we need to work toward all kinds of efforts we can find that will get our message to people in whatever way we can do it, and particularly focusing upon youth, and as Dr. Richmond has been so well known for, the young people and the development with the brain, information we know today, what can be assimilated and how quickly, and how remarkably these children can learn if properly given the opportunity. We can actually go back and be recycled and take advantage of that time, but my computer has been shut down a long time in that brain work.

[Laughter.]

But anyway, I still have a little recall, if I can find the button, or what compartment it's in.

But anyway, focusing on the young people and really working hard on education. On the local level, we've had some doctors get into the community schools, and yet that's been limited. I think it needs to be expanded on, teaching against smoking and other health behaviors, the benefit for health. I think we really need to concentrate on that.

I think we need to spread our word around more to the organized medicine groups that we indicated before. Public health has been primarily the spectrum in which this has all been dealt with on the local, State and federal levels. I think the private sector of medicine, academia, and/or delivery of medicine, those people have not been as much on board as I think they should be. We're fortunate in Florida with our Governor Childs, when he was in the Senate, as you know, as a leader in the effort in biomedical research. Also, infant mortality was one of his big strong points and still is. He's focusing his last term as governor on children's issues more than he ever had before. So we got cooperation there from that particular leadership.

Also in Florida, we're pleased that this past year our State legislature had the wisdom after many years of lobbying to form a separate Department of Health, which just got underway recently. It's just amazing to see the tremendous output of energy and esprit de corps that exists now that they are separated out of the social service programs. Heretofore, they were enmeshed into the great Department of HRS in Florida that was one of the largest employment groups in the country outside of the federal system, and they were just lost in that network. Now, we're one of some, I guess, 36 States that do have separate departments in one form or another.

So we have the leadership of a physician who has been in public health most of his life, and combined also with some academic background and practice, so we're very pleased with his leadership. He has asked me to help him as he goes forward because of all the other problems he has to deal with. His concern about this, he feels, should be a highlight. I'm going to try to help him out in the next few years as we go toward our goals of 2010, but also try to complete the 2000 goals.

One thing I did do is, just last week or so, I met with his staff to sort of get an update on what's going on. I am pleased to find that Florida has moved very well on the State level. They have a computer consolidation now that apparently is the only one in the country for a State to have. It has so much of the data on one computer base, which makes it easy to go back to the 1960s in fact, to dig up this information from county to county, city to city. So we are trying to track and keep on top of what is going on at the local level.

The one thing I heard that I think exemplifies what I felt for a while is that environmental health and public health often are not on the same wavelength. I think we are seeing more importance towards environmental health and what problems of the environment can do to affect public health. I think we need to work on better coalition in the two areas which seem sometimes to have their own turf battles and go different ways and not cooperate as much as I feel it's important, so we go into 2000 with a unified effort in that particular area.

Another area in our particular part of the country is diseases brought in from the South, particularly through Florida, one of the largest importation, immigration States in the country, and also food products that come in with contamination. How do they track these important issues that we must pursue.

One last thing, in Sarasota, my little community, we had the first PATCH program in the country that CDC started, Planned Approach to Community Health, which now is 11 years old or so. They are very much involved on that small level of the community to keep up to date and to think of new ways they can intervene to get the local citizens, the local coalitions together. That's where the whole problem is going to be resolved--how well we get down to the grassroots and get those people in our own neighborhoods active and aware of what's going on at the federal level, too.

So I look forward to being here as we proceed further and thank you for having us here today, and I wish you well as you go forward in your deliberations over the next 3 years to get 2010 on the books. Thank you.

DR. BOUFFORD: Thank you. Let me just mention that about 70 percent of local health departments in 44 States are now using Healthy People in some incarnation, not all the entire thing, but using it as a reference document. Many are using it to chart their own progress. Dr. Lee.

DR. DUVAL: We usually introduce Phil incidentally as the youngest, the oldest, the first and the last.

[Laughter.]

DR. LEE: All in one.

DR. BOUFFORD: The greatest, but not last.

DR. LEE: First a comment, particularly, Kevin, for you and for Donna. The monthly reviews for Healthy People are probably the best single way for you and the Secretary to get informed of what's going on. To me, they were the most interesting, and probably the most fun part of, the job. They were very, very well done, with both inside people and outside people involved. It's a tremendous education. We were thinking at some point of trying to have some way of, every month, when we finish those, to have some way of disseminating the information. But if you or Donna or Bill could participate periodically in those, I think you could learn quicker about what's going on in terms of where we're really responsible than in any other thing that could be done.

I just want to say a few things about Healthy People. First of all, I want to say to Julie, and I would also with his good right hand Mike McGinnis, put H into health policy. I mean put health into health policy. Before, it was basically financing and medical care that dominated the health policy in this Department. Not that it isn't still the 800-pound gorilla, with all apologies to HCFA, but nonetheless it's a totally different world now than it was before that. And Julie's comments about Elena Nightangale and the effort that the IOM made to put the science base under prevention was a seminal contribution and one that's been built on, really, ever since.

I think, in the report itself, we need to have in the beginning a conceptual framework. What is the sort of conceptual basis for this approach? It isn't the old paradigm, which is medical care, or a biomedical paradigm, it's really a determinants of health paradigm, or a biopsychosocial paradigm which George Engel wrote about more than 20 years ago. We have a very strong science base now for this, and I think that that ought to be included in Healthy People at the beginning.

Second, I think we need a better way of setting priorities. I think that what New York State did in their report--let's see if I have a copy of it sitting around here somewhere--it was published in September of last year. Yes, Communities Working Together for a Healthier New York. This really builds on the Healthy People process, but it focuses --and in the beginning they talk about five principles. Local communities can have the greatest impact on health by intervening in the causes of poor health. Now, we're beginning to do that, but mostly we've focused on the problem itself, tuberculosis, HIV/AIDS, et cetera, et cetera, et cetera. We have I don't know how many categorical programs, but a lot.

Second, the greatest improvements in health can be achieved where there are effective interventions that involve the entire community and individuals. The third priority out there--we must address those conditions that result in the greatest morbidity, mortality, disability and years of productive life lost. Four, the priority health areas should reflect problems of greatest health concern to local communities, and five, progress should be measurable through specific, quantifiable and practical objectives. Then they have 22 priority areas.

But this setting of the priorities--how do we set the priorities? We've got three broad goals and then we've got--I think it's now 319 objectives. Well, your eyes roll back when you think about 319 objectives. When you're thinking about five, when you're thinking about the causes of poor health as opposed to categorical diseases, you take a different approach.

A third area, and this has to do with really the scope, and clearly in terms of scope, I think, clearly, we are adding environmental health and mental health. Those have been seriously deficient in the past, yet that's in the process of correction. I think, Bob, it's going to help foster the reintegration of environmental health, which is public health. It got spun off for political reasons in the sixties, at least at the federal level, in the early seventies when EPA was created. I think it's time to bring it back into the Department of Health and Human Services. It would then have a much stronger science base and I think that's been one of the problems.

Third, and I'm glad Ed is going to talk about data, because without an integrated health information system, instead of the fragmented systems that we have, we're not going to be able to achieve our objectives. I think with the National Center for Health Statistics, the Agency for Healthcare Research and Quality (AHRQ), HCFA, all in the ball game--and I think people there are very willing to work together through the Data Council--there's a mechanism to solve some of these problems.

They've got to be solved. We have now inadequate systems at the State level. We don't have the data at the State level. We have even less data at the local level or the health plan level. And, increasingly, as CDC is working with managed care plans, and particularly capitated managed care plans, which some people would almost call potentially mini-public health agencies, because it's a population base, it's capitated and there presumably are incentives for prevention. Some of the incentives have been distorted, and they're used for sucking out profits to investors and also for decreasing services but with adequate information that problem, I think, can be dealt with.

The third area is the link between Healthy People and performance measurement. We have the recent report of the Department's Subgroup on Technical Assistance and Training as it relates to performance measurement, the March 3rd report. That outlines all the activities in the Department from ACF, AOA, through all the public health service agencies, and is a very good, I think, means of putting these two at least together at the federal level. I think that when Shoshanna talks this afternoon, maybe we can talk a little bit more about how we get the accountability in this. Again, the data is absolutely critical for that.

There have been a number of spinoffs from Healthy People. I would say perhaps the most valuable--and it really almost directly traces I think, Julie, to Elena's report--that's the Guide to Clinical Preventive Services, the 1989 report, and now the 1996 report. Within that guide 6,000 references were reviewed by the advisory, by the task force, and 70 areas in which recommendations were made. It's an absolute, I would say, gold standard in terms of public health, not only for individual clinicians, and provider organizations, but health plans and public health agencies. If one wanted to learn public health, you would have to go no further than to turn to that guide.

Then the Surgeon General's Reports--and when we talk about dealing with the problem as opposed to dealing with the disease, starting in 1964 with the Surgeon General's Report on Smoking, the 1988 Report on Nutrition, and the 1996 Report on Physical Activity, we've now got at least the framework for a real approach. I think the Department and the Administration deserve tremendous credit for what's happening on tobacco. It's a revolution since August of 1995, when the President supported the FDA going forward with its proposed regs. We're just in a different world.

Had it not been for FDA, had it not been for the Secretary, had it not been for the President, that simply would not have happened. It's the most important public health problem--I think it will be in the world; it certainly is in the United States today. In the future, it will be more important than all the emerging infections if the current trends continue.

So there are a number of activities really putting prevention into practice that supplement what we're trying to do with Healthy People. Putting prevention into practice, use the guidelines, but give practical tools to practitioners and consumers to use these tools at the local level, at the individual level, at the practice level, as well as the health department level.

The fourth area I want to just comment on is the private sector and the impact of market forces. I've already mentioned managed care, and CDC is working very, very, I think, effectively now with managed care plans, particularly with capitated group practices, with managed care organizations. The fee-for-service IPA ones don't have the capacity for this kind of prevention orientation, but now HCFA, which is moving from being a payer to being a purchaser, is beginning to look at this in a way that's very similar to the way CDC looks at it. So there's a real partnership developing there, and with the kind of clout that HCFA has got with both Medicaid and bringing people to the table, and in the future with Medicare, we have an extremely powerful partnership to move this ahead.

The partnership with the States is also important. I mentioned New York State. Many States are carrying out similar efforts. I don't know of a better one than New York because of the approach they took, which was rather different than Healthy People. Healthy People didn't have the priority process, I think, as clearly structured.

Foundations need very much to be part of this, particularly Robert Wood Johnson and Kellogg, both major actors now in prevention and in strengthening the public health infrastructure. Obviously, non-profit organizations, and here the IOM is probably, from the time that Julie worked with them--we go through the reports on the, the 1988 report The Future of Public Health, which had a huge role to play while I was Assistant Secretary, and still does in terms of bringing to the fore the key issues that have to be dealt with both at the federal level, at the State level and the local level. Again, the recent reports which IOM has been developing with support from the Department, very important around community interventions and around performance measurement.

Then finally, and Bob's mention of this I think was very useful, about how to engage the community. The Kellogg Foundation has probably done more than any foundation to engage the community in the process of public health at the local level, and the IOM has clearly, in its more recent reports supplementing the 1988 report, has stated very clearly, and I think better than almost any of the rest of us have, although we all believe it, that you have to involve the community. Therefore, you have to know who is responsible to who and who is going to do what. Shoshanna I think will talk about this this afternoon. She has done a very good paper on accountability. Who is accountable to who if you've got this melange of actors at the local level. Just as an example, if you take STDs, a traditional public health agency issue, only eight percent of the people with STDs are now treated in public STD clinics, over 60 percent in private doctor's offices. If you're not working with that sector, if you're not working with the community, you're going to touch less than 10 percent of the problem.

She also talks about getting the right measures for success. I think the process that is described in the Department report on this, I think, tells us what the barriers are, where we need to move, data being perhaps the number one, and the decentralization, devolution, delegation representing another issue about how you measure performance when you're decentralizing as rapidly as we are.

But I think this has been a tremendous contribution and I think it's very, very much a part of the Department, and I think very much a part of the process at the State and local level, and increasingly engaging the private sector. So I'm, like my colleagues, very happy to be here and part of this effort to just extend it a little bit farther.

DR. BOUFFORD: Because we are going to break for lunch at 11:45, I think we're just going to keep moving. Those who need to get up can excuse themselves quietly and come back.

I wanted to--can I get you to say something before you leave--because I wanted to start actually--

MR. THURM: I bet you can now.

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