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Section 2. A Comprehensive Public Health Strategy and the Five Essential Components of the Plan: A Platform for Action

A Framework for a Comprehensive Public Health Strategy

Developing a comprehensive public health strategy requires considering the full scope of a public health problem and the array of potential approaches to controlling it. It also requires recognizing the present reality and having a vision of the future that includes the most favorable conditions that can result from effective public health action. Bringing these four elements together in one action framework provides guidance and helps ensure that all relevant aspects are addressed. The framework developed for the Action Plan provides a useful point of reference for considering the recommendations and proposed action steps (see figure 1).

This framework is intended to represent the full scope of CVH in all its aspects, including the progressive development of CVD and the corresponding opportunities for CVH promotion and CVD prevention. It reflects the extensive research and practical experience of the past 50 years and more, which have provided a solid understanding of the causes of CVD and identified a wide range of opportunities for intervention. The framework also indicates where intervention approaches can be applied, through greatly expanded public health efforts, to advance from the present reality toward the vision of the future.

The Present Reality

The present reality of the burden of heart disease and stroke, especially in the United States, was documented in Section 1.^1,2 Underlying this burden are the long–term development of atherosclerosis and high blood pressure, conditions that are widely prevalent throughout our society. The causes begin with unfavorable social and environmental conditions that foster adverse behavioral patterns and result in a high prevalence of major risk factors. Inadequate measures for preventing, detecting, and controlling risk factors lead to first CVD events (e.g., heart attack, heart failure, stroke) from which many victims die suddenly, while others survive with a high risk for recurrence and often with disability. Many victims ultimately suffer fatal complications or cardiovascular decompensation months or years after the initial event.

A Vision of the Future

We envision a future when the epidemic of heart disease and stroke has been arrested and reversed. This future includes social and environmental conditions that are favorable to health, a predominance of health-promoting behaviors, a low prevalence of risk factors, fewer and less frequently fatal CVD events, rapid recovery of full functional capacity for victims who survive, and good quality of life thereafter until death from whatever cause. The critical question is, how do we move from the present reality to this vision of the future?

Intervention Approaches

The answer can be found in the six–fold array of intervention approaches available today. First, policy and environmental change addresses fundamental social and environmental conditions that operate early in CVD development; this approach can also influence later phases of the disease process (e.g., by improving accessibility, use, and quality of health care).³ Second, behavioral change, especially population–wide, can reduce the effects of adverse social and environmental conditions. It can also reinforce the approaches that follow (e.g., by fostering community awareness and support for heart disease and stroke prevention). The third approach—detecting and controlling risk factors—has been a mainstay of CVD prevention and is needed continually once risk factors are present, to prevent both first and recurrent CVD events. (This approach comes too late in the process to prevent the risk factors themselves.) The fourth approach is emergency care and acute case management for those victims of first events who survive long enough to receive intervention. This approach continues to apply when survivors of previous acute CVD events experience recurrent ones. The fifth approach is rehabilitation, which should be applied following most acute events, and long–term management, which continues throughout the remainder of a victim's life until the sixth approach, end–of–life care, may be required.

Healthy People 2010 Goals

The action framework establishes a clear link between the proposed comprehensive public health strategy and Healthy People 2010 goals.⁴ Together, the six intervention approaches will help achieve the two overarching goals of Healthy People 2010, as well as the specific goal for preventing heart disease and stroke. The Healthy People 2010 Heart and Stroke Partnership divided this goal into four separate goals based on the different intervention approaches that would be needed to achieve them.

Target Population

Each intervention approach has the potential to affect millions of people in the United States.¹ The total U.S. population of 281 million people stands to benefit from policy and environmental change and populationwide behavioral change. The more than 100 million people with risk factors (e.g., high cholesterol, high blood pressure, smoking, obesity, diabetes) could benefit from effective risk factor detection and control. In addition, the hundreds of thousands of victims of first major CVD events each year can gain from acute or long–term case management and, potentially, from end–of–life care.

Interventions with the greatest impact on the population as a whole are those applied in the earliest phases of CVD development. To treat victims of heart disease, stroke, or other cardiovascular conditions is clearly to intervene late in the disease process. For those who die suddenly without warning, it is too late to have any benefit. Today, only a few cents per person per year are invested in the most far–reaching intervention approaches, whereas thousands of dollars per person per year are spent in efforts to treat established risk factors, rescue the victims of acute events, restore function and reduce risk for recurrent events among survivors, and provide end–of–life care. There is a need and opportunity to support a continuum of care, from the whole population to the individual victims of CVD, but we as a nation are not doing so. To attain our vision of the future and achieve the applicable goals of Healthy People 2010, a change in the balance of investment between early and late intervention is needed. A comprehensive public health strategy to prevent heart disease and stroke must aim for greatly increased application of the earliest intervention approaches, while working toward assurance that appropriate services of high quality will be accessible and used by all those who continue to need them. In the vision of the future, that need will be substantially reduced.

Finally, the action framework offers a clearer understanding of CVH promotion and CVD prevention, as these terms are defined and used in the Action Plan (see Section 1 and Appendix A). CVH promotion is intended to prevent risk factors (goal 1) and includes policy and environmental change and behavioral change, especially at the population level. CVD prevention applies to subsequent phases of CVD development and includes primary and secondary prevention. Primary prevention is intended to prevent first clinical events by detecting and treating risk factors (goal 2), whereas secondary prevention follows the first event and, for victims who survive, seeks to restore full functional capacity and reduce the risk of recurrence (goal 4). Goal 3, early detection and treatment of heart attacks and strokes, is part of CVD prevention and falls between primary and secondary prevention.