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~ - ~ - Citizens Chart tbe Course Michael A. Stoto Ruth Behrens Connie Rosemont Editors Institute of Medicine National Academy Press Washington, D.C. ~ 990

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NATIONAL ACADEMY PRESS . 2101 Constitution Avenue, NW Washington DC 20418 NOTICE: This volume was prepared as a record of the public hearings and other activities designed to gather and organize information for the United States Public Health Service in formulating national health objectives for the year 2000. The opinions expressed in this report are those of the testifiers, not the Institute of Medicine or its parent organization, the National Academy of Sciences. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions In the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. The project was supported by the Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary of Health, Department of Health and Human Services under corporate agreement no. HPV-87-002-03- O. Library of Congress Catalog Card Number 90-62772 International Standard Book Number 0-309-04340-9 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, NW Washington, D.C. 20418 S-541 Copyright ~ 1990 by the National Academy of Sciences Printed in the United States of America First Printing, September 1990 Second Printing, May 1991 Third Printing, May 1992 Fourth Printing, July 1994

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COMMITTEE ON HEALTH OBJECTIVES FOR THE YEAR 2000 MERLIN K DuVAL, Chairman, Committee on Health Objectives for the Year 2000, Institute of Medicine, National Academy of Sciences, Washington, D.C. KATHARINE BAUER SOMMERS, Scholar-in-Residence, Institute of Medicine, National Academy of Sciences, Washington, D.C. JACK ELINSON, Distinguished Visiting Professor, Institute of Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey ANNE HUBBARD MATTSON, Director of Adult Health Services, Jefferson County Health Department, Birmingham, Alabama GILBERT S. OMENN, Dean, School of Public Health ~ Community Medicine, Professor of Medicine and of Environmental Health, University of Washington, Seattle, Washington STAFF GARY B. ELLIS, Director, Division of Health Promotion and Disease Prevention MICHAEL ~ STOTO, Study Director KAY C. HARRIS, Staff Officer CYNTHIA HOWE, Research Associate CONNIE ROSEMONT, Research Assistant MARTY ELLINGTON, Research Assistant RUTH BEHRENS, Writer RENIE SCHAPIRO, Writer ROSEANNE Mc[YRE, Writer JANE S. DURCH, Consultant DONNA D. THOMPSON, Project Secretary ~. 111

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TABLE OF CONTENTS Preface Acknowledgments . . 1. Introduction .............. History and Purpose of the Objectives . Hearings and Testimony . Questions for Testifiers Scope of the Testimony Purpose and Structure of this Report . Structure of this Document . . . References . . . . . . .. .. .. . . Testifiers Cited in Chapter 1 .... Objectives Process and Structure . . . Nature of the Objectives ......... ... ........ x''' , .... x~v Need to Address Social Conditions ......... Concepts of Health Promotion and Disease Prevention Format and Focus of the Objectives ..... Measurement Issues ............... Group Objectives by Population Subgroups . . . Missing Objectives .................... Priority Setting ........................ Need for Priorities Among the Objectives .... Models for Setting Priorities . . . References . . . ... . . . Testifiers Cited in Chapter 2 3. Implementing the Objectives at State and Local Levels . . State and Local Public Health Initiatives ........... State and Local Health Department Experience . . . The Model Standards ................... Federal Funding ......................... Intersectoral Cooperation: Role of the Private Sector . . . Community Participation . . . Corporate Partnerships ...... Surveillance and Information Resources .... State and Local Data Systems . . Specific Diseases and Problems . . Special Needs of Minority Populations . . . Information Resources . . References . . . . . . . . . . . . Testifiers Cited in Chapter 3 ...... 4. Children and Adolescents . . Crosscutting Topics .... Access to Care ..... 9 10 11 12 12 13 14 14 15 15 15 17 19 21 21 22 23 23 24 24 25 26 26 28 28 28 29 29 30 30 Child-care Centers and Health .... The Media and Children's Health ......... Coordination of Adolescent Health Services . . Chronic Illness and Disability in Children .... v

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Health Promotion . . . Nutrition . . Physical Fitness ....... Substance Abuse ........... Mental Health and Suicide ..... Health Protection ........... Unintentional Injury ........ Child Abuse and Family Violence Lead Poisoning ............ Preventive Services Infectious Diseases ..... Oral Health ........ Screening for Chronic Health Problems in Children Data Needs .................. References .. . . . Testifiers Cited in Chapter 4 ...... 5. Older Adults . .... . ... .. . ..... Crosscutting Issues and Quality of Life Health Promotion and Health Protection for Older Adults Smoking Cessation ......... Alcohol Misuse of Medication ....... Mental Health .......... Physical Activity and Recreation O . Injury Control ~ Elder Abuse ................... Preventive Services for Older Adults ..... Cardiovascular Disease ........ Cancer ~ Osteoporosis ............... Infectious Diseases ........... Dental Health ............... Hearing and Communication ............ Long-term Health Care Needs of the Aging ..... Implementation Access to Health Care ........ Data and Information Needs .... References . . . . Testifiers Cited in Chapter 5 ...... 6. Racial and Ethnic Minorities .... Social, Behavioral, and Cultural Factors . . Socioeconomic Factors ...... Poverty. Unemployment. . ... Education. . .. Behavioral Factors .... The Role of Culture ....... Access to Health Care ........ Specific Health Problems of Minority Groups ..... Infant Mortality ............ vi 31 31 31 32 33 34 34 35 35 35 36 36 36 37 37 38 40 40 42 42 42 42 42 43 43 44 44 45 45 45 45 46 46 46 47 47 48 48 49 51 52 52 52 52 52 53 53 54 55 55

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Chronic Diseases ................ Heart Disease and Stroke. .... Cancer. ... ~ ............. Diabetes. . Common Risk Factors and Interventions HIV Infection and AIDS ............ Homicide, Suicide, and Violence ....... Tobacco, Alcohol, and Substance Abuse . Teenage Pregnancy ......... References . .... .. ... . . . ... Testifiers Cited in Chapter 6 ..... 7. People with Disabilities ......... Health Promotion for People with Disabilities . . . Access to Health Services Implementation References . . . . Testifiers Cited in Chapter 7 ........ 56 56 ~6 57 57 57 58 59 60 60 62 8. Health Promotion and Disease Prevention in the Health Care System . Problems with Access to Health Care Poor and Homeless ........... Racial and Ethnic Minorities People with Disabilities . . Health Promotion and Disease Prevention in the Health Care System . . Physicians . ~ . . e ~c Other Health Professionals ........ Health Care Settings and Organizations ................................ Financing Health Promotion and Disease Prevention Programs in the Health Care System . . . . ~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Federal Funding Programs ......................................... Medicare . ~ . . .... . .. . . . . ... ...... . . Medicaid .... .. Block Grants ............ Health Insurance ................ Implementation within the Health Care System Coordination of Services ....... Training of Health Professionals . . Underserved Areas ........... Minority Practitioners . . . References . Testifiers Cited In Chapter 8 9. Health Promotion and Disease Prevention in Community Settings Health Promotion and Education in Schools ................ Implementation of School-based Health Promotion ..... Specific Problems and Interventions ....... Nutrition. . ......... . . Physical Fitness................. Mental Health................... Family Planning and Reproductive Health. AIDS Education. ................ 64 64 65 66 67 67 68 69 69 70 7t 71 71 72 73 74 75 75 75 76 76 77 77 77 78 79 79 80 82 82 83 84 84 84 85 85 86 . V11

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Smoking, Alcohol, and Substance Abuse. . . Health Promotion in the Workplace ........... Implementation of Workplace-based Programs . Specific Problems and Interventions . . Screening for Chronic Diseases. Smoking. .. ..... Nutrition. ...... Stress Management. ........ Community-level Interventions .......... Specific Problems and Interventions . . . Problems of Adolescents. ........... Alcohol-Related Problems............ Cardiovascular Problems. ........... Racial and Ethnic Minorities ............... Linking Community-level Programs With Larger Efforts . Crosscutting Implementation Issues ................ Content of Health Promotion and Education Programs . Financing Health Promotion and Health Education References . . .......... Testifiers Cited in Chapter 9 10. Tobacco . . . . . . . . . . . . Adolescent Smoking ...... Smoking and Pregnancy . . . Worksite Smoking ........ Smokeless Tobacco ...... Implementation Issues ..... References . Testifiers Cited in Chapter 10 11. Alcohol and Drug Abuse ........... Alcohol Problems ................ Adolescent Substance Abuse ........ Substance Abuse by Minority Groups . . Blacks . . . ~ . Hispanics . ........ . . . Native Americans .............. The Indigent, Homeless, and Disadvantaged Implementation References ............ .. Testifiers Cited in Chapter 1 1 1 2. Nutrition Hunger . . . .. ....... Specific Nutritional Risk Factors Hypertension ... ..... Cholesterol ......... Obesity . . . ......... Anorexia and Bulimia . . Anemia . ........... Special Target Groups .... Pregnant Women . . . . . viii 86 87 87 89 89 89 90 90 91 91 91 92 92 92 93 94 95 95 96 96 99 99 100 100 101 102 102 103 104 105 105 106 107 107 107 107 107 108 109 110 110 . 111 . 111 e owe 111 i 112 . 112 112 112 113

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Infants and Children ..... Hospitalized Patients ................ Education and Other Preventive Strategies . . . Implementation References . ................... Testifiers Cited in Chapter 12 13. Physical Fitness and Exercise . . New Emphases Needed ........... Special Populations ............... Revising Goals for Children and Youth . . Implementation References . ........ ......... Testifiers Cited in Chapter 13 ........ 14. Mental Health ...................... Particular Problems ......... Stress ........................ Depression . . Schizophrenia and Other serious Mental lIlnesses .... Interventions Wanted and Healthy Babies ...... Prevention of Adolescent Pregnancy School Programs ............. Support, Information, and Training in Situations of Extreme Stress . . . Implementation References . . . Testifiers Cited in Chapter 14 .................... 113 ................... 114 114 115 116 116 . . . ~ t5. IJnintentional Injuries ..... Motor Vehicle Injuries ........... Other Causes of Injury . . . Falls . . . Fires . .. Poisonina . . . . . . . . . . . . . . . . ~ . . . . . Drowning .. .... Disabling Injuries .......... Implementation Manpower and Organization . Surveillance and Data Collection . . References .. ...... . . . . . . Testifiers Cited in Chapter 15 ..... 16. Violent and Abusive Behavior ..... Homicide and Interpersonal Violence Suicide . . . . ........ . . . Family Violence .... Child Abuse ..... Spouse Abuse ..... Elder Abuse ....... Implementation .... References 118 118 119 119 120 121 122 123 124 124 124 125 125 125 126 126 126 127 127 128 ... 129 .... 129 .... 130 .... 130 .... 131 .... 131 .... 131 .... 131 .... 132 .... 132 .... 132 .... 133 .. 134 .............. 135 . 135 .. 136 . 137 . 138 . 138 . 138 . 139 .. 139 ix

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Testifiers Cited in Chapter 16 . . . 17. Occupational Safety and Health . . . Groups with Particular Needs ..... Agricultural Workers .... Health Care Workers . . . Other Hazardous Occupations . Retired Workers .......... Working Children . . . Workplace Protection Issues . Toxic Agent Exposure . . . Injury Control .. . . ... . . Reproductive Effects . . . Noise Reduction ...... The Workplace as a Site for Health Promotion and Disease Prevention Activities Implementation Surveillance ......... Manpower .... . . ~ . . . References . . . . Testifiers Cited in Chapter 17 . . . . . . . . . 18. Environmental Public Health Toxic Agents .......... Hazardous Wastes .... Water Contamination . . . Lead Poisoning . . . Air Pollution ........... Food-borne Disease . . . Implementation References ... .. . ... . .. Testifiers Cited in Chapter 18 19. HIV Infection and AIDS Education, Testing, and Counseling .... Mandatory Testing, Reporting, and Contact Notification Special Populations .......... Children and Adolescents . . . Minorities .... . .. . ... . .. Intravenous Drug Users ..... Mothers and Infants ....... At-risk Professionals ..... Implementation References . .. Testifiers Cited in Chapter 19 . . 20. Sexually Transmitted Diseases . . Targeting Youth ............. Reducing Congenital Sexually Transmitted Diseases .... Implementation Improving Services .............. Expanding Research and Reporting . . Setting Quantifiable Goals ......... x ... 140 141 141 141 142 142 143 143 143 143 144 144 145 145 145 145 146 146 146 148 148 149 149 149 150 150 151 151 152 153 153 154 154 154 155 155 156 156 156 157 157 159 159 160 161 161 161 162

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References . . . . . . . .. . . . . . . Testifiers Cited in Chapter 20 . . 21. Infectious Disease Immunizable Diseases Nosocomial lofections Tuberculosis . . . . . . . . . Other Infectious Diseases Implementation References . . .. . . . . . . . . . . .. .. . . . . . Testifiers Cited in Chapter 21 Maternal and Infant Health . . Prenatal Care . . . . . Maternal Mortality and Complications . . . Newborn Care .......... Implementation ... . ..... Availability of Providers . . .; . . . Financial Constraints ......... Need for Outreach Programs ...... Data Needs ~ ................... References . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . Testifiers Cited in Chapter 22 23. Adolescent Pregnancy ........ Contributing Causes ...... Availability and Use of Contraception .... Socioeconomic Factors ..... Prevention Strategies ......... References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Testifiers Cited in Chapter 23 . . . Cardiovascular Disease . . . Hypertension . .. . . . ... High Blood Cholesterol . . . Target Populations ...... Blacks . Hispanics ... . . . ... Elderly . .... . . . ... Children . . . . Implementation References Testifiers Cited in Chapter 24 25. Cancer ........ Specific Cancers ......... Breast and Cervical Cancer . . . Malignant Melanoma .... Poor and Minonties ...... References . ... . . . ..... Testifiers Cited in Chapter 25 ............. 162 163 . 164 . 164 . 166 . 166 . 167 . 167 168 . 168 . 170 170 . 171 . 172 . 172 . 172 173 174 174 174 . 175 . 176 . 176 . 176 . 177 . 177 . 178 . 179 ... 181 ... 181 ... 182 .. . 183 ... 183 ... 183 ... 183 ... 184 _J.. 184 .... 184 ..... 185 .. 186 .. 186 .............. 186 '. 187 . 188 189 . 189 X!

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26. Oral Health Fluoridation Infants and Children ...... Adults . . . . . . . ear Older Adults . ~ ~ ~ ~ en Underserved Populations: Problems and Strategies Implementation References . ...... . . . . . Testifiers Cked in Chapter 26 ............................................ 191 191 192 192 193 193 194 195 195 . 27. Other Chronic Diseases and Disabling Conditions Diabetes . . . . ....... . ...... ..... . . . . . . ... . Musculoskeletal Conditions . . Osteoporosis . ~ Arthritis Hearing Disorders . I ~ ~ ~ Vision ni~nr~rc Developmental and Chronic Disabilities Mental Retardation .......................................... References . . . . . . . . . . . . . Testifiers Cked in Chapter 27 ............................................ Appendix A: Testifiers for the Year 2000 Health Objectives Appendix B.: Year 2000 Health Objectives Consortium .................... Appendix C: Local Cosponsors for Year 2000 Regional Hearings ............ e X11 196 196 197 197 198 199 199 200 200 201 201 202 204 221 228

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P reface Our nation's willingness to commit almost 12 percent of its economy to health care-from one-third to three times more than all other nations~hould be rewarded with the best health outcomes in the world. Unfor- tunately, it isn't. On the contrary, many of our health statistics indicate poor outcomes. Some have argued that this discrepancy can be attributed to such things as our geographic size, our multiracial and ethnic diversity, and the extreme socioeconomic heterogeneity of our citizens. Others believe it is futile to seek a direct relationship between good health and what we spend in its pursuit because, as often as not, our health profiles may be an expression of the choices we make as we go through life rather than of the care we receive when we are ill. Clearly, both views have validity. For example, some of the best health statistics in the world come from nations that are barely the size of one of our western states, and whose homogeneous populations are not even one-third as great in number. At the same time, our citizens jealously guard their right to make unconstrained personal choices about the way they wish to live. And they do, for good or for ill. The genius of the Health Objectives for the Year 2000 project, an initiative of the U.S. Public Health Service, is that it rises above these discontinu~ties by acknowledging that demography, biomedical science, and personal behavior all play roles in determining our health status; therefore, all must be addressed as part of any effort to prevent diseases through the promotion of health and the reduction of risks. To give both energy and breadth to this effort, Health Objectives for the Year 2000 solicits the active participation of America's businesses, industries, and education and professional institutions and agencies, whether for-profit or voluntary. It Invites them to join hands with federal, state, and local governmental units in a common pursuit of better health for everyone. In this pursuit, the problems of particularly difficult target groups, such as those who live at the extremities of life as measured by age or circumstance, are being emphasized because of their special sig- nificance to, and impact upon, all of us. The specific role played by the U.S. Public Health Service in orchestrating this remarkable effort de- serves particular comment. For almost 200 years the PHS has served us well through its mixed missions of regulation, biomedical research, and service to specifi- cally designated beneficiaries. Then, barely 15 years ago, our Congress added Title XVII to the Public Health Service Act authorizing the Secretary of the Department of Health, Education and Welfare (now Health and Human Services) to establish, for the first time, national goals and strategies in disease preven- tion and health promotion. The Health Objectives for the Year 2000 project is the Department's principal response to that challenge. It was crafted so well that it permitted all interested parties-as exemplified by more than 800 pieces of testimony-to help define the kind of society they want for the next decade by giving form and substance to the objectives themselves. Even Marshall McLuhan might argue that, in this instance, the medium not only is the message but also may have successfully in- tegrated the ends with the means. Merlin K DuVal, M.D. Chairman Con2n2ittee on Health Objectives for the Year 2000 ... x''

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Acknowledgments This volume represents the work of well over 1,000 individuals around the United States. As we explain in more detail in the introduction, the text is based on testimony presented at seven major regional hearings held in the winter of 1988 and other special hearings, and in writing to the Institute of Medicine. Much of the testimony comes from the 300 national organizations and state health departments that make up the Consortium on the Year 2000 Health Objec- tives, or people these organizations nominated. The individuals and organizations that submitted testimony as well as the organizers and cosponsors of the regional hearings are listed in the appendix. Although we were not able to quote every piece of testimony in the text, we are truly grateful for the efforts of the people who prepared testimony or helped to organize the hearings. This volume was prepared under the guidance of the Institute of Medicine's Committee on Health Objectives for the Year 2000 (whose members are listed on p. iii) and the Board on Health Promotion and Disease Prevention. We have benefited from many helpful suggestions from the members of these committees, and from members of the Institute of Medicine who read and commented on early drafts. The final responsibility for the content of the report, however, rests with the editors. The work also benefited from many Institute of Medicine staff members, only some of whom are listed with the project staff. I would especially like to note the contributions of Queta Bond, the current Execu- tive Officer, who served as Director of the Division of Health Promotion and Disease Prevention when this project began, and Marian Ostenveis, who served as Director in 1989. In addition, Connie Rosemont and Donna Thompson, the project's research assistant and secretary, respectively, worked long and hard hours revising and preparing the text for publication, checking the references, and making sure that our at x~v tributions were as accurate as possible. Note on Authorship The following list identifies the persons who shared the responsibility for preparing the first draft of each chapter in this volume. Marty Ellington: Chapter 6 Kay Harris: Chapter 18 Cynthia Howe: Chapters 4, 5, and 17 Roseanne McTyre: Chapters 10 and 11 Connie Rosemont: Chapters 6, 7, 9, 15, 16, and 18 Renie Schapiro: Chapters 12, 13, 19, 20, 21, 22, 23, 24, 25, 26, and 27 Michael Stoto: Chapters 1, 2, 3, 4, 5, 6, 8, 9, and 14 The material in the chapters is drawn from testimony submitted to the Institute of Medicine. The initial drafts were submitted to the Public Health Service for use in formulating the Year 2000 Health Objectives and for review. The draft chapters also were reviewed by the testifiers cited, the Committee on Health Ob- jectives for the Year 2000, members of the Institute of Medicine, and others. Taking these reviews into account, the editors revised and reorganized the draft chapters into what appears in this volume. The opinions expressed in this report are those of the tes- tifers, not the Institute of Medicine or its parent or- ganization, the National Academy of Sciences. Chapter authors are listed above to give credit to individuals but not to assign final responsibility for the published text. The revision and editing of the volume were shared by Ruth Behrens, Connie Rosemont, and myself. Michael A. Stoto, PhD. Study Director Committee on Health Objectives for the Year 2000