Agenda Item: Setting the Context for 2010 Objectives

DR. BEZOLD: It is an honor to be here. I have worked with many of the people here and also many of the states and local governments where Healthy People 2000 objectives have been used over the years. It is the closest thing to an operationalizable vision for health in the United States. So, it is an honor, as I said, to be working with this effort.

It is also an honor to be here because of the decision which was reaffirmed this morning, which is basically the second over-arching objective. That is, by 2010, health disparities in the United States will be eliminated. The elimination of health disparities is an audacious goal. In our professional work as futurists, that is one aspect of our work, that we help organizations think about what they really want to create. Being audacious is a prime technique.

What I have been asked here to do is to say how scenarios can help to understand how the future can be your friend and your foe as you look at working to create Healthy People and achieve the objectives. In that sense, what you have before you -- and I will go over that in a minute in some detail -- the scenarios that we have drafted are a work in progress. They are definitely qualitative. If there is a decision to take this further, it may be relevant to look quantitatively at some aspects of it.

Essentially, there are four different stories about how we did or did not achieve the objectives by 2010. Frankly, being assigned to write a story of how the United States eliminated health disparities by 2010 was a wonderful challenge for me. I am going to ask you to decide in a minute whether I got it even close to right.

That is, I think, the challenge of the objectives, to say how we make America healthy. Not only that, you said, lengthen years of healthy life and eliminate disparities. That is no small task.

In terms of scenarios, what their job is, in effect, is to paint different pictures of the future, to say we can go one way or another. They help you understand that future. In that sense, as the Surgeon General said, they are plausible. They should also enable you better to be clear about what it is that you want to create. The objectives at that level are about what is it that you want to create, what your vision is.

The vision is "Healthy People and Healthy Communities". That is the vision that underlies this effort. The two audacious goals are lengthening years of healthy life and eliminating health disparities. In developing the scenarios, I focus more or less on the second one.

Again, in relation to the details that you have been talking about here, there are many things in the future over the next decade which may help or hurt you. There was a discussion about type II diabetes and what genomics is going to do for that, in terms of understanding the different pathologies. By 2010, I think that diabetes will be looked on as a series, as a much larger series, of syndromes, rather than as a disease, but so will cancer and so will a number of major diseases, and genomics will give us a tool for doing that. That may help or hurt or speed or slow achieving your objectives, or it may mean rewriting them.

That level of detail is more fine-grained than what these scenarios deal with. What these deal with is -- what would it take in the United States to eliminate health disparities?

Again, this is definitely a work in progress. This is a first draft based on a poll that I took at the Indianapolis meeting of all the people heading the Healthy People 2010 teams -- and I will go over the results of that in a minute -- and conversations that I have had with a number of the people leading up to this question of how you would write a scenario -- one or more -- that said, how did we really achieve the objectives, in this case, the over-arching objectives?

What I would like to do before we do that is ask you to talk to the person next to you and answer for them -- each of you answer this question -- what is your assessment of the likelihood that, by 2010, we will have eliminated health disparities in the United States, zero to 100 percent. I want you to talk about that, just spend a minute. Introduce yourself, if you don't know the person next to you, but just share with each other what is the likelihood you will be able to do it.

[Discussion among participants takes place.]

DR. BEZOLD: I will ask you to raise your hand when I get in the range of the likelihood, and I am going to ask -- zero to 25, 25 to 50, 50 to 75, 75 or above?

How many people thought it was zero to 25? Raise your hand. Okay, 25 to 50 percent, raise your hand. Fifty to 75 percent, raise your hand. Seventy-five to 100 percent, raise your hand. [Hands are raised at different times.]

DR. SATCHER: With this group, I don't know.

DR. BEZOLD: Now that I have gotten your attention -- is this an audacious goal that you have put in front of the United States?

I have had the pleasure of working a lot with WHO and PAHO over the last few years. As well, we do a lot of corporate work and work in the United States health care system. I have been impressed with the nature of the Health for All objectives as WHO is putting it out.

The first of the values of the Health for All objectives is equity. What I am struck by, in being asked to work on this project, is this call for equity. Now, most of you think that it is not likely that we will achieve that. I would argue that, to the extent that you honor this objective -- I might even use the words of one of the Surgeons General who said, it is better to set a goal that you honor and want to achieve and fail than not to stretch far enough. So, keep that in mind as you think about this. I would argue that part of this job is to increase the likelihood that you will achieve it.

Part of the conversation earlier was, you will need to involve the larger community. Both the Surgeon General and the Secretary said that a variety of the groups involved would need to have more ownership of it. I would argue -- as you go through that ownership process -- part of the ownership question is why anyone should want to own a goal of reducing health disparities as boldly as you set it out. I think that is the task as you think about it.

So, now that I have got your attention, let me walk you through the scenarios that I have developed which answer the question -- which will fit all of your probabilities in one way or another about whether we did or not. This is under the tab, Scenarios for Achieving the 2010 Goals.

Just let me say, in leading up to it, I asked many of you in the room who were at the Indianapolis meeting what forces you thought would be most significant in affecting whether or not we achieve the over-arching goals -- I'm sorry, objectives. The top four were diet and lifestyle, jobs -- and here it was the relationship of jobs, income and meaning.

It was interesting the number of times that the WHO global burden of disease forecasts have been talked about today. I read that and say that depression is the fastest growing burden of disease globally. So, the issue -- you will see in a minute -- is how that plays out in terms of what it means for the job structure in the United States.

Third, the information revolution will clearly make lots of things very different in the next decade, and biotechnology is poised to both bring on new products and new ways of looking at health. Then, there are a variety of others. What I would ask you, as you look over the remaining 20 in that list, is that we would like feedback on that list. Write it down on that list and give it to me or Debbie Maiese. We will refine these scenarios again.

In terms of the forces that will affect whether or not we are successful in achieving the objectives, what are they? What is your field of forces? This is one first cut at it. We are open to hearing from that again.

Now, the scenarios -- part of what we want the scenarios to do is have those people use the objectives. Understand that the future can be both friend and foe.

Even more importantly, we want the people looking at these scenarios to say, I could aspire to both lengthening years of healthy life and eliminating health disparities. I could aspire to do that, and I could work with my organization in joining that aspiration.

The only way we are going to raise the likelihood -- in other words, I think as a forecaster your percentage was probably right, under 25 percent. As a futurist coach and vision coach, I would argue that simply means that you have a lot of work to do. So, the question is, as you think about it, you want to engage people in saying -- there are not only a high level of technical questions about the achievability of these, but there is a high level of nobility in the relationship of these targets to where you want to head.

Then, in terms of the scenarios, the scenarios should in some way inspire people, but also give them some fright, because that is the range of the future that is out there. Given that, the four scenarios, I will just tick off some of the aspects of them. I would welcome either written or verbal comments. I know it is late in the afternoon, so we won't have a prolonged conversation about them today. But I would welcome that, and my e-mail address and FAX number is at the beginning of the section.

If you look at the scenarios, the first one is continued growth. There are basically -- at the bottom of page two -- you basically continue growth with greater health for many. That is pretty good news. Disparity also increases, and that is the general trend, absent any intervention.

Second, hard times. There are a variety. This is after the futurist tab. We are now on the bottom of page one, the numbered page one. The second is hard times. Lots of things could go wrong. So, what are the things that could go wrong relative to people thinking about the Healthy People objectives?

The third and fourth, we argue, should be structurally different. In here, they are both attempts to say that we are pretty successful at achieving the over-arching goals. They deal with both new ways to contribute and how we get core systems in society working. So, I will run through those.

So, first, continued growth. Basically, we see steady economic growth and dramatic revolutions take place in technology. This is now on page two. We had global warming and that has health effects in a variety of different places.

Access to primary care did improve to 90 percent. So, we didn't make that objective. Again, I would praise -- you have an objective of 100 percent access to health care for everyone -- I would applaud that. Remember, we didn't make it the last time that was a serious effort. The Governor of Oregon has reduced it to five percent without access through a series of state initiatives. So, a lot more could be done. This is a question of aspiration and commitment, as much as anything else. So, the issue here -- this is the sort of most likely scenario, given where things are headed, this continued growth. So, 10 percent.

Care is far more effective and customized. There will be dramatic revolutions in health care in any scenario we write. The diet and lifestyle are improved for some and that has a health effect. Life expectancy here grows, but disparity in years of healthy life increases, particularly for the poor and near poor. This is a scenario that doesn't deal real well for the poor. But that is growth.

If you look at hard times, you say, what could go wrong? Lots of things. Start with the year 2000 problem, and we haven't gone into much detail with that. We say that there is going to be a significant recession, whether caused by that or something else, within the first couple of years of the next decade. Unemployment, rising up to 15 percent

-- but the tricky thing is that many jobs will be lost, even coming out of recessions, to automation and expert systems and new forms of retail. So, there is a high degree of unemployment.

We get greater community stress. We just don't deal well with those hard times, and we get greater environmental problems. Food problems also grow, and the depletion of the nutrient capacity of the soils makes food scarcer and prices rise. Healthy life expectancy actually drops, and the technical people, in writing scenarios -- I didn't walk the plank to say how much they dropped but I am open to saying so. We know that in the Soviet Union, the former Soviet Union countries, the health of men has dropped. We know that that can happen.

The question is, if things got really bad in the United States, what would be the right number? That is one of the questions you ask with scenarios. Again, this is not a good scenario for achieving objectives. There is not the political will and events conspire against it.

Could you write scenarios where you move toward achieving them? Yes. Now the question to answer is, how good are these and what would you advise us in terms of rewriting them.

The first is new ways to contribute. Longer healthier lives and reduced disparities are achieved through commitments, trust, and effort, and good luck, despite periodic hard times in this scenario.

There was a significant recession around and after the year 2000. It left many people out of work. What was interesting was the response to that was, what can we do about it, because the economy is coming back but jobs are not? Research showed the strong link between the sense of making a personal contribution and your health, and that most people define that personal contribution by their paid work. That didn't work any more.

People came to realize that we should be able to deal with that. So, in effect, just as education, in terms of high school education, had been seen as a right -- everyone has access to education through high school. We will see in a minute how well that high school education works. In this scenario it said, well, the ability to contribute is the same. That means that you have to have the equivalent of a negative income tax, first proposed in 1972. In this scenario, that is put into effect. The expectation is that, if you are not making enough money, you still need to contribute, but you get that.

In this scenario also, the high school completion rates went up. What is significant for the conversation here is, by the time you graduate from high school, you really know things and you can really do things, and that has significant effects on your health behaviors and on your work behaviors.

In this scenario also, consumers vote with their dollars. In effect, the market place has come to tell them what difference one product has from the other, both in terms of its quality but also its impact on the environment and some other values. So, just as $1 trillion is now invested in the socially responsible investment movement -- this is people voting, in addition to investing, around their values. So, the marketplace becomes significant.

Health care in this scenario is dramatically better. Health care providers in 2010, those who have won the race to produce long-term outcomes, are doing a variety of things differently, including focusing their care much more specifically on the individual. It is customized care, given what we have learned through genomics.

What is interesting in this scenario is that the dramatic advances that came on between 2000 and 2010 -- given the value shift toward saying we want Health for All, we want to eliminate disparities -- is that new technologies are looked on in terms of their effect on whether everybody is going to be able to get access to that. So, that plays out for this scenario.

Where rationing takes place -- in effect, Oregon has shown us that we do ration. Many other countries ration, and get higher health outcomes for lower shares of GNP. So, rationing is not the issue. All systems ration. The question is, how do we do it? In this scenario it is more consciously attacked by public discussions, as Oregon showed us we could do.

The energy efficiency has increased dramatically, as have diets. Basically in this scenario it is positive and it moves forward.

The fourth scenario says, yes, we could do all that as well but, if you look at the basic systems in the United States that aren't working very well, they are education, health care and justice. In order to achieve the kind of objectives that you have put on the table, we have to have education, learning and health systems that, in fact, work, one, and that work for everybody, two. In this scenario, that happens.

In a series of incidents, people came to say, we just can't afford it. When you look at what the United States health care system gets for its dollar expenditures, in terms of both health outcome and access, and you look at any of the European countries, we get about a third less for about a third more in payment. Companies and business people said, well, if you look at our justice system, that is about the rate we have got, and if you look at our education system, that is about what we have got. We have this incredible competitive deficiency.

That, and value shifts in the fourth scenario said, well, let's make this change. The change begins to say that, again, like the third scenario, that jobs basically become far shorter. There is a long boom that some of my futurist colleagues had forecast. That long boom is fantastic. It makes the kind of run on the stock market that we have seen go on. There are some dips, but it keeps on going. The problem is, it is jobless growth.

Again, it is looked on as, how can we contribute? How can we meaningfully contribute if lots of people continue working for pay, but lots of people will not be able to work for pay? So, again, in this scenario, it is called a citizen's income. Here, again, the marketplace reinforces these kinds of values.

If you look at the ISO, the International Standard Organization's standards -- this is now page 6 -- for products, they have gone from ISO 9000, which is basically work place safety, to ISO 14000 standards, which are environmental safety. As a futurist, it is clear that in the next decade we will ask them to enlarge their standards of quality and goodness, which is what those are.

We think that equity is going to be one. So, you are going to get some help for your Healthy People objectives by the kind of books, like Shopping for a Better World, if you know it, in the United States, that rates all the food in the grocery store. In a decade, in this scenario, they will be rating the equity relevance, the fairness relevance, of products and companies.

The issue is also that, in this scenario, biotechnology and health care advances have actually gotten to the point where we can prevent or control most diseases.

Dean Ornish has shown us that lifestyle can control heart disease and maybe even control cancer. But we will have a variety of vaccines and pharmaceutical breakthroughs in this scenario that will be tremendous in terms of reaching the Healthy People disease objectives. In this scenario -- again the question is -- we ensure that those are available for everyone, that there is not a disparity because of income.

Again, this is a scenario where, in health care, best practices are known and discussion about updating the pharmacist, and updating their system, every three months as part of your objective -- that would be seen, in effect, as relatively minor. Why not every 24 hours? In other words, the information system would be such that that would be automatic, probably within five years, for most systems. This scenario takes that further.

These are the four scenarios. Again, the question is, if you think about your task, one, is it useful to have scenarios? In other words, should these be carried on? And there is a parallel question of, what is the best way to use these -- in the one volume that has become three, or the Internet, or whatever in terms of presenting things? One, should there be scenarios? Two, to the extent that there should be, any feedback on the forces or these scenarios themselves?

DR. SATCHER: Okay, very interesting. Questions, comments?

DR. DUVAL: I would only make this comment, that, while this is intriguing, and I hope ultimately will turn out to be important, I am a little anxious over what I call the Hawthorne effect. If you start observing things through scenarios, you will change what happens.

I guess I would add to that a second phenomenon. Every epidemiologist, as far as I know, knows that to eliminate a disease, let's say in childhood, you don't have to immunize 100 percent of the children. There is a critical mass. There is a point beyond which you have succeeded, and it is less than 100 percent.

To that extent, I would say that, to me, one of the great values of this entire exercise that we are going through, of which today is simply a microcosm of all the discussions that have gone on -- that this exercise is, itself, on the way to achieving whatever constitutes that critical mass at which culture shifts. Thereafter, the achievement of objectives becomes easier. To that extent, maybe the scenarios would be helpful. I don't think you are challenging us to look at the scenarios as a way of achieving the objectives.

DR. BEZOLD: You have just made my argument. In effect, the Hawthorne effect says you want to observe something. You don't want to observe something. You want to create and achieve some objectives.

So, there is this -- as we do scenarios -- there is a small set of companies that do scenarios. Our difference from many of those is just this, and that is that dealing with futurist techniques is really about better understanding, choosing and creating a future. We want you to be sure that you are creating the Hawthorne effect that you want. That is what we do.

In effect -- the issue about a culture change -- I would argue that, in fact, if you think about how many communities you have seen around the United States that have been materially impacted by the 1990 and 2000 objectives developed through this process, all of us know lots of communities that haven't. In effect, what you are saying is that, okay, you are being asked to set the bar. Where are you going to set the bar for the next round?

I would say that this process has already made a contribution to the culture change that you have described. It needs, obviously, to go much further, because we haven't been doing real well in the last few years about the disparity elimination aspect of policy. It is a question of, you know, picking the scenarios for the right Hawthorne effect you would like to create.

DR. SATCHER: Other comments, questions?

DR. BROOME: I thought, in reading over the scenarios, I didn't really see any discussion of media and--well, there are some allusions to consumerism. I think a lot of the forces that are sort of working against the last two scenarios are fairly powerful.

DR. BEZOLD: I would encourage any comments like that. We can try to explore those. I would relate that to the earlier conversations here. You can take the conversations about the media either as to athletic role models or smoking in movies. You could easily play that out.

The question is also, as a futurist, if you said what media will we be using in 2010. There will be an evolution of that. The big question is, in effect, has there been leadership reinforced by the market that says, in effect, we kept smoking out of movies for about two decades, and now it has come back? No one has talked about what the payment structures are that have brought it back. But you know, I could add a section on whether the media -- in effect, either the media and the learning processes -- either reinforced or didn't.

I can write how they do in those third and fourth scenarios. You might not think that is plausible, but I would turn it around and say, if you want a scenario that works to happen, then I am very open to your telling me how to write it. What are the images that would make things work. As a futurist, I can come up with a range of forecasts for almost anything.

In terms of things that work for the media, to reinforce the achievement of the objectives, what would the right ones be? I would welcome any off-line conversations about that.

DR. SATCHER: How do you incorporate a global perspective into scenarios in certain areas that are going to be more important than others?

DR. BEZOLD: There is sort of an implicit discussion in the third and fourth that there is more global concern. We haven't written that into these scenarios. The discussion here was about both diseases and tuberculosis. Forty percent of all the cases originated from outside the United States, if I got the quote right earlier today.

DR. SATCHER: But on food supply -- I forget the percentages, but it is growing rapidly, in terms of the proportion of our food supply that is coming in from outside the country. So, Mike's job and USDA's job have changed considerably.

DR. BEZOLD: I agree, and we are the futurists for military medicine. The question there is -- they are looking at health operations other than war. Those conversations are identical to a hospital asking what kind of health promotion role they should have. At first, public health people say, stay out of the market, but the hospitals and health promotion become significant.

The global issue has a number of those cuts and we can work that into the next round.

DR. SONDIK: It would be interesting to see this for some specific objectives. This set is so eclectic -- that was my difficulty with the question that you posed to all of us, because I am not sure that question is really answerable, eliminating disparities in general. If we look at it for some specific set of objectives that are very different in nature -- disease outcomes, behavioral outcomes, service outcomes, that type of thing -- that would, I think, give us insight.

DR. BEZOLD: Part of the problem is this is a relatively resource-small effort. If you pick diseases -- I can see technological solutions, say, to cancer or to heart disease. If you were suggesting diseases to pick, we picked two or three.

DR. SONDIK: I think it would be very useful to look at the six that are in the race initiative. I think it is absolutely critical that the working groups that we have think about this in terms of scenarios from one end, so to speak, and from the other end. What are the factors that specifically could influence these, or would lead us in the right direction? And then try to look at the confluence of these factors.

DR. BEZOLD: In behavior and service outcomes, is there anything equivalent to the six in the race initiative?

DR. SONDIK: Yes.

DR. SATCHER: Just one more question and then we are going to go to the public comment.

MR. KRING: I don't know if you mention it here, immigration. What we see, at least in the population area, is the Hispanic birth rate going up above, now, the black birth rate in terms of disparities for teens. A lot of it is because of the newly-arrived immigrants, specifically, in the southwest. That is part of why were sitting here earlier saying that we don't think we will see the disparities change in 10 years. With constant new arrivals -- and that happens at this point in time to be a minority group -- that creates a scenario that basically makes it almost impossible to bring it about, unless we expand our reach far beyond the border of the United States into other countries.

DR. BEZOLD: You have just given me a great link for global. The flip side of it is -- I would argue that, as developers of the objectives, if you take the eliminating disparities seriously, then the question is, what is the set of strategies in those areas with the image you just presented? It comes down to the question of what do you do.

Part of our job as futurists is to be where the rubber meets the sky and become both inspired and more imaginative in doing that. I would argue that, to the extent that you can come up with a problem like you just described, it is incumbent upon you as the Healthy People team to say, you know, what you can do about it, and the more you can build into this round of the objectives, the better. It is also a conversation, as you get people taking ownership and commitment to the objectives to do that.

DR. SATCHER: Okay, very good. Thank you. Okay, we are to the last item on our agenda, really, except the summary. We are going to take a few minutes for public comments. If there are people here who would like to make comments, I would like to ask you two things. Number one, state your name and your organization, and be brief -- those two things.

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