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

Back to Part 1...

DR. BOUFFORD: I think the invitation wasn't just to delete it, it was to add--just so we're clear on what the invitation was.

DR. FOX: I thought I said delete and add, and the addition was based in large part on things like the diabetes progress review where the new science dedicated some objectives that were not present before. The elimination could be in part because it's an area where the goal has been achieved, or that, for some other reason, the objective was no longer pertinent, separate and apart from whether or not they're objectives that we can't collect anything for. So there were really three things we asked people to do, to add, delete and identify where we had duplication, so that we could pare that number down.

DR. SIMPSON: So we really haven't gotten to the criteria?

DR. FOX: No. Actually, they made recommendations that have been compiled and will be part of the process.

MR. PAPPAS: James T. Wilson, a sociologist, has observed in his book on bureaucracies that the difference between public sector bureaucracies and private bureaucracies is just this sort of thing. Businesses are able to focus on a few goals. Governments, by their very nature, have a lot of objectives.

My question to Dr. Sofaer is--I heard her speak before; what came through much more clearly in her previous presentation was the business community's critique about the lack of connection with strategies and attainability--your actionability. That seemed to be a much stronger theme in your previous presentation.

MS. SOFAER: Yes, they definitely did--they are action oriented, and so they're looking.... What they look to the Federal government for, and what they value, is the science base, is the legitimacy. They want that extended not just to the objectives, but to how to achieve the objectives.

One other thing I didn't mention that they said was that, from the employer's perspectives--it was brought to me by the comment earlier--morbidity objectives are much more meaningful to them than mortality objectives are, because they're coming to this from, in part, an economic perspective, but more broadly from a human resources perspective where they're concerned about morbidity data, because that speaks to the issue of the health of the workforce. So I think, for them, Healthy People means healthy workforce and healthy families of people that are in their workforce, and their concern is really more with morbidity than it is with mortality.

DR. BOUFFORD: Comments? Tom.

MR. KRING: Family planning is an interesting one, and we're delighted to have one chapter of our own in the Healthy People 2000, although there's ways in which I wish it was not ours. I think we, along with women's health, minority health, could argue that it was certainly important enough to be there.

On the other hand, I think if you look at health indicators, the family planning section in terms of intendedness probably puts us as far away from reality as anything. We have probably the highest unintended pregnancy rate of any developed country, and higher than most non-developed countries in terms of the unintendedness of pregnancy.

I think that we also point out a prime example of what's wrong with Healthy People 2000 or the whole concept, and that is that our section was written based on very idealistic goals. When I say idealistic, it's not pie in the sky idealistic. It's based on political ideology. They created a set of goals for family planning that are unattainable. They may be nice some place, but if you look at where we are today, versus where we were in 1990, we're probably further away in terms of statistically attaining any of the goals than we were in 1990, because they weren't based on reality.

Having dealt with people in California when I was there, the State health department, and Los Angeles County Health Department, and other county health departments, I was interested in your comments, because we started with the basic Healthy People 2000, discarded the entire section and rewrote our own section goals and objectives on family planning.

DR. SATCHER: Could I just follow up? I'm curious. It's very interesting, because you're right, that area stands out when you compare the United States with other countries. One of the questions I guess you have to raise is, how do we determine reality? How do we determine what's feasible. One thing that Hank Foster argues in discussing teenage pregnancy is, if you're going to set goals for this country, you ought to be able to compare us with similar countries and you ought to be able to set goals based on that. Why can't we attain what England and some other countries have obtained, even though they're not at the top? We're so far ahead of those countries in terms of number of teenage pregnancies per base population. How do we decide what's attainable? One of the problems in this country is we're not committed to an objective strategy. We don't want sex education in the schools, information. We want to hide information from people and then blame them when they make their own decisions. So I would be very careful about what we decide is attainable.

MR. KRING: That's where I say I would be happy to see some of our things just left out, almost, in the objectives, on the one hand. On the other hand, I think it goes back to what you were saying about people being frustrated and saying, give us some idea how we're supposed to get there. Don't just set us goals that are pie in the sky, that say we're going to reduce teenage pregnancy to 15 percent when we're at 76 percent, or whatever it is. Give us some idea of the priorities to get us there.

DR. BOUFFORD: I think there are two strategy issues here. One is, is there a strategy that's going to mobilize, and the second one, is there a science base for the strategy that one can include with the directory, sort of the user's manual for Healthy People or something that sort of says, from what we know, these are things that work. There are some interesting examples, I think, of how just giving people information about what works and leaving communities to develop their own strategies have been interesting in Oregon and some other States around things like teenage pregnancy. John had his hand up, and then Marty again.

DR. EISENBERG: Shoshanna, I want to come back to the issue about the private sector and the business community in particular. Your report describes a desire that there be consensus among the agencies on the measures that would be used to determine whether the outcomes were met, and that performance standards and outcomes would be--the implication is they would be measured by the same metric.

Now, if this is more than just a government project, then the implication is that there's also a desire for there to be consensus among the measures that would be used by the private sector as well. Are we really saying that? Are we willing to go so far as to say that we're looking for a standard set of measures and metrics that we would agree upon, private and public sector, and that we're willing to come together and say we're going to measure our performance in health by the same measures?

MS. SOFAER: I would have to say, John, that the call for the--the cry for correspondence across different kinds of measurement systems came primarily from the people in the first set of groups, who were people who were concerned about, for example, the possibility that the objectives used in the performance partnership grant orientation would be different from the Healthy People 2000 objectives, or that individual--

DR. BOUFFORD: Those are consumers of federal funds, as it were, for their programs.

MS. SOFAER: Right, and these are especially the people who, for example, may be operating a categorical TB program and who want to make sure that the kinds of metrics that are being used when they are reporting on their TB program are the same kinds of objectives or the same kinds of metrics.

Now, I think the issue that you raise about can we come to some consensus on a metric across the public sector and the private sector is a very good one. I would say that that's one which may fall into the category that was just being talked about, which is that it may be a very idealistic kind of goal to have, but I'm not sure how--I don't know whether or not I would be in a position to stand up here and say how realistic it is, knowing, because I've had some involvement with it, how highly politicized something like the HEDIS 3.0 process is and how much it's buffeted between what the purchasers on the one hand want to be--what kinds of demands they want to be making on the health plans, and the kinds of resistance that you get from the health plans to any kind of measurement, and to particularly this issue, that I mentioned earlier, which is being accountable for anything that they don't feel they have complete control over and that won't be too expensive to collect data on. So you get very odd, for example, immunization measures in HEDIS 3.0.

DR. WASSERMAN: I want to raise a question maybe to Dave and Tom, and maybe Phil would want to comment on it, too. Would it be possible--do you think it's possible for us to achieve some of the targets achieved by some of the other industrialized nations if our political process didn't interfere with certain strategies? Could we achieve pregnancy reduction? Phil has commented a number of times, if it's the right thing to do, we ought to be doing it, but by God, you can't get condoms introduced in our high schools no matter what the HIV rate is or what the teen pregnancy rate is. You just can't do certain things. And how are we going to change--well, if we could, should we, and if we could do it, would we be able to achieve those objectives?

DR. SOFAER: Is that a rhetorical question?

[Laughter.]

MR. KRING: Dave, he asked you first.

DR. SATCHER: I remember the statement that goes something like, our system is worse except for all the rest. I think we have a system which just needs some nurturing, and I think we can achieve a lot.

But let me say, I guess it is Bill Foege who says that government is the only institution that represents all the people. So I do think--and I'm responding to two points at one time--I think when it comes to setting goals and priorities, I think that is a responsibility of government, because we're the only ones that are responsible to all the people, regardless of how much money they've got, regardless of where they work, regardless of their sex, their gender, their race, et cetera. Government is responsible to all the people. Therefore, that responsibility to set goals and priorities, I think, is important.

Having said that--now getting to Marty's question--I just think that these are the kinds of things that we need to discuss more. We've been through a lot of periods in this country when it didn't seem like we were going to go on the right path, but the more we discussed it, we somehow find the right way. I think that can happen in this area, too. We need more education.

DR. FOX: I think one of the ways out of this conundrum, Marty, is involvement of the private sector and outside groups. Part of the problem is, I think we as public health professionals have been the primary home of Healthy People, although there are some notable exceptions to that and there are other groups that have used it. I think part of the answer, the solution, is getting the rest of this country outside government involved in supporting and advocating for prevention. We are always going to be under some constraints because of the political process. I think, to me, that is part of the real challenge of taking this the next step forward. We've got to get those other people engaged. I think that is not going to solve our problem, but it will help it.

Just one other comment, to go back to what Craig said. CDC, the project on the community prevention guidelines--which I think you all took--immunizations and injuries, I think, are the first two that are being looked at. It's a four-year project that is going to look at what the science says about what interventions we ought to be doing at the community level on population-based prevention. Our thoughts have been--and again this is just an idea--that maybe a set of sentinel objectives might be selected for 2010. Maybe, at least for those sentinels, we could then take the work that CDC is doing in this project, that's ongoing right now, and identify those interventions that work. We couldn't do it for every one of them, because if we had 300 and then multiplied that by whatever, we would have to have whatever--we wouldn't be able to carry it around.

We have right now a project going on that's going to provide whatever the science or--it's not going to be a double blind controlled study--but whatever the best science says about interventions, and I think will provide a basis for us then to do that with a core set or subset of these objectives. That's, again, one of the ways we could package the 2010 process.

DR. BOUFFORD: Susan, Monty, Phil and Julie.

DR. BLUMENTHAL: My comments are basically echoes of yours, Earl, on this. I think public/private partnerships are critical in terms of developing action-based strategies. We've used them. I think many other offices and agencies have, and I think that they really help to leverage what's best about government and the private sector in addressing common public health problems that face our nation.

I think the second thing is that, several decades ago, when the Institute of Medicine Health and Behavior Report formed the scientific underpinnings for the launching of the Healthy People 2000 campaign--several decades later we are now as, we address 2010 looking for what the science says about what works in terms of individual-based, community-based, and public health strategies.

I think it is time to try to bring what's known together, and also I think to underscore to our research- based organizations that, with 50 percent of the cause of all 10 of the leading killers of Americans being behavioral and life style factors, we still do not invest sufficiently in developing behavior change strategies that work for diverse groups because, just as Madison Avenue tells us that there's no one way to sell a product to all people, we have to really look at target-based strategies to diverse populations in order to see what works.

So I think it is time to invest more at NIH and elsewhere in this critical health issue, because more than any vaccine or miracle drug we could discover, we know that changing those behaviors could decrease premature mortality, morbidity, disability and health care costs.

DR. BOUFFORD: Monty, then Phil.

DR. DUVAL: In an earlier comment that Susan made about the women's issues, it served to--and incidentally I immediately turned to the NPR section of our books and looked up a couple things--and it reminds me of sort of an irritation that I've carried in my mind about the objective exercise, and I'm sorry to say it will bring up the issue of semantics, because an objective should have specific goals and a time frame included. But I looked at one that says increase to at least 90 percent the proportion of all pregnant women who receive prenatal care in the first trimester. To me that's a perfectly stated objective.

Then I turned to the very next page, and it says here, reduce rape and attempted rape of women age 12 and over to no more than 108 per 100,000. To me 108 is not acceptable. I would wonder why we don't identify two forms at least of objectives, those in which the objective is zero, and let's see how far we can go, but where the service is up to us to provide, give us a dateline so to speak by which we would like to get, let's say, prenatal services to women in the first trimester, X percent.

I have always been bothered by the fact that, for instance, it's perfectly okay to have homicides up to 7.2 per 100,000. That is our objective.

DR. SATCHER: Down to 7.2.

DR. DUVAL: Of course.

DR. BOUFFORD: Your point is the level of tolerance.

DR. SATCHER: Are these 10-year objectives, and therefore are you setting--this is the point you want to be at now?

DR. DUVAL: I would submit that the objective ought to be zero, and even though we're working in a 10-year framework, knowing full well that we aren't going to get to zero, the objective should be zero, and let's see if we can get it down to 7.2 percent, but don't state the figure. This is a personal irritation to me but, to me, 7.2 rapes for 12-year-old women or whatever it is is not acceptable. It's not acceptable language.

DR. BOUFFORD: Phil.

DR. LEE: One comment, to point up Tom's comment about the distance between where we are with reality and where we are with goals. For contraceptive use by sexually active adolescents, oral contraception and condom use at most recent intercourse--females 15 to 19, two percent; the goal is 90 percent. For males in high school, it's 2.3 percent. So we do have a long way to go, but the comment is that, if somebody had said 10 years ago we would be where we are with respect to tobacco--it's a totally new ball game and we have to--part of it was the science base on second-hand smoke and the impact that had in mobilizing grassroots constituencies.

Somehow we have to think about how we mobilize those constituencies in the community. Marty says you can't do it in Maryland, but as a matter of fact, at least in some schools in San Francisco, you can do it. Now, it's Sodom and Gomorrah maybe, but there are some very, very big differences, and in fact the non-smokers' rights movement began in a number of communities in California. So I think it's possible, Tom, if we really think about it, to maybe find some other ways to reach this objective. To me, smoking is a good example. Now, of course, we're not there yet, but the whole context has been transformed.

MR. KRING: Yes, I would much rather see an objective like that rephrased and change the attitude to be, 90 percent of the people in America feel that someone should use contraception at the time of first intercourse, rather than say kids should use it at the time, which puts the blame on the kids, number one, but it's also an unrealistic thing for us to think until we get to sex education, until we get to a lot of other things we're going to change that, because we're not.

DR. LEE: But also your strategy of post-coital contraception, the morning-after pill, so-called, and the FDA now approving that--again you've got to totally change. So we can now mobilize around that issue to reduce unintended pregnancy, perhaps significantly, whereas we can't have this kind of premeditated use of contraceptives the way we might like.

MR. KRING: Yes, that may be an easier one to sell.

DR. BOUFFORD: Dr. Richmond.

DR. RICHMOND: Just for a moment on this point--I think all through the work on objectives, it was my impression that we could establish these targets with a view toward hoping we might achieve some successes, but where we didn't--I think this was particularly true with the initiatives in terms of midcourse reviews--to look at why we weren't. So that, if the "failures" are out there, we ought to, of course, do an autopsy and see why it is that may be the case. So these should be dynamic issues and we should be learning from them. I think that, by and large, those kinds of midcourse corrections have been taking place.

I alluded to the report of the focus groups in my introductory comments because, if you look through that, you can pick through all of the problems that we're facing and the ambivalence that everybody has. The comment that, well, it's encyclopedic, but we don't want to lose it--so use it as an encyclopedia and you look up what you need to have at any given point in time.

Now, it seems to me there is a lot of room for creativity as we contemplate the 2010 objectives, and particularly in this context. I think the proliferation of objectives has been important, I think, to certain constituencies and those have been alluded to. Most of the associations, the advocacy groups, professional groups of all kinds, I think, find this very useful because it stimulates them to go through the process and see if they're going to be critics of what emerges, or whether they're going to embrace these, but they find it useful. So I think --and also I think within the Public Health Service--I think this has been an extremely useful process.

If I have to look at where our weaknesses are, it's really more as social strategists in terms of getting the messages out to the broader American community. I think we get it out to the international community fairly well, particularly, as I said earlier, through the ministries. Let me illustrate this.

I was very saddened when the event took place here in Washington, to release the year 2000 objectives, that there was virtually no press attention, not that press attention is the end all. But nonetheless, my recollection was that there were hardly two inches in the Washington Post, the local paper. So when I say we haven't been very effective strategists, if that's all you get when you release the 10 year goals, we're doing something that's not very right.

I would suggest there are at least two areas where we really need to exercise some real creativity, and I don't think that can all happen in this one day. I'm not going to make any pointed suggestions--

DR. LEE: Even with us here, Julie?

DR. RICHMOND: Yes, even with these creative minds in the room, and we've got plenty of them.

I think we have to pay more attention to boiling the goals down. We've got to go through some clustering process, where most of the major public health objectives we want to attain can be encapsulated, phrased in some way that captures the public imagination, but yet, in terms of Phil's earlier comment, it's got to have some conceptual--that is, if we're going to do that, there's got to be some conceptual basis for doing it.

Then, the other issue along with that--I think these go in tandem--is visibility. I think, for the public at large, we really have just not made these issues as visible as they might be. I think in the process of thinking this through, Phil has put his finger on a very important point in the whole anti-smoking effort that we've been engaged in now for decades. What were the processes that we went through with the public that seemed to have had some major impacts? Here Phil is very right, and I think it's where NIH and CDC come in so strongly, and that is the knowledge base helped us become more effective. So that, as the database accumulated and as we learned more about the impact--that's why the tobacco companies can no longer really maintain the sort of semi-credibility that they try to now. It's so much in the public domain, that is, the knowledge base is in the public domain, that they look ridiculous.

Well, I think we need to learn some lessons from that. How to get fewer goals that are readily understood by the public and how to keep these more visible, it seems to me, are the creative thrusts that need to emerge in this process.

DR. BOUFFORD: Yes, I think the other piece about the tobacco initiative, which was mentioned earlier, is that it has been a very broad-based public/private partnership with, obviously, leadership at the highest level and the enormous amount of time, work and effort going into sustaining that initiative over months and months and months, and continuing to sustain it in the face of lots of other activities. So it's a big investment and I think it speaks to the priority issue.

I think that these first couple of sessions are going to kind of run into each other, so just to kind of--if we can sort of segue, I want to mention, and this is just a thought, because I think picking up on the notion that we're not going to solve all these problems here. One of the things that we do do after each of the Healthy People meetings is have this sort of summary of the meeting and the high points of the meeting. I think it's going to be really important to do that for this meeting today so that we can share it and get comments on it, so that we don't leave this as a sort of large tape in the sky that only the staff have to ferret through.

From this conversation, I've heard a couple of key points in this first hour. One is that we clearly need a conceptual framework that makes it clear what the document is and options for perhaps how it might be used or has been used, because we have been at this for 20 years and we know some things about that.

Secondly, this question of priorities--that while there are sentinel events, we haven't highlighted them. We really need to think about the priority setting process and a strategy around that. We've talked about the issue of the federal responsibility in that process, either from leadership, investment of time, money, attention around the priority-setting question.

We've also talked about strategies and the fact that, while we have goals and objectives, we really need to look at the question of strategy. Is there a science base to strategy, as well as the sort of social supports for a national initiative? We might want to think about the strategy, the mention of this, so that people know what to do with the objectives and that they're based on science.

Then we've got some issues around objective- setting. Are we talking about aspirational goals in some instances, with time frames towards what we think we can achieve? The question, should we tolerate any of certain things is, I think, a very legitimate one to deal with.

Then this question of sort of metric setting. If we're going to set objectives. Certainly, getting the federal act together is no small task in some of these areas, as we know. John has raised the challenge, I think, if we're serious about certain of these priorities, do we need to really sit down with the private sector and the various other players to deal with an agreed upon metric and measurement?

So there's a lot of ideas in this first hour of discussion. I suspect we will sort of logically segue into the next, as Earl tells us how far they've gotten in beginning to deal with 2010. Then we will try to continue this conversation without too much interruption.

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