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2
HEALTHY
PEOPLE
2000
National Health Promotion and
Disease Prevention Objectives
EDITION: SUM
SERVICES
HUMAN
USA.
DEPARTMENT OF HEALTH & HUMAN SERVICES
Public Health Service
HEALTH
OF
DEPARTMENT
Office of the Assistant Secretary
for Health
Washington DC 20201
The Honorable Louis W. Sullivan
Secretary of Health and Human Services
Dear Mr. Secretary:
I am pleased to submit to you Healthy People 2000: National Health
Promotion and Disease Prevention Objectives. This document contains a
national strategy for significantly improving the health of the Nation
over the coming decade. It addresses the prevention of major chronic
illnesses, injuries, and infectious diseases.
The Public Health Service has served as leader, convener, and facilitator
over the three-year period of this report's development. However, it can
truly be labelled a national, not just a Federal, initiative to focus
existing knowledge, resources, and commitment to capitalize on our
opportunities to prevent premature death and needless disease and
disability. Thousands of professionals from many different disciplines,
as well as many health advocates and consumers, have contributed
substantially to produce this set of measurable targets to be achieved by
the year 2000. They have voluntarily testified at public hearings,
written eloquent letters and papers, engaged in extensive reviews of draft
materials, and organized and attended informational forums in support of
Healthy People 2000. The comprehensiveness and depth of this report stand
as a tribute to their commitment to better health for Americans through
prevention. In addition to their contribution, Federal staff from other
departments, other Operating Divisions of this Department, and the Public
Health Service Agencies, have worked above and beyond the call of duty to
produce this national prevention strategy. The Institute of Medicine of
the National Academy of Sciences has served as an important partner in our
efforts to involve a broad consortium of participants in the process.
Each deserves a special note of appreciation.
I commend Healthy People 2000 to you and through you to the American
people. This set of objectives for the year 2000 makes an important,
compelling point to us and to all health policy makers: we can no longer
afford not to invest in prevention. From the perspective of avoiding
human suffering as well as saving wasteful costs for treating diseases and
injuries that could have been prevented, the 1990s should be the decade of
prevention in the United States.
With the submission of Healthy People 2000, I commit the Public Health
Service to work toward achievement of these objectives for the coming
decade.
Sincerely yours,
James James O. Mason, M.D., Dr.P.H.
0.
maton
Assistant Secretary for Health
Enclosure
HEALTHY
PEOPLE
2000
National Health Promotion and
Disease Prevention Objectives
Conference Edition: Summary
U.S. Department of Health and Human Services
Public Health Service
Healthy People 2000 is a statement of national opportunities. Although the Federal Government
facilitated its development, it is not intended as a statement of Federal standards or requirements. It is
the product of a national effort, involving 22 expert working groups, a consortium that has grown to
include almost 300 national organizations and all the State health departments, and the Institute of
Medicine of the National Academy of Sciences, which helped the U.S. Public Health Service to manage
the consortium, convene regional and national hearings, and receive testimony from more than 750
individuals and organizations. After extensive public review and comment, involving more than 10,000
people, the objectives were revised and refined to produce this report.
Foreword
Americans today are taking a more active interest in their health than ever before. They
are coming to realize the influence that they, themselves, can have on their own health
destinies and on the overall health status of the Nation.
It wasn't always thus. Until fairly recently, we Americans gave little thought to health as
a positive concept. The past 15 years or so, however, have witnessed important changes
in our thinking about the protection and enhancement of personal health. Three of those
changes are of great importance for the well-being of our people as we move into the
final decade of this century.
First, personal responsibility, which is to say responsible and enlightened behavior by
each and every individual, truly is the key to good health. Evidence of this still-evolving
perspective abounds in our concern about the dangers of smoking and the abuse of al-
cohol and drugs; in the emphasis that we are placing on physical and emotional fitness; in
our growing interest in good nutritional practices; and in our concern about the quality of
our environment. We have become, in a word, increasingly health-conscious, increasing-
ly appreciative of the extent to which our physical and emotional well-being is dependent
upon measures that only we, ourselves, can affect.
We can control our health destinies in significant ways, then, but if we are to realize,
fully, the benefits of assuming that control, and this is the second of the three points I
would make, we must find the means of extending the benefits of good health to the most
vulnerable among us.
The correlation between poor health and socio-economic status has been well docu-
mented, but that does not make it right or inevitable. Good health should not be seen, or,
for that matter, be permitted to exist in fact, as a benefit for only those who can afford it;
it should be available and accessible to every citizen.
Medical care, alone, will not eliminate the devastating impact of chronic disease on the
disadvantaged, nor will it reduce, as much as we would like, the rate of infant mortality
or the burden of homicide and violence or any of the other "health" problems that are
borne by the poor in our society. If we are to extend the benefits of good health to all our
people, it is crucial that we build in our most vulnerable populations what I have called a
"culture of character," which is to say a culture, or a way of thinking and being, that ac-
tively promote responsible behavior and the adoption of lifestyles that are maximally con-
ducive to good health. This is "prevention" in the broadest sense. It is also an absolute
necessity, both because we are a humane and caring society and because, if we are to
remain a vital society, we cannot afford to waste human resources. Good health must be
an equal opportunity, available to all Americans.
Finally, health promotion and disease prevention comprise perhaps our best opportunity
to reduce the ever-increasing portion of our resources that we spend to treat preventable
illness and functional impairment. Smoking, for example, is the single most preventable
cause of death and illness in this country. Smoking-related illnesses cost our health care
system more than $65 billion annually.
AIDS is an almost entirely preventable disease. The cost of caring for a person with
AIDS for his or her lifetime is, today, about $75,000. The annual cost of treating all diag-
nosed AIDS patients, about $4.3 billion this year, could climb as high as $13 billion by
1992, the Public Health Service estimates.
Conference Edition
iii
Healthy People 2000
The yearly cost of treating alcohol and drug abuse is at least $16 billion. The total
economic impact of alcohol and drug abuse, including not only treatment but premature
death, accidents, crime, and lost productivity, is more than $110 billion annually.
We would be terribly remiss if we did not seize the opportunity presented by health
promotion and disease prevention to dramatically cut health-care costs, to prevent the
premature onset of disease and disability, and to help all Americans achieve healthier,
more productive lives.
Healthy People 2000: National Health Promotion and Disease Prevention Objectives ad-
dresses these three points. It lays out a series of national opportunities. To support the
development of these opportunities, a national consortium composed of nearly 300 na-
tional membership organizations and all of the State health departments joined the
Department's Public Health Service to solicit and analyze comments and suggestions
from people across the Nation. The Federal Departments of Agriculture, Education,
Labor, and Transportation and the Environmental Protection Agency participated
generously in the development of the national objectives. In regional and national hear-
ings, the Public Health Service and its partner in this venture, the Institute of Medicine of
the National Academy of Sciences, learned what people from many sectors of society
consider to be the priorities for prevention in the coming decades.
This input has shaped the content of Healthy People 2000 as it has evolved from its first
drafts through extensive public review and comment to the final publication. Participants
included health professionals and others in health-related industries. The Department has
had the honor of serving as a convener and facilitator in developing these goals, but they
truly belong to the Nation.
I commend this document for your consideration, to use as appropriate in your com-
munity. All those who participated in its development over the past three years can take
pride in its clarity of vision. All of us can feel humility in the face of its monumental
challenges, but we also can share a new sense of resolve to move forward to achieve a na-
tion of healthy people.
Louis W. Sullivan, M.D.
Secretary
September 1990
iv
Conference Edition
Contents
Foreword
iii
Part I
Healthy People 2000
1. Introduction
1
2. The Nation's Health: Age Groups
9
3. The Nation's Health: Special Populations
29
4. Goals for the Nation
45
5. Priorities for Health Promotion and Disease Prevention
55
6. Shared Responsibilities
87
Appendices
A. Healthy People 2000 Consortium
93
B. Priority Area Lead Agencies
97
Contents of the Full Report
Part II
National Health Promotion and Disease Prevention Objectives
Health Promotion
1.
Physical Activity and Fitness
6. Mental Health and Mental
2. Nutrition
Disorders
3. Tobacco
7. Violent and Abusive Behavior
4.
Alcohol and Other Drugs
8. Educational and
5.
Family Planning
Community-Based Programs
Health Protection
9. Unintentional Injuries
12. Food and Drug Safety
10. Occupational Safety and Health
13. Oral Health
11. Environmental Health
Preventive Services
14. Maternal and Infant Health
18. HIV Infection
15. Heart Disease and Stroke
19. Sexually Transmitted Diseases
16. Cancer
20. Immunization and Infectious
17. Diabetes and Chronic Disabling
Diseases
Conditions
21. Clinical Preventive Services
Surveillance and Data Systems
22. Surveillance and Data Systems
Age-Related Objectives
Children
Adults
Adolescents and Young Adults
Older Adults
Additional Appendices
C. Mortality Objectives Technical
D. Recommendations of the U.S.
Appendix
Preventive Services Task Force
E. Summary List of Objectives
Note: This is the conference edition of Healthy People 2000. Some minor corrections in
certain baseline data, graphs, charts, or references may be made in the final edition.
vi
Part I
Healthy
People
2000
Contents
1. Introduction
2.
The Nation's Health:
Age Groups
3.
The Nation's Health:
Special Populations
4.
Goals for the Nation
5. Priorities for Health
Promotion and Disease
Prevention
6.
Shared Responsibilities
1. Introduction
The year 2000 appears ahead on the calendar of our Nation's history as a turning point.
It may well be like any other year in the ongoing lives of people who inhabit this country
and the world. But from the perspective of history, the year 2000 will bring to its con-
clusion a tumultuous century, characterized by astounding scientific achievements, devas-
tating world wars, and explosive population growth. It will inaugurate at once a new cen-
tury and a new millennium, a future so vast in its human and historic dimensions that it
defies prediction while posing momentous questions about social and economic viability
and human vitality in the face of a new era.
The year 2000 connotes change. Its arrival contains enough power to shape that change,
motivating actions that can improve American lives. The beginning of the twenty-first
century beckons both with challenge and opportunity for improved health of Americans.
We began the current century with a sense of fatalism about the Nation's health
problems. As we reach its conclusion, we do so with confidence in our ability to control
many of the events that form our health prospects. A century of biomedical research has
made available sophisticated techniques for diagnosing and intervening against disease.
Scientific studies of even the last generation have revealed much about the factors that
predispose to various health threats and therefore about actions that each of us can take to
control our risks for disease or disability.
We have learned that a fuller measure of health, a better quality of life, is within our per-
sonal grasp. If tobacco use stopped entirely today throughout the Nation, an estimated
390,000 fewer Americans would die before their time each year. If all Americans
reduced their consumption of foods high in fat to well below current levels and engaged
in physical activity no more strenuous than sustained walking for 30 minutes a day, addi-
tional results of a similar magnitude could be expected. If alcohol were never carelessly
used in our society, about 100,000 fewer people would die from unnecessary illness and
injury. Together, deaths from these causes comprise a sizable share of the 2.1 million
deaths that occur annually and are examples of the impact of personal lifestyle choices on
the health destiny of individual Americans and the future of the Nation.
New knowledge has brought with it both a keen sense of potential and a keen apprecia-
tion of how far most Americans, especially those with low incomes, are from that poten-
tial. Moreover, we are already feeling the effects of momentous new issues emerging on
the horizon-the aging of our society, the prohibitive costs of many of the technologies
developed for diagnosing and treating disease, and the ecologic consequences of in-
dustrialization and population growth.
These problems compel careful engagement on the national agenda. This report frames
the elements of that agenda from the perspective of the potential to prevent unnecessary
disease and disability and to achieve a better quality of life for all Americans. It grows
out of a health strategy initiated in 1979 with the publication of Healthy People: The Sur-
geon General's Report on Health Promotion and Disease Prevention and expanded with
publication in 1980 of Promoting Health/Prevention Disease: Objectives for the Nation,
which set out an agenda for the ten years leading up to 1990.
Healthy People 2000 offers a vision for the new century, characterized by significant
reductions in preventable death and disability, enhanced quality of life, and greatly
reduced disparities in the health status of populations within our society. It is the product
of a national effort, involving professionals and citizens, private organizations and public
agencies from every part of the country. Work on the report began in 1987 with the con-
vening of a consortium that has grown to include almost 300 national membership or-
Conference Edition
1
Healthy People 2000
ganizations and all the State health departments (see Appendix A). The Consortium,
facilitated by the Institute of Medicine of the National Academy of Sciences, helped the
United States Public Health Service to convene 8 regional hearings and received tes-
timony from over 750 individuals and organizations. This testimony became the primary
resource material for working groups of professionals to use in crafting the health objec-
tives themselves. After extensive public review and comment, involving more than
10,000 people, the objectives were refined and revised to produce this report.
This report does not reflect the policies or opinions of any one organization, including the
Federal government, or any one individual. It is the product of a national process. It is
deliberately comprehensive in addressing health promotion and disease prevention oppor-
tunities in order to allow local communities and States to choose from among its recom-
mendations in addressing their own highest priority needs.
The Year 2000: A Profile of The American People
Over the course of the 1990s, the profile of the American population will change. Bar-
ring unforeseeable major events, the demographic contrasts between 1990 and 2000 will
be evident, if not dramatic. Based on the best available information:
By the year 2000, the overall population of the United States will have grown about
7 percent to nearly 270 million people, with the slowest rate of growth in the
Nation's history projected between 1995 and 2000. 12 Average household size is ex-
pected to decline from 2.69 in 1985 to 2.48 in 2000, 1 with husband-wife households
decreasing from 58 to 53 percent of all households.
By the year 2000, the American population will be older, continuing the aging
trend of the present century, with a median age of more than 36 years, compared to
29 years in 1975. The number of children under age 5 will actually decline from
more than 18 million to fewer than 17 million between 1990 and 2000. By 2000,
the 35 million people over age 65 will represent about 13 percent of the population,
in contrast to 8 percent in 1950. The population of the "oldest old"-those over
age 85-will have increased by about 30 percent to a total of 4.6 million by
12
2000.
By the year 2000, the racial and ethnic composition of the American population
will form a different pattern. Whites, not including Hispanic Americans, will repre-
sent a smaller proportion of the total, declining from 76 to 72 percent of the popula-
tion. The fastest growing population group will be Hispanics, some estimates
forecasting a rise from 8 to 11.3 percent, to more than 31 million Hispanic people
by 2000. Blacks will increase their proportion from 12.4 to 13.1 percent. Other ra-
cial groups, including American Indian/Alaska Natives and Asian/Pacific Islanders,
will increase from 3.5 to 4.3 percent of the total. 11,12
By the year 2000, economic expansion will create up to 18 million new jobs, but
the number of young job seekers will decline due to a shift in birth rates. Reflect-
ing changes in racial and ethnic populations, the entry rate of blacks, Hispanics,
Asian/Pacific Islanders, and American Indians/Alaska Natives into the workforce
will be higher than for whites. Women of all racial and ethnic groups will be the
major source of new entrants into the labor force, comprising 47 percent of the total
workforce by 2000, compared to 45 percent in 1988. Half of women in the
workforce will be between the ages of 35 and 54, a shift from 1986 when the
majority were between 25 and 44. Between 1988 and the year 2000, white men
will comprise only 25 percent of the net growth of the labor force. 4 Occupations
most likely to grow include service, professional, technical, sales, and executive
and management positions.
2
Conference Edition
1. Introduction
By the year 2000, the American population may have increased by up to 6 million
persons through immigration. Certain States and cities, especially those on the east
and west coasts, can be expected to receive a disproportionately large number of
these immigrants.⁶
While 10 years in the history of a Nation seems a comparatively short time, it is long
enough to alter population patterns in ways that are of great importance to current and fu-
ture decision-makers seeking to design an effective program of health promotion and dis-
ease prevention. Informed estimates about the changes in households and family constel-
lations, age groups, racial and ethnic populations, the workforce, and immigration can
provide a context that is crucial to decisions and programs to achieve a nation of healthy
people.
Promoting Health and Preventing Disease: Progress
Ten years is also long enough to bring about marked changes in the Nation's health. (Fig.
1.1) During the 1980s, there were major declines in death rates for three of the leading
causes of death among Americans: heart disease, stroke, and motor vehicle crashes.
Infant mortality also decreased, and some childhood infectious diseases were nearly
eliminated. Gains in these areas give hope that the 1990s will see more progress, espe-
cially for diseases such as cancer that have SO far not declined.
Heart disease
Cancer
Fig. 1.1
Stroke
Leading causes of
Injuries
death, U.S. popula-
Chronic lung disease
tion (crude rates)
Pneumonia/influenza
Diabetes
Suicide
1987
Liver disease
1977
Atherosclerosis
0
50
100
150
200
250
300
350
400
Source: Health, United
Rate per 100,000
States, 1989
Much of our progress mirrors reductions in risk factors. The more than 40-percent drop
in heart disease mortality since 1970 reflects dramatic increases in high blood pressure
detection and control, a decline in cigarette smoking, and increasing awareness of the
role of blood cholesterol and dietary fats. The precipitous drop in stroke death rates—
over 50 percent in the same period-also reflects gains in hypertension control and
declines in smoking.
Unintentional injuries have declined. In the last decade and a half, traffic fatalities
dropped by one-third, partly reflecting increased use of seatbelts, lower speed limits, and
declines in alcohol abuse. Recent reductions in fatal occupational injuries have been
facilitated by enhanced occupational safety standards. Studies are beginning to yield
promising approaches for alcohol and other drug problems.
Progress has been made in the health status of children as well. In 1987, we achieved a
record low rate of 10.1 infant deaths per 1,000 live births. Although still higher than
rates in many other developed countries, this figure represents a 64-percent decline since
1950. Preventable childhood diseases, such as mumps, measles, and rubella, are now un-
Conference Edition
3
Healthy People 2000
usual in this country due to widespread use of vaccines. Immunization levels among
school children exceed 95 percent for most of these diseases.
In other areas, progress is mixed. Lung cancer deaths have increased steadily since 1960,
although rates among men aged 50 and younger began to turn around in the 1980s, a sign
that changes in smoking patterns are beginning to have an effect. Breast cancer death
rates remain stubbornly high, as they have for 35 years, despite the fact that early detec-
tion and treatment could reduce deaths due to breast cancer by an estimated 30 percent. 10
For cervical cancer, the widespread use of Pap tests has contributed to a 73-percent reduc-
tion in death rates from the disease since 1950.
Changing trends point to still other areas that require attention. In the past decade, rising
rates of syphilis and the emergence of HIV infection point to the need for new strategies
to address these public health problems. Air and water quality have improved since the
Environmental Protection Agency and the States began regulating them in the early
1970s. However, the last decade has seen increasing concern expressed by individuals,
communities, and public agencies about toxic substances, solid waste, and global environ-
mental change.
When taken together, the progress of the last ten years has brought the Nation a consider-
able distance toward the health goals set forth in Healthy People in 1979. That report tar-
geted for the year 1990 a 35-percent reduction in infant mortality, a 20-percent reduction
in death rates for children aged 1 through 14, a 20-percent reduction in death rates for
adolescents and young adults aged 15 through 24, and a 25-percent reduction in death
rates for adults aged 25 through 64. For older adults, aged 65 and older, the target was a
20-percent reduction in days of disability. Figure 1.2 summarizes progress toward these
goals, as of the most recent year for which data are available.
Life Stage
1990 Target*
1987 Status
Infants
35% lower death rate
28% lower
Children
20% lower death rate
Fig. 1.2
21% lower
Adolescents/
20% lower death rate
13% lower
Progress toward
Young Adults
1990 life stage
Adults
25% lower death rate
21% lower
goals-1987
Older Adults
20% fewer days of
17% lower
restricted activity
* relative to baseline (1977 data)
Source: Office of Disease
Prevention and Health
Promotion
A more detailed record of national efforts in health promotion and disease prevention is
provided by tracking progress toward achievement of the 226 measurable objectives that
were laid out in Promoting Health/Preventing Diseases: Objectives for the Nation in
1980-objectives established to achieve the broad goals of Healthy People. As of 1987,
it appeared that nearly half of the objectives had been achieved or were well on their way
toward achievement by 1990; about one-quarter appeared unlikely to be achieved; and
the status of the other quarter was uncertain because data were unavailable for tracking
their progress. Among the 15 priority areas that were the focus of the 1990 objectives,
areas in which progress seemed to be lagging included pregnancy and infant health, nutri-
tion, physical fitness and exercise, family planning, sexually transmitted diseases, and oc-
cupational safety and health. On the other hand, priority areas related to high blood pres-
sure control, immunization, control of infectious diseases, unintentional injury prevention
and control, smoking, and alcohol and drugs showed substantial progress.
4
Conference Edition
1. Introduction
Healthy People: The Economics of Prevention
Despite the overall health improvements achieved as a result of preventive interventions,
the Nation continues to be burdened by preventable illness, injury, and disability. In
1960 the share of the Gross National Product (GNP) going to medical services was 5 per-
cent. It is estimated to reach nearly 12 percent in 1990.2 Lost economic productivity at-
tendant to illness and early death compounds the impact of this problem, so that in 1980
the total costs of illness equalled nearly 18 percent of GNP. Injury alone now costs the
Nation well over $100 billion annually,⁹ cancer over $70 billion, and cardiovascular dis-
ease $135 billion.
Sophisticated technology for the diagnosis and treatment of disease conditions has out-
stripped society's ability to pay for it. (Fig. 1.3) But many of these expenses are
avoidable. Coronary artery disease affects approximately 7 million Americans and
causes about 1.5 million heart attacks and 500,000 deaths a year. The number of
Overall
Avoidable
Cost per
Condition
intervention
1
magnitude
patient
2
Heart
7 million with coronary
Coronary bypass surgery
$30,000
Fig. 1.3
disease
artery disease
500,000 deaths/yr
Costs of
284,000 bypass
treatment
procedures/yr
for selected
Cancer
1 million new
Lung cancer treatment
$29,000
preventable
cases/yr
510,000 deaths/yr
Cervical cancer treatment
$28,000
condtions
Stroke
600,000 strokes/yr
Hemiplegia treatment
$22,000
150,000 deaths/yr
and rehabilitation
Injuries
2.3 million
Quadriplegia treatment
$570,000
hospitalizations/yr
and rehabilitation
(lifetime)
142,500 deaths/yr
177,000 persons with
Hip fracture treatment
$40,000
spinal cord injuries
and rehabilitation
in the United States
Severe head injury treat-
$310,000
ment and rehabilitation
HIV
1-1.5 million infected
AIDS treatment
$75,000
infection
118,000 AIDS cases
(lifetime)
(as of Jan 1990)
Alcoholism
18.5 million abuse
Liver transplant
$250,000
alcohol
105,000 alcohol-related
deaths/yr
Drug
Regular users:
Treatment of cocaine-
$66,000
abuse
1-3 million, cocaine
exposed baby
(5 years)
900,000, IV drugs
500,000, heroin
Drug-exposed babies:
375,000
Low birth
260,000 LBWB born/yr
Neonatal intensive care
$10,000
weight baby
23,000 deaths/yr
for LBWB
Inadequate
Lacking basic
Congenital rubella
$354,000
immunization
immunization series:
syndrome treatment
(lifetime)
20-30%, aged 2 and
younger
3%, aged 6 and older
Source: Office
of Disease
1 Examples (other interventions may apply).
Prevention and
²Representative first-year costs, except as noted. Not indicated are non-
Health Promo-
medical costs, such as lost productivity to society.
tion
Conference Edition
5
Healthy People 2000
coronary bypass procedures performed each year is approaching 300,000, each one of
these procedures at a cost of approximately $30,000. Yet much of coronary artery dis-
ease is preventable. A representative cost for treating a single case of lung cancer is
$29,000 and $28,000 for invasive cervical cancer. A liver transplant for alcoholic cir-
rhosis can cost $250,000 or more. The lifetime treatment costs per patient are $570,000
for quadriplegia from a spinal cord injury, $354,000 for congenital rubella syndrome, and
$75,000 for Acquired Immunodeficiency Syndrome (AIDS). Yet virtually all of these
conditions are preventable. Mobilizing the considerable energies and creativity of the Na-
tion in the interest of disease prevention and health promotion is an economic imperative.
Healthy People 2000: The Challenge
The Nation has within its power the ability to save many lives lost prematurely and need-
lessly. Implementation of what is already known about promoting health and preventing
disease is the central challenge of Healthy People 2000.
But Healthy People 2000 also challenges the Nation to move beyond merely saving lives.
The health of a people is measured by more than death rates. Good health comes from
reducing unnecessary suffering, illness, and disability. It comes as well from an im-
proved quality of life. Health is thus best measured by citizens' sense of well-being. The
health of a Nation is measured by the extent to which the gains are accomplished for all
the people. The purpose of Healthy People 2000 is to commit the Nation to the attain-
ment of three broad goals that will help bring us to our full potential, namely to:
increase the span of healthy life for Americans
reduce health disparities among Americans
achieve access to preventive services for all Americans
The challenge of Healthy People 2000 is to use the combined strength of scientific
knowledge, professional skill, individual commitment, community support, and political
will to enable people to achieve their potential to live full, active lives. It means prevent-
ing premature death and preventing disability, preserving a physical environment that
supports human life, cultivating family and community support, enhancing each
individual's inherent abilities to respond and to act, and assuring that all Americans
achieve and maintain a maximum level of functioning.
We have a broad array of opportunities for prevention. This report presents many of
these opportunities in the form of measurable targets, or objectives, to be achieved by the
year 2000, organized into 22 priority areas. The first 21 of these areas are grouped into
three broad categories: health promotion; health protection; and preventive services.
(Fig. 1.4)
Health promotion strategies are those related to individual lifestyle-personal choices
made in a social context-that can have a powerful influence over one's health prospects.
These priorities include physical activity and fitness, nutrition, tobacco, alcohol and other
drugs, family planning, mental health, and violent and abusive behavior. Educational and
community-based programs can address lifestyle in a crosscutting fashion.
Health protection strategies are those related to environmental or regulatory measures
that confer protection on large population groups. These strategies address issues such as
unintentional injuries, occupational safety and health, environmental health, food and
drug safety, and oral health. Interventions applied to address these issues are generally
not exclusively protective in nature-there may be a substantial health promotion ele-
ment as well-but the principal approaches involve a community-wide rather than in-
dividual focus.
6
Conference Edition
1. Introduction
Health Promotion
1. Physical Activity and Fitness
Fig. 1.4
2. Nutrition
3.
Tobacco
Healthy People 2000
4.
Alcohol and Other Drugs
Priority Areas
5.
Family Planning
6. Mental Health and Mental Disorders
7.
Violent and Abusive Behavior
8.
Educational and Community-Based Programs
Health Protection
9. Unintentional Injuries
10. Occupational Safety and Health
11. Environmental Health
12. Food and Drug Safety
13. Oral Health
Preventive Services
14. Maternal and Infant Health
15. Heart Disease and Stroke
16. Cancer
17. Diabetes and Chronic Disabling Conditions
18. HIV Infection
19. Sexually Transmitted Diseases
20. Immunization and Infectious Diseases
21. Clinical Preventive Services
Surveillance and Data Systems
22. Surveillance and Data Systems
Age-Related Objectives
Children
Adolescents and Young Adults
Adults
Older Adults
Preventive services strategies include counseling, screening, immunization, or
chemoprophylactic interventions for individuals in clinical settings. Priority areas for
these strategies include maternal and infant health, heart disease and stroke, cancer,
diabetes and chronic, disabling conditions, HIV infection, sexually transmitted diseases,
and infectious diseases. Crosscutting professional and access considerations in the
delivery of clinical preventive services are also addressed.
A special category has been established for surveillance and data systems. Given the
centrality of monitoring progress toward the stated targets in the overall approach of
Healthy People 2000, the integrity of our data collection efforts at every level is critical.
Objectives have therefore been established to improve those efforts.
Finally, because issues and approaches vary by age, priority areas are presented for each
of four age groups: children, adolescents and young adults, adults, and older adults. Ob-
jectives related to each of these age groups are found throughout the priority areas. To
give them special emphasis, some of the key targets have been collected and presented ac-
cording to these four ages.
The full set of objectives with commentary is presented as Part II of Healthy People
2000. The material presented here in Part I defines the overall national agenda and out-
lines goals, objectives, and strategies for change. Chapter 2 of Part I reviews the
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Healthy People 2000
challenges for people in various age groups. Chapter 3 addresses high risk populations.
Chapter 4 presents the broad goals. Chapter 5 gives synopses of each of the priority areas
with selected examples of the objectives addressed. Chapter 6 reviews the challenge for
implementation for various groups throughout the Nation.
The last chapter deserves special comment. Healthy People 2000 uses the three ap-
proaches of health promotion, health protection, and preventive services as organizing
categories, but running through the priority areas and the objectives is a common theme
of shared responsibility for carrying out this national agenda. Achievement of the agenda
depends heavily on changes in individual behaviors. It requires use of legislation, regula-
tion, and social sanctions to make the social and physical environment a healthier place
to live. It calls on medical and health professionals to prevent, not just to treat, the dis-
eases and conditions that result in premature death and chronic disability. All are neces-
sary. None is sufficient alone to achieve Healthy People 2000's goals and objectives.
The challenge spelled out in Healthy People 2000 calls upon communities to translate na-
tional objectives into State and local action. To accomplish this, a new edition of Model
Standards-Healthy Communities 2000: Model Standards, Guidelines for Attainment of
Year 2000 Objectives for the Nation-provides a flexible planning tool to enable com-
munities to share in the various efforts necessary to attain these objectives. The volume
covers the priority areas of Healthy People and includes all of the national objectives that
call for action at the community level. It offers community implementation strategies for
putting the objectives of Healthy People 2000 into practice and encourages communities
to establish achievable community health targets.
References
1
Bureau of the Census. Projections of the Numbers
8 Public Health Service. Promoting
of Households and Families: 1986 to 2000.
Health/Preventing Disease: Objectives for the
Washington, DC: U.S. Department of
Nation. Washington, DC: U.S. Department of
Commerce, 1986.
Health and Human Services, 1980.
2
Health Care Financing Administration, Office of the
9
Rice, D.P.; MacKenzie, E.J.; Jones, A.S.; Kaufman,
Actuary. Expenditures and percent of gross
S.R.; deLissovoy, G.V.; Max, W.; McLoughlin,
national product for national health expenditures,
E.; Miller, T.R.; Robertson, L.S.; Salkever, D.S.;
by private and public funds, hospital care, and
and Smith, G.S. Cost of Injury in the United
physician services; calendar years 1960-87.
States: A Report to Congress, 1989. San
Health Care Financing Review 10:2, Winter
Francisco, CA: Institute for Health and Aging,
1988.
University of California and Injury Prevention
3
Hodgson, T.A., and Rice, D.P. Economic impact of
Center, The Johns Hopkins University, 1989.
cancer in the United States. In: Schottenfeld, D.,
10 Shapiro, S., Venet, W. Strax, L., and Roeser, R.
ed. Cancer Epidemiology and Prevention.
Selection, Followup, and Analysis in the Health
Chapter 13, in press.
Insurance Plan Study: A Randomized Trial With
4 Kutscher, R.E. Projections 2000: Overview and
Breast Cancer Screening. National Cancer
implications of the projections to 2000. Monthly
Institute Monographs 67:65-74, 1985.
Labor Review September, 1987.
11 Spencer, G. Projections of the Hispanic Population:
5 National Center for Health Statistics. Health United
1983-2080. Current Population Reports,
States, 1989. DHHS Pub. No. (PHS)90-1232.
Population Estimates and Projections. Series
Hyattsville, MD: U.S. Department of Health and
P-25, No. 995. Washington, DC: U.S.
Human Services, 1990.
Department of Commerce, Bureau of the Census,
1986.
6
Passel, J.E., and Woodrow, K.A. Immigration to
12
the United States." Paper presented to the Census
Spencer, G. Projections of the population of the
Table, August 1986.
United States, by age, sex, and race: 1988 to
2080. Current Population Reports, Population
7
Public Health Service. Healthy People: Surgeon
Estimates and Projections. Series P-25, No.
General's Report on Health Promotion and
1018. Washington, DC: U.S. Department of
Disease Prevention. Washington, DC: U.S.
Commerce, Bureau of the Census, 1989.
Department of Health and Human Services, 1979.
8
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2. The Nation's Health: Age Groups
Responding effectively to the health challenges of the 1990s will require a clear under-
standing of the health-related threats and opportunities facing all Americans. One way to
grasp the dimensions and the realities of the tasks laid out in this report is to consider the
special problems of infants, children, adolescents and young adults, adults, and older
adults. The health profiles of these age groups can help us remember that the improve-
ments envisioned here are not generalizations about the population, but prescriptions for
healthier lives for each of us-newborn babies, boys and girls, teenagers and young
people, women and men, and people in their retirement years.
Infants
One of the most heartening indicators of our Nation's improvement in health during the
20th century has been the steady decline in the infant mortality rate. Between 1950 and
1987, the infant mortality rate in the United States dropped from 29.2 per 1,000 live
births to 10.1. 34 Eight years after Healthy People (1979) posed the challenge of a 35-per-
cent reduction in infant mortality by 1990, we had achieved a reduction of 28 percent in
that rate.
34
Yet comparison of even our 1987 rate of infant mortality with that of other industrialized
nations demonstrates the continued importance of efforts in this regard. Moreover, the
continuing disparities between minority and majority populations represent a major
health challenge. In 1987, the mortality rate for black infants was still over twice that of
whites, and rates for some American Indian tribes and for Puerto Ricans were also consid-
erably higher than for white infants. 34
Infant mortality rates provide a summary measure of the effects of major health threats to
the developing fetus and newborn baby. But for every 10 babies who die, 990 live.
Some of those who live have been harmed, often permanently, by unhealthy beginnings.
The quality, not just the quantity, of their lives is a function of health during both the
prenatal and infant periods.
Technology has contributed significantly to the improved prospects for infant survival
over the past several decades. Neonatal intensive care, new surgical techniques, and
other medical interventions save lives and even overcome conditions that formerly
guaranteed life-long disability. But opportunities for primary prevention offer new fron-
tiers for improving infant health in the coming years. Some opportunities will result from
breakthroughs in understanding the genetic origins of human diseases; most will be in
areas of personal lifestyle and use of existing health interventions.
Major Health Concerns
No period of life is more important to good health than the months before birth. The
prenatal period can be the starting time for good health or it may be the beginning of a
lifetime of illness and shortened life expectancy. Each year in the United States, nearly
39,000 babies-about 1 percent of those born-die before the age of one, two-thirds
during their first month. 35 Four causes account for more than half of all infant deaths: dis-
orders relating to low birth weight, congenital anomalies, sudden infant death syndrome
(SIDS), and respiratory distress syndrome. (Fig. 2.1)
Low birth weight (less than 2,500 grams) occurs in about 7 percent of all live births and
is the greatest single hazard to infant health. 58 This dangerous condition has been linked
to several preventable risks, including lack of prenatal care, maternal smoking, use of al-
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Healthy People 2000
cohol and other drugs, and pregnancy before age 18.⁵⁷ Approximately three-quarters of
deaths in the first month and 60 percent of all infant deaths occurred among low-birth-
weight infants. Low socioeconomic and educational levels are often associated with low
birth weight. 57 Black infants are more than twice as likely as white babies to be born
weighing less than 2,500 grams.
Congenital anomalies
Fig. 2.1
Sudden infant death
Leading causes of
syndrome
infant mortality
Short gestation and
(1987)
low birth weight
Respiratory distress
syndrome
Maternal complications
of pregnancy
0
50
100
150
200
250
Source: Health, United
Deaths per 100,000 live births
States, 1989
Very low birth weight (less than 1,500 grams) is associated with 40 percent of all infant
deaths. Very low birth weight declined slightly from 1970 to 1981 but rose by about 0.9
percent per year from 1981 to 1986 57 Low-birth-weight babies are nearly twice as likely
to have severe developmental delay or congenital anomalies. 64 These babies are also at a
significantly greater risk of such long-term disabilities as cerebral palsy, autism, mental
retardation, and vision and hearing impairments, and other developmental disabilities.
Congenital anomalies (birth defects) most likely to be lethal include malformations of the
brain and spine, heart defects, and combinations of several malformations. Infant mor-
tality from congenital anomalies has been declining, although the last decade has seen
slight increases in the incidence of some birth defects. 52 In 1985, about 11,000 babies
were born with moderate to severe impairments. Congenital anomalies, when they do
not result in death, may cause disability. One-fourth of all congenital anomalies are
caused by genetic factors, suggesting a need for preconception genetic counseling for
both men and women. Environmental hazards and alcohol use during pregnancy are
other important factors. Fetal alcohol syndrome (FAS) affects as many as 1 to 3 infants
per 1,000 live births. 35 In some populations, the incidence is higher. A similar syndrome
has been observed in babies born to drug-addicted mothers.
After the first month of life, sudden infant death syndrome (SIDS) is the leading cause of
infant mortality, accounting for about one-third of all deaths in this period. 50 The causes
of SIDS are not known, but risk factors include maternal smoking and drug use, teenage
birth, and infections late in pregnancy. Infants born to families with a history of SIDS
are also at risk.
Respiratory distress syndrome occurs primarily in premature babies whose lungs are not
fully developed. Therefore, risk factors for respiratory distress syndrome include those
for prematurity.
Increasing rates of HIV infection and cocaine addiction in newborns are also of concern.
By January 1990, more than 2,000 babies had been born with HIV infection, and some
hospitals from urban communities reported rates of cocaine-addicted babies as high as 20
percent. The long term consequences of these alarming trends are inestimable.
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2. The Nation's Health: Age Groups
Maternal Factors
Several major maternal risk factors are associated with low birth weight, as well as with
other major causes of infant death and disability, including:
Cigarette smoking;
Alcohol and other drug use;
Age;
Nutrition;
Socioeconomic status;
Environmental hazards.
An estimated 25 percent of pregnant women smoke throughout their pregnancies.61
There is some evidence that pregnant women are quitting smoking and that smoking
prevalence during pregnancy is decreasing for some but not all groups. Women in the
lowest age and socioeconomic groups have the highest likelihood of smoking during
pregnancy. Maternal cigarette smoking has been linked with from 20 to 30 percent of
all low-birth-weight births in the United States.³⁰ If all pregnant women refrained from
smoking, fetal and infant deaths would be reduced by approximately 10 percent, saving
about 4,000 infants per year.
Heavy alcohol consumption during pregnancy is associated with increased risk for fetal
alcohol syndrome, including growth retardation, facial malformations, mental retardation,
and central nervous system dysfunctions. A safe amount of alcohol consumption during
pregnancy has not been documented; however, adverse effects are associated primarily
with heavy consumption during the early months of pregnancy.
The effects of maternal drug use on pregnancy outcome have not been fully explored.
Studies of the effects of maternal drug abuse are hampered by difficulties in distinguish-
ing effects of drug exposure from those resulting from inadequate prenatal care or poor
maternal health and nutrition. However, low birth weight and prematurity are the most
serious known consequences of maternal illicit drug abuse. Risks due to maternal drug
abuse are heightened by lack of prenatal care. Between 50 and 75 percent of substance-
abusing women receive little or no prenatal care.2⁸ Reliable data on the prevalence of
substance abuse by pregnant women is also difficult to obtain. Extrapolations of local
studies suggest that perhaps as many as 10 percent of babies are born each year to women
who have used one or more illicit substances during their pregnancy. 13,14,23
Both pregnant women and newborn infants are particularly vulnerable to poor nutrition.
Women who gain less than 21 pounds during pregnancy are more than twice as likely to
deliver low-birth-weight infants than those who gain more.66 Nutrition is also vital to
growth and development of infants, including brain function. For most mothers,
breastfeeding is an ideal way of nurturing their infants.
Maternal age is a risk factor at both ends of the childbearing years: under age 17 and over
age 40. Teenage women, more than a million of whom become pregnant each year in the
United States, are at particular risk of having low-birth-weight babies. 54 Birth rates for
women aged 15 through 19 are virtually unchanged since 1980, remaining at more than
50 live births per 1,000 women.² Infants born to women over age 40 experience higher
rates of congenital anomalies, such as Downs Syndrome.
Women with less than 12 years of education, one important indicator of socioeconomic
status, are about 70 percent more likely to give birth to a low-birth-weight baby or ex-
perience an infant death than women with more than 12 years of education. Similarly,
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Healthy People 2000
poor pregnancy outcomes have been linked to other indicators of socioeconomic status
such as lack of health insurance, poor nutrition, and low educational level. 62
An estimated one-tenth of congenital anomalies are caused by environmental factors such
as viruses, chemicals, and radiation. Toxic substances can affect the fetus directly,
through exposure of the mother, and indirectly, by altering maternal and paternal germ
cell chromosomes. Industrial toxins, such as lead, vinyl chloride, and hydrocarbons, may
affect workers in industrial plants. The reproductive effects of workplace toxins, how-
ever, are still uncertain and controversial. 62
Prenatal Care
Numerous studies have demonstrated that early and comprehensive prenatal care reduces
rates of infant death and low birth weight. An expectant mother with no prenatal care is
three times as likely to have a low-birth-weight baby. The effect of early prenatal care is
especially evident in studies of high-risk groups, such as adolescents and poor women.54
About 76 percent of women receive prenatal care, but rates are considerably lower for
many minority groups. 62
The 1970s saw significant increases in early prenatal care, especially in groups with the
lowest levels of care. Since 1980, however, the proportion of women who begin prenatal
care in the first 3 months of pregnancy has reached a plateau among all racial and ethnic
50
groups.
Prenatal care can save money. The Office of Technology Assessment has studied the
potential effectiveness of prenatal care for all pregnant women living in poverty. Its find-
ings indicate that for every instance of low birth weight averted by prenatal care, the
United States health care system saves between $14,000 and $30,000 in health care costs
associated with this condition. 54
Children
The health profile of American children has shifted markedly in the past 40 years. Once
dominated by the threat of major infectious diseases, such as polio, diphtheria, scarlet
fever, pneumonia, measles, and whooping cough, today, widespread immunization has
virtually eliminated many of these diseases. Others are in steep decline.
Between 1977 and 1987, the rate of childhood deaths declined 21 percent, exceeding the
1990 target set in Healthy People. Unintentional injuries have now replaced infectious
diseases as the cause of greatest concern for the health of children. But even for the lead-
ing cause of injury-related deaths among children-motor vehicle crashes-heartening
progress has occurred. Since 1978, the rate of childhood deaths from motor vehicle
crashes has declined 40 percent for children aged 1 through 4, and 20 percent for those
aged 5 through 14, primarily due to the use of car seats and seatbelts. 34 Other causes of
injury-related deaths among children-drowning, falls, poisoning, fires-have also
declined as a result of improved protections, with the sole exception of child homicide.
Several threats to children's health are associated with low socioeconomic status. Mental
retardation, learning disorders, emotional and behavioral problems, and vision and
speech impairments all appear to be more prevalent among children living in poverty,
often in inner cities, than among those at higher socioeconomic levels. 57 An accurate
profile of the health of U.S. children, therefore, must go beyond mortality and morbidity
data. It must also consider emotional, psychological, and learning problems, the social
and environmental risks to which they are related, and the total costs to the Nation.
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2. The Nation's Health: Age Groups
Major Health Concerns
The leading cause of death in childhood-unintentional injuries-not only accounts for
the most deaths but also is among the most preventable. (Fig. 2.2) Other major, prevent-
able problems include homicide, suicide, child abuse and neglect, developmental
problems, and lead poisoning.
Injuries
Cancer
Fig. 2.2
Congenital anomalies
Leading causes of
Homicide
death for children
Heart disease
aged 1 through 14
Pneumonia/influenza
(1989)
Suicide
Meningitis
Chronic lung disease
HIV infection
0
2
4
6
8
10
12
14
16
18
Source: National Center
Deaths per 100,000 children
for Health Statistics
Nearly half of all childhood deaths are due to unintentional injuries, and about half of
these stem from motor vehicle crashes. Declines in childhood deaths from motor vehicle
crashes are due in part to increasing use of child safety seats and safer automobile design.
In one of the major public health successes of the decade, all 50 States now require safety
restraints for young children, contributing to a 36-percent decline in motor vehicle
fatalities in this age group between 1980 and 1984.⁵ However, many States still do not
mandate child restraints for children over age 5, and in some States there is no require-
ment after age 3 or 4. Furthermore, although studies suggest that 4 out of 5 passengers
under age 5 now use occupant protection systems, many of the child safety seats in use
have been found to be either not attached to the car seat or attached incorrectly.⁴⁴
Drownings and fires account for most other injury-related deaths among children.
Drownings are most frequent in swimming pools and home spas among children under 5.
Household fires are a particular risk to children because they have more difficulty escap-
ing than adults and are less likely to survive fire-related injuries. Deaths from fires are
often due to asphyxiation and traumatic injuries, as well as burns. Children under age 5
who live in substandard housing without smoke detectors are at special risk.²²
Injuries from falls and poisonings are not major causes of death in children but do cause
many nonfatal injuries. Playground equipment and upper-story windows are frequently
implicated.
Many injuries can be and are being prevented. During the last decade, improved safety
measures have reduced fatalities. These measures include swimming pool and spa covers
and childproof enclosures; child-resistant packaging for prescription drugs and some
other hazardous materials; safer playground equipment; and smoke detectors. All of
these, plus increased public awareness of injuries and their prevention, have helped save
lives, and their wider use could save many more.⁵²
Some infections and respiratory illnesses remain problems for children. For example, in-
fluenza and other respiratory problems are the chief illness-related reasons that children
miss school. In addition, the increased number of reports of asthma among children,
especially those living in cities, have raised concern in recent years.³⁵
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Healthy People 2000
Violence toward children has become of increasing concern as an American health issue,
with rapidly rising rates of reported cases of child deaths due to violence. 34 The periodic
Study of National Incidence of Child Abuse and Neglect estimated that, in 1986, nearly 2
percent of children-or more than 1,000,000-were demonstrably harmed by abuse or
neglect. The most common kind of abuse identified was physical, followed by emotional
and sexual; the most common kind of neglect was educational, followed by physical and
emotional.
69 Substantial increases in reported physical and sexual abuse cases have oc-
curred since 1980, but the 1986 study concluded that this was due more to improved
reporting, reflecting greater public and professional awareness of the problem, than to an
actual increase in child abuse. On the other hand, the study also demonstrated that many
incidents of child maltreatment still go unreported.⁶⁹
Developmental Problems
Psychological, emotional, and learning disorders are on the rise among children, as are
chronic physical conditions such as hearing and speech impairment. 57 Low-income
children are at a significantly higher risk for such problems.
One contributor to developmental problems in children is lead poisoning. In 1984, an es-
timated 3,000,000 children between 6 months and 5 years of age had blood lead levels
above 15 µg/dL and 250,000 had levels above 25 µg/dL, making lead poisoning one of
the Nation's most prevalent childhood threats.¹ Severe lead poisoning can lead to
profound mental retardation, coma, seizures, and death. Even low levels of exposure can
impair central nervous system function, causing delayed cognitive development, hearing
problems, growth retardation, and metabolic disorders. 1 Reduced lead in gasoline, air,
and food, and reduced industrial emissions have produced lower mean blood lead levels
nationwide. Nevertheless, homes and play areas, particularly in substandard housing
areas, remain a significant source of this toxin in children's blood. The chief sources of
lead exposure are thought to be old flaking lead-based paint, dust, and soil.
Healthy Child Development
Childhood is the prime time of human development. This is no less true for development
of good health than it is for social, educational, emotional, and moral development. It
may be easier to prevent the initiation of some behaviors, such as smoking and alcohol
and drug abuse, than to intervene once they have become established. Likewise, it may
be easier to establish healthful habits, such as those related to basic hygiene and those re-
lated to dietary and physical activity patterns, during childhood than later in life.
Childhood is the opportune period for such healthy development.
Early use of tobacco, alcohol, and marijuana is associated with alcohol and other drug
abuse later in adolescence or adulthood. 16 While most smokers start when they are
young teenagers, many start even earlier.⁵³ About one-quarter of high school seniors
who have ever smoked report that they smoked their first cigarette by grade 6, over half
by grades 7 or 8, and three-quarters by grade 9.53 Although cigarette smoking is declin-
ing among all age groups, those who do smoke are starting at younger ages. A wide
array of factors promote smoking by children, including peer pressure, parental smoking
behavior, lack of knowledge and understanding of health consequences, advertising and
promotion, and the easy availability of cigarettes in unsupervised vending machines.⁵³
Although the average age of first use of alcohol and marijuana is 13, pressure to begin
use starts at even younger ages. Elementary school students report peer pressure to try
beer, wine, and distilled spirits. Moreover, 26 percent of 4th graders and 40 percent of
6th graders reported that many of their peers had tried beer, wine, distilled spirits, or wine
coolers.⁴⁶
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2. The Nation's Health: Age Groups
Lifetime diet and exercise patterns may also be established in childhood. Fat makes up
more than 36 percent of calories in the average American diet, a figure that is too high ac-
cording to most experts. It'is recommended that children over 2, as well as adults, reduce
that figure to no more than 30 percent and that saturated fats be reduced to less than 10
percent of calories. Exercise habits established in childhood may help in maintaining a
physically active lifestyle throughout adolescence and adulthood. Both moderate and
vigorous physical activity on a regular basis help promote overall fitness and control
weight. In 1984, a little more than two-thirds of children aged 10 through 17 engaged
regularly in vigorous physical activity. 67 A comparison of body composition among
children between 1965 and 1985 showed a steady increase in skinfold thicknesses, a
measure of body fat.
Most schools provide some health education, although the amount and content vary
among States and school districts. According to recent data:
75 percent of school districts have antismoking education in elementary schools; 48
63 percent of school districts and private schools provide some instruction concern-
ing alcohol and other drugs and 39 percent provide related counseling; 60
12 States require nutrition education from preschool through grade 12;4
32 percent of children in grades 1 through 6 and 44 percent of those in grades 7
through 9 participate in daily physical education programs, but only 1 State re-
quires daily physical education from kindergarten through grade 12;67
25 States require comprehensive school health education programs and 9 States
17
recommend that local school districts implement such programs.
Appropriate educational strategies vary according to community and age group, but
health education curricula can change attitudes and behavior.
Schools can also be used to facilitate children's access to basic health services. Although
the traditional childhood infectious diseases have declined steeply since vaccines became
available, immunization is still incomplete. Better school-based programs, information
for the public, and more immunization education for physicians and health professionals
are needed.
Improving the health of American children requires a wide range of social and economic
interventions. For example, more and better preschool education for disadvantaged
children and children with disabilities could help to detect and prevent developmental
problems. Educational and support programs for parents in high-risk environments hold
promise for reducing child abuse and other health problems, such as lead poisoning. The
complex developmental problems besetting children in these environments demand con-
certed efforts by many different sectors of society. Primary care health providers, social
service professionals, health educators, housing officials, community groups, and con-
cerned individuals can each make a difference in the health of American children.
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Healthy People 2000
Adolescents and Young Adults
The years from 15 through 24 are a time of changing health hazards. Caught up in
change and experimentation, young people also develop behaviors that may become per-
manent. Attitudes and patterns related to diet, physical activity, tobacco use, safety, and
sexual behavior may persist from adolescence into adulthood.
The dominant preventable health problems of adolescents and young adults fall into two
major categories: injuries and violence that kill and disable many before they reach age
25, and emerging lifestyles that affect their health many years later.
Two major causes of death in older age groups, heart disease and cancer, have declined
sharply among adolescents since 1950-heart disease by 65 percent and cancer by 40 per-
cent. 52 Although they are still important threats in this age group, these diseases are over-
shadowed by the three leading causes of death: unintentional injuries, homicide, and
suicide. (Fig. 2.3)
Injuries
Homicide
Fig. 2.3
Suicide
Leading causes of
Cancer
death for youth aged
Heart disease
15 through 24 (1987)
Congenital anomalies
HIV infection
Pneumonia/influenza
Stroke
Chronic lung disease
Source: Monthly Vital
0
10
20
30
40
50
60
Statistics Report,
Deaths per 100,000 youth
September 1989
Motor Vehicle Crash Injuries
Unintentional injuries continue for about half of all deaths among people aged 15 through
24; three-quarters of these deaths involve motor vehicles. More than half of all motor
vehicle crashes involve alcohol. Young white men had the highest death rates for motor
vehicle crashes in 1987, at 59 per 100,000. The rate for young black men was much
lower: 36 per 100,000. The rate was lower yet for women of both races.⁵²
Motor vehicle crash deaths decreased in this age group in the early 1980s, possibly be-
cause of the raised minimum drinking age in many States and decreasing alcohol use.
The recent trend, however, is upward. The raised speed limit on rural interstate highways
may be a factor in this trend. 52 Further, nearly 60 percent of 8th and 10th graders
reported not using seatbelts on their most recent ride. 5
Homicide and Suicide
Homicide is the second leading cause of death among all adolescents and young adults,
and it is the number one cause among black youth. The homicide rate for young black
men increased by 40 percent between 1984 and 1987 to nearly 86 per 100,000, more than
7 times the rate for young white men.³⁴ Race, however, appears not to be as important a
risk factor for violent death as socioeconomic status. Racial differences in homicide rates
are significantly reduced when socioeconomic factors are taken into account.
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2. The Nation's Health: Age Groups
As with motor vehicle accidents, about half of all homicides are associated with alcohol
use. Nationwide, 10 percent are drug-related, but in many cities this figure rate is sub-
stantially higher. Over half of all homicide victims are relatives or acquaintances of the
perpetrators. Most are killed with firearms.⁵²
Suicide is the second leading cause of death among young white men aged 15 to 24, and
rates continue to climb. From 1950 to 1987 the death rate from suicide in this group in-
creased from under 7 to about 23 per 100,000 population. The rate of suicides among
black adolescents and young adults is half of that among whites. White men between 20
and 24 years of age are more likely to commit suicide than their counterparts aged 15
through 19, but the gap between these two groups is narrowing. In general, suicides have
decreased among older youth and increased among the younger cohort. 35,52
Both white and black young women have relatively low suicide rates (4.7 and 2.3 respec-
tively in 1987), although young women attempt suicide unsuccessfully approximately
three times more often than young men. 35,52 As is the case with homicides, 60 percent of
suicides among adolescents and young adults are committed with firearms.
Tobacco, Alcohol, and Drugs
Many of the most important risk factors for chronic disease in later years also have their
roots in youthful behavior. The earlier cigarette smoking begins, for example, the less
likely the smoker is to quit. 52 Three-fourths of high school seniors who smoke report that
they smoked their first cigarette by grade 52 Young people, especially teenage girls, are
taking up smoking at younger ages. The age of initiation for regular smoking among
females is now roughly the same as for males.
In 1976, about 29 percent of high school seniors reported daily smoking. Between 1977
and 1981, the rate of smoking dropped to 19 percent and has since leveled off. The an-
nual surveys of high school seniors do not gather information on school dropouts-about
15 percent of white youths and 23 percent of black youths among whom smoking is
more prevalent. 56 But data for young adults aged 20 through 24 have shown a continued
steady decline in cigarette smoking for young men and a recent equivalent decline for
young women.
The use of snuff and chewing tobacco has increased dramatically in recent years among
teenage boys. Between 1970 and 1986, snuff use increased fifteen-fold and chewing
tobacco use increased fourfold among young men aged 17 through 19. In 1987, the
prevalence of smokeless tobacco use among young men aged 18 through 24 was nearly 9
percent. Among younger adolescent boys aged 12 through 17, nearly 7 percent had used
some form of smokeless tobacco within the last month. 53
Alcohol consumption among teenagers and young adults is declining slowly, but it
remains a major problem for both. It is a particular problem among school dropouts. Al-
cohol is a major contributor to both motor vehicle crashes and violence, two of the lead-
ing causes of death and disability among young people. In 1989, about 60 percent of
high school seniors reported drinking alcohol in the previous month, while 33 percent
reported occasions of heavy drinking-having five or more drinks on one occasion in the
last 2 weeks; both figures represented slight declines from 1988 survey results. 43
Alcohol use is also prevalent both among younger teenagers and those who are beyond
high school age. In a 1987 national survey, 28 percent of 8th graders and 38 percent of
10th graders reported occasions of heavy drinking. 35 Among young people aged 18 to
24, drinking is more prevalent than in any other age group. In 1985, more than 71 per-
cent of this group reported alcohol use during the past month. 35
The use of illicit drugs among adolescents has been declining since the late 1970s, at
least among young people who remain in school.⁴⁶ The number of high school seniors
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Healthy People 2000
reporting illicit drug use reached a record low of about 20 percent in 1989, indicating a
50 percent drop in drug use over the last decade. Marijuana use, which peaked in 1978 at
37 percent, was down to 17 percent at the close of the 1980s. Only 3 percent of the class
of 1989 reported using cocaine at least once in the last 30 days, a significant decline from
the 1985 peak of 6.7 percent. Use of crack cocaine declined slightly, from 1.6 percent of
high school seniors in 1988 to 1.4 percent in 1989. A more dramatic drop occurred the
previous year, however, when the percentage of seniors who reported having ever used
crack declined by 20 percent.⁴³
Experimentation with illicit drugs often starts early. For example, in a 1987 survey of 8th
and 10th graders, 6 and 10 percent, respectively, reported using marijuana in the preced-
ing month. Slightly smaller percentages reported trying cocaine, and about a third of
these had tried crack. Students' attitudes toward drugs, as toward alcohol, underwent a
change during the 1980s. 46
Sexual Behavior
An estimated 78 percent of adolescent girls⁴⁹ and 86 percent of adolescent boys have
engaged in sexual intercourse by age 20.65 The risks of early sexual activity include not
only unwanted pregnancy, but also infection by sexually transmitted diseases. Of the ap-
proximately 1.1 million girls aged 15 through 19 who become pregnant each year, an es-
timated 84 percent did not intend pregnancies. Many of these young women face serious
health and psychosocial risks. Teenage mothers are more likely than others not to finish
school, to be unemployed, to have low-birth-weight babies, and to lack parental skills. 27
Clearly for young adolescents the most effective means of preventing possible physical
and psychosocial problems related to sexual intercourse is to delay sexual activity. But,
teenage sexual activity is a complex issue, embedded in family, social, and economic fac-
tors. Interventions to prevent associated negative health outcomes must address those fac-
tors if they are to succeed. For example, it has become clear to many that such interven-
tions cannot be successful without the full support and involvement of parents and others
who serve in advisory and role-model capacities with teenagers.
Although the 1980s brought some improvements in the health status of adolescents and
young adults, many other young people still must confront a constellation of problems, in-
cluding alcohol and other drug abuse, school failure, delinquency, peer group violence,
and unwanted pregnancy. While education about risks to health is important, programs
for adolescents and young adults must go beyond education to include in-depth counsel-
ing and support. Especially for youth in high-risk environments, comprehensive
programs are needed to provide positive alternatives to alcohol and other drug abuse,
teenage pregnancy, and lifestyles conducive to violence.
Lifelong Health Habits
It is important for adolescents and young adults to lay the foundation for chronic disease
prevention by the promotion and maintenance of healthy lifestyles. The adoption of low-
fat and low-salt dietary patterns are important for many people in the prevention of
coronary heart disease and high blood pressure, and certain cancers. Further, the adop-
tion of dietary and physical activity habits that will reduce the onset of obesity will help
reduce the likelihood of coronary heart disease, diabetes, and high blood pressure. The
case of physical activity is important because as students leave the school setting they
lose the physical and social supports and incur time constraints that can result in
decreased levels of physical activity. It is especially important for adolescents and young
adults to recognize the importance of regular light to moderate physical activity in the
prevention of weight gain associated with leaving the high school setting.
18
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2. The Nation's Health: Age Groups
Adults
Perhaps more than any other age group, adults have the opportunity to assume personal
responsibility for their health. Many of the leading causes of death for people between
the ages of 25 and 65 are preventable, wholly or in part, through changes in lifestyle. Not
only can adults change established lifestyles, social norms related to health can be
changed as well.
Behavioral changes have saved many adult lives in the past two decades. For example,
the declines, by more than 40 percent and 50 percent, respectively, in coronary heart dis-
ease and stroke death rates since 1970, are associated with reduced rates of cigarette
smoking, lower mean blood cholesterol, and increased control of high blood pressure. In
the same period, deaths from motor vehicle crashes declined by almost 30 percent.
Lower rates of alcohol use, increased seatbelt use, and changes in speed limits con-
tributed to this reduction. Accompanying these trends were reduced public acceptance of
certain risks, such as smoking and drinking and driving.
As deaths from heart disease have declined, cancer has became the leading cause of death
for people aged 25 through 64.52 (Fig. 2.4) These and the other top causes of death be-
tween the ages of 25 and 65-unintentional injuries, stroke, and chronic liver disease and
cirrhosis-have all been associated with risk factors related to lifestyle.
Cancer
Heart disease
Fig. 2.4
Injuries
Leading causes of
Stroke
death of adults aged
Suicide
25 through 64 (1987)
Liver disease
Chronic lung disease
Homicide
HIV infection
Diabetes
0
50
100
150
200
Source: National Center
Deaths per 100,000 adults
for Health Statistics
Cancer
Cancer, which is actually not one but many diseases, is associated with a variety of risk
factors. Although cancer mortality rates overall have changed little since 1950, there
have been significant changes in mortality for some age groups and cancers. Several
prevalent forms of cancer can be either prevented or diagnosed early enough to prevent
spread to other organs. It is estimated that 30 percent of cancer deaths are linked to smok-
ing and that another large proportion, perhaps 35 percent, may be associated with diet. 18
Lung cancer is the most common-and most preventable-cancer in the United
States for both men and women, and is increasing as large numbers of smokers
grow older. Smoking is responsible for more than 85 percent of all lung cancer
deaths. Since 1975, lung cancer incidence has risen more than 15 percent for black
men, about 12 percent for black women, 12 percent for white men, and 8 percent
for white women.⁵³
Colorectal cancer is the second leading cause of death due to cancer. Some
studies have suggested that high fat and/or low fiber diets increase the risk of
colorectal cancer. Since 1969, death rates from these cancers have fallen among
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Healthy People 2000
white men and women, remained about the same for black women, and increased
markedly for black men.³² Although there is no general agreement that screening
for colon cancer definitely reduces mortality among those not at high risk, consen-
sus recommendations have suggested screening by digital rectal exams, fecal occult
blood testing, and sigmoidoscopy for those over age 50.
Breast cancer has become the second most common cause of cancer deaths among
women, having been surpassed by lung cancer in the past decade. However, the in-
cidence of breast cancer is more than twice that of lung cancer in women. 3 Early
diagnosis of breast cancer improves the chance of survival significantly, with 90
percent of those diagnosed when the cancer was localized reaching the 5-year sur-
vival mark. 63 Breast cancer death rates could be reduced 30 percent with regular
screening. Some evidence suggests that high-fat diets may increase the risk of
breast cancer.
Cervical cancer can be cured if detected early. Increased use of the Pap test has
contributed to a 50-percent drop in cervical cancer deaths among both black and
white women since 1969. However, black women continue to have 3 times the cer-
vical cancer death rate of white women. Although the death rates have been
decreasing, the in situ rates have risen in younger women aged 15 through 19.³
Oropharyngeal cancer-cancer of the mouth and throat-accounts for 13.2 per
100,000 in 1987. Increased risk has been linked both to use of tobacco products
and to heavy alcohol use.
Heart Disease and Stroke
Despite a recent decline, coronary heart disease still kills more than 500,000 Americans
annually. Another 1,250,000 people suffer nonfatal heart attacks each year. About 20
percent of those who die from heart attacks are between the ages of 24 and 64, and most
are between 55 and 64.52 Quitting smoking, reducing dietary fat (especially saturated
fat), and controlling high blood pressure can reduce the risk of heart disease.
Approximately 13 percent of the nearly 150,000 Americans who died of stroke in 1986
were between the ages of 25 and 64, and the majority of these were aged 55 through 64.
Black men have the highest rate of stroke among all population groups, with a death rate
from stroke about twice that of white men and a substantially higher rate than for black
women. A much smaller gap exists between the stroke death rates of white men and
white women.50
High blood pressure is a well-defined risk factor for both heart disease and stroke among
adults. Approximately half of all heart attack victims and two-thirds of all stroke victims
have high blood pressure.⁵² About 30 percent of adults have high blood pressure (over
140/90 mm Hg or taking high blood pressure medication), but most do not have it under
control.³⁹ It is estimated that, during 1982-84, only about 24 percent of hypertensive
adults between 20 and 75 had achieved blood pressure control for 2 or more years. 42
Weight control, physical activity, lower intake of alcohol and sodium, and if necessary,
medication are means of controlling blood pressure.⁴¹
Health Habits
Several major health risk factors, sometimes alone and sometimes in combination, are as-
sociated with the 5 major causes of death in the United States: cancer, heart disease,
stroke, injury, and chronic lung disease. Reducing these risks has already significantly
reduced the number of years of life lost before age 65, and greater reductions are possible.
Certain eating patterns-especially excessive consumption of fats-are linked to a higher
risk of heart disease, breast and colon cancer, and gallbladder disease.⁵ Total dietary fat,
20
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2. The Nation's Health: Age Groups
including saturated and unsaturated fats, now accounts for more than 36 percent of the
total calories consumed in the United States. A fat intake of no more than 30 percent of
calories is recommended by most groups, including the American Heart Association, the
American Cancer Society, and the United States Departments of Agriculture and Health
and Human Services. These groups recommend that the major reduction in dietary fat
come from saturated fats, which are common in foods from animal sources, such as
meats and dairy products.
Overweight is a problem for about one-quarter of American adults, affecting about 27
percent of women and 24 percent of men.³⁷ This problem is associated with high blood
pressure, elevated blood cholesterol, diabetes, heart disease, stroke, some cancers, and
gall bladder disease. It also may be a factor in osteoarthritis of the weight-bearing joints.
Socioeconomic status has been linked to overweight. One national survey found that 37
percent of women below the poverty level were overweight, compared with 25 percent of
those above the poverty level. Overweight is especially prevalent among members of
some minority groups. 37
To reduce this risk factor, both exercise and diet are important. As of 1985, however,
only about 25 percent of overweight men and 30 percent of overweight women, among
people 18 and over, were combining regular physical activity with sound dietary prac-
tices to lose weight. 61 Fewer than half of adult Americans exercise regularly (3 or more
days a week, sustained for at least 20 minutes each time regardless of intensity)⁷, a matter
of concern because a sedentary lifestyle appears to be an independent risk factor for
coronary heart disease. Older adults are less likely to be physically active than younger
adults. Research increasingly suggests that even moderate physical activity can decrease
the risk of coronary heart disease, especially among the sedentary. Regular physical ac-
tivity can also help to prevent and manage hypertension, diabetes, osteoporosis, and
obesity.⁹ Further, it may play a role in mental health, having a favorable effect on mood,
depression, anxiety, and self-esteem.
Cigarette smoking is an important risk factor for heart disease, stroke, and some forms of
cancer. In 1965, 40 percent of all Americans smoked cigarettes. Today, that figure is
below 30 percent. This dramatic decline is credited with saving nearly 800,000 lives be-
tween 1964 and 1985, with an average gain in life expectancy of 21 years for each death
avoided or postponed. 53 Despite these gains, smoking is still responsible for one of every
six deaths in the United States. Moreover, it is still placing certain groups at greater risk
of disease than others, and it is still the single most important preventable cause of death
in our society. 53
More than 50 million Americans still smoke. In 1987, 29 percent of adults aged 20 years
and older smoked cigarettes. Almost as many have quit. By 1987, nearly half of those
who ever smoked cigarettes (45 percent) had stopped. Since 1974, the rate of change for
quitting has been similar for blacks and whites and for men and women. 55 Though more
men smoke than women, the gender gap is decreasing. Prevalence of cigarette smoking
has declined sharply among men since 1965 (from 50 to 32 percent) but only slightly
among women (32 to 27 percent). 21 In general, smoking rates are higher among blacks,
Hispanics, blue-collar workers, and people with fewer years of education. 21
Alcohol is a major factor in thousands of preventable deaths, including motor vehicle
fatalities, homicides and suicides, cirrhosis of the liver, and some cancers, such as
esophageal and liver cancer. Alcohol is also the leading preventable cause of birth
defects.
34
There is evidence that the use of alcohol is beginning to decline. Based on alcoholic
beverage sales and tax data, the consumption of hard liquor declined 21 percent between
1978 and 1986. Wine sales increased and beer sales remained about the same. While the
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Healthy People 2000
overall trend in the consumption of alcoholic beverages is down, it is estimated that about
9 percent of people aged 21 and older consume more than two drinks daily.⁴⁵
Increasing public concern about alcohol and other drugs, evident in many opinion polls,
has helped galvanize organized action on the part of parent groups, government agencies,
community groups, schools, and businesses. 6 Drinking and driving has been the focus of
much of the attention: the Surgeon General has called for stricter regulation of advertis-
ing for alcoholic beverages; citizen groups have lobbied for and legislators have passed
laws raising the drinking age and establishing stiff penalties for driving while intoxicated;
the news media have devoted much coverage to the problem, and even the entertainment
media have incorporated messages about drinking and driving into television programs. 51
This widespread public concern and the programs that accompany it have had an impact.
The proportion of motor vehicle deaths related to alcohol dropped by 10 to 15 percent be-
tween 1982 and 1986 34 More recently, however, the decline has slowed, indicating the
need for continued efforts.
Hospital emergency room visits related to use of illicit drugs, one indication of the health
impact of drug abuse, rose sharply in the 1980s, and this high rate is expected to continue
for some years. Cocaine is responsible for many of these visits. In 1987, cocaine-related
emergency room visits constituted 32 percent of all visits related to drugs. 19 Other data
indicate that young men between the ages of 25 and 44 are at a higher risk than the total
population of being killed or injured by illicit drugs. In addition, drugs are implicated in
about 10 percent of all homicides, many of which occur in this age group.
Seatbelt use is an important health habit, saving an estimated 4,000 lives in 1987, a year
in which only about 42 percent of motor vehicle passengers used their seatbelts. Most of
the crashes in which lives were saved by seatbelts occurred in States with mandatory seat-
belt laws. 36 Passage of such laws in other States should increase usage and save many
more lives. In addition, beginning with 1990 models, automobile manufacturers are
equipping all passenger vehicles with automatic crash protection-automatic belts or air-
bags-in response to a new Federal requirement. Automatic belts are expected to in-
crease overall usage to about 85 percent.
Health Services
Preventing chronic disease depends often on individual decisions-to quit smoking, to
drink in moderation if at all, to consume less saturated fat, to increase physical activity.
What then is the role of health services?
One answer is patient education and counseling. Clinical studies have demonstrated that
counseling by health professionals is effective in helping people change dietary and
smoking behaviors. The U.S. Preventive Services Task Force, in surveying the effective-
ness of 169 clinical interventions to prevent disease, concluded that counseling may be
even more valuable overall than conventional clinical activities to prevent disease, such
as many screening tests. 68
Screening can be extremely important, when tailored appropriately to an individual's age
and risk. Early diagnosis of disease can have a significant impact on mortality rates, as
shown by the results of screening for high blood pressure and high blood cholesterol.
The means are also available to detect various cancers when they are still curable, such as
the Pap test for cervical cancer, mammography and physical examination for breast can-
cer, fecal occult blood testing and sigmoidoscopy for colorectal cancer, and skin examina-
tion for skin cancer.
None of these procedures is widespread. In 1987, just 75 percent of women aged 18 and
over had received a Pap test in the preceding one to three years, and this was by far the
highest proportion of adults screened for any type of cancer.³³
22
Conference Edition
2. The Nation's Health: Age Groups
Only about 25 percent of women aged 50 and older surveyed in 1987, had received a
mammogram and clinical breast exam in the preceding two years. 33 The percentage of
adults aged 50 and older who received a digital rectal exam and fecal occult blood testing
in the preceding two years was estimated at 27 percent. 33
Increasing awareness about preventive services by both health professionals and the
public is essential to increasing their use. More and better insurance coverage for screen-
ing and counseling would also encourage wider use of these services. Expansion of
managed care systems such as health maintenance organizations (HMOs) and preferred
provider organizations (PPOs) can also provide basic preventive services to more people.
The challenge facing adults as individuals is to modify their lifestyles to maintain health
and prevent disease. But even in adulthood, individual decisions are subject to many for-
ces. Lifestyles once established are difficult to change, addictions even more difficult.
Resolution of many of these difficulties is compounded by factors beyond the control of
individuals. Socioeconomic status, the environment, community norms, media images
and coverage, advertising, worksite standards, access to health care and counseling are
powerful influences on adult behavior. So the other challenge facing adults, as members
of society, is to work together to create an environment that facilitates and supports
healthful behavior.
Many sectors of society have made a beginning. Some employers support smoking cessa-
tion, stress management, nutrition and exercise, screening for high blood pressure and
high blood cholesterol, and other health-related programs. Hospitals provide patient
education services and community health promotion programs. Community groups and
churches sponsor classes and support groups. State agencies have initiated community-
based prevention programs in many areas. In particular, minority communities, rural
communities, and people with low incomes need relevant information and programs that
address their particular risks and their need for preventive services.
Older Adults
In 1900, people over 65 constituted 4 percent of the population. By 1988, that proportion
was up to 12.4 percent, by 2000 it will be 13 percent and by 2030, 22 percent. The most
rapid population increase over the next decade will be among those over 85 years of
25
age.
People who reach the age of 65 can now expect to live into their eighties. 35 However, it
is likely that not all those years will be active and independent ones. Thus, improving the
functional independence, not just the length, of later life is an important element in
promoting the health of this age group.
One measure of health that considers quality as well as length of life is the years of heal-
thy life. While people aged 65 and older have 16.4 years of life remaining on average,
they have about 12 years of healthy life remaining. 35 (Fig. 2.5) Another indicator of
quality of life is an individual's ability to perform activities required for daily living, such
as bathing, dressing, and eating. Difficulty in performing these necessary tasks leads to
the need for assistance and often limits opportunity for remaining independent in the com-
munity. People aged 85 and older constitute a substantial share of all people who are not
independent in physical functioning. 35
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23
Healthy People 2000
Years
20
18.7
18
1960
1987
Fig. 2.5
15.8
16
14.8
Life expectancy at
14
12.8
age 65 by gender
12
10
8
6
4
2
0
Men
Women
Source: Health, United
States, 1989
While many people think of health problems in old age as inevitable, a substantial num-
ber are either preventable or can be controlled. The major causes of death among people
aged 65 and older are heart disease, cancer, stroke, chronic obstructive pulmonary dis-
ease, pneumonia, and influenza. Chronic problems, such as arthritis, osteoporosis, incon-
tinence, visual and hearing impairments, and dementia, are of equal concern because of
their significant impact on day-to-day living. To accommodate the changing needs of an
increasingly older society, we must prevent the ill from being disabled and help people
with disabilities preserve function and prevent further disability.²⁴
A growing body of evidence shows that changing certain health behaviors, even in old
age, can benefit health and quality of life. Cigarette smoking is one of these habits.
Studies have shown that when older smokers quit, they increase their life expectancy,
reduce their risk of heart disease, and improve respiratory function and circulation. 53
Good nutrition is also important in the promotion and maintenance of health for older
adults. Diet can play an important role in mitigating existing health problems with older
people. Reducing sodium intake and losing weight, for example, can help keep blood
pressure under control, and there is growing evidence that nutrition counseling and food
programs can reduce the risk of disease among older adults.²⁵
Physical Activity
A key ingredient to healthy aging is physical activity. Often physiological decline as-
sociated with aging may actually be the result of inactivity. Over 40 percent of people
over age 65 report no leisure time physical activity. 7 Less than a third participate in
regular moderate physical activity, such as walking and gardening, on a regular basis, and
less than 10 percent engage routinely in vigorous physical activity. Yet regular physical
activity and exercise are critical elements of health promotion for older adults. Increased
levels of physical activity are associated with a reduced incidence of coronary heart dis-
ease, hypertension, noninsulin-dependent diabetes mellitus, colon cancer, and depression
and anxiety which are diseases prominent in older adult populations.⁵
Moreover, increased physical activity increases bone mineral content, reduces the risk for
osteoporotic fractures, helps maintain appropriate body weight, and increases longevity.
It may also be that increased physical activity levels can improve balance, coordination,
and strength, factors that may reduce the likelihood of falls in the older adult. Recent
studies of exercise training among this age group have shown that older persons can
adapt to increased levels of exercise with positive health benefits resulting from both
high and low intensity exercise. In addition to these health benefits, a more important
24
Conference Edition
2. The Nation's Health: Age Groups
result of regular physical activity appears to be the maintenance of functional inde-
pendence throughout the later years of life.
Health Services
People over age 65 need regular primary health care services to help them maintain their
health and prevent disabling and life-threatening diseases and conditions. Clinical
preventive services include the control of high blood pressure, screening for cancers, im-
munization against pneumonia and influenza, counseling to promote healthy behaviors,
and therapies to help manage chronic conditions such as arthritis, osteoporosis, and incon-
tinence. For example, skin cancer screening can detect the majority of malignant
melanomas and basal cell carcinomas.
Especially important among these clinical services are those to detect breast cancer:
screening mammography and clinical breast examination. These screening interventions
are estimated to reduce mortality from breast cancer in women over age 50 by about 30
percent. 63 In addition, Pap tests to detect cervical cancer are important for older as well
as for younger women.
Because pneumococcal disease is 3 times more prevalent among those over 65 than
among younger people and takes many older lives, immunization of older adults is an im-
portant preventive service. Pneumonia was responsible for an average 48 days of
restricted activity per 100 people aged 65 and older in 1987 38 Likewise, immunization
against influenza is recognized now as a basic preventive intervention for older adults.
During 6 flu epidemics from 1972 to 1982, the death rate was 34 to 104 times higher in
this age group than in younger people. 50 Only about 10 percent of older adults living in
the community receive pneumococcal vaccine and 20 percent receive influenza vac-
cines.
11,12
The number of medicines prescribed to persons over the age of 65 increases the risk of ad-
verse drug reactions, drug interactions, and other health problems associated with the use
and misuse of medications. The risk of adverse reactions may be exacerbated by the
physiological changes associated with aging. For example, decreased kidney and liver
function can change the way the body processes medications. In some cases, the adverse
effects of medication can be prevented by using a different drug or lower dose.
Physicians, nurses, pharmacists and other health professionals can help reduce this risk
through careful reviews of medication use and patient counseling.
Primary health care providers are necessary partners in the maintenance of good health
and functional independence for older adults. In addition to ensuring appropriate screen-
ing, counseling, and immunization, they can monitor health status to detect early signs of
other health problems that can threaten independence such as dementia or depression, as
well as ensure an accurate distinction between the two in diagnosis. Alzheimer's disease
is the best known and leading cause of cognitive impairment in older adults, but there are
other, more treatable forms of dementia, characterized by deterioration of memory, orien-
tation, general intellect, specific cognitive capacities, and social functioning. The
prevalence of dementia ranges from about 5 to 10 percent of people over age 65, to 20 to
40 percent of those who have reached age 80. While most cases are not treatable, 10 to
20 percent of them-those caused by drug toxicity, metabolic disorders, depression, or
hyperthyroidism-may be reversible. 15,31
Providers can play an important role in identifying patients at risk for conditions for
which interventions may be appropriate, e.g., counseling women at high risk for os-
teoporosis about the benefits and risks of estrogen replacement therapy. Urinary incon-
tinence is another condition that can have serious consequences for functional inde-
pendence. It affects many noninstitutionalized older adults and about half of all nursing
home residents. 47 The risk of incontinence increases with age but it often is a sign of
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Healthy People 2000
other problems. Various treatments are available, including pelvic muscle exercises and
other behavioral treatments, drug therapy, and surgery. A major impediment is that only
about half the people with incontinence report it to their physicians. Increased awareness
of available treatments could reduce this often incapacitating problem.
Social Networks
Social isolation is both a risk factor for disease and a measure of reduced functional inde-
pendence. Social support networks are of critical importance in promoting the health and
independence of older adults. 25 Life changes common to the seventh and eighth decades
can increase the risk of social isolation. Retirement and changes in social roles can affect
systems of contact and support, as can the loss of spouses and close friends.
Depression, a frequent outcome of such changes, is of particular concern among older
adults because of its impact on functional independence and its importance as a risk fac-
tor for suicide. Men aged 65 through 74 have the highest suicide rate in the United
States. 10 Depression is treatable but often goes unsuspected by families and undiagnosed
by physicians, perhaps because it is often only one of several health problems besetting
an older adult. However, primary care providers who recognize the clinical signs and
risk factors for depression-bereavement, loneliness, and low self-esteem-can help
reduce suicide among older adults. Illness and disrupted marital status have also been
linked to suicide in this age group.
Community support networks that provide services to help older adults maintain inde-
pendence are also critical interventions for reducing social isolation. Primary care
providers can also play a critical role, not only in the identification of individuals at risk,
but also by supplying information and referral to available services.
References
1
Agency for Toxic Substances and Disease Registry.
8
Bureau of the Census. Educational Attainment in the
The Nature and Extent of Lead Poisoning in
United States: March 1987 and 1986. Current
Children in the United States: A Report to
Population Report, Series P-20, No. 428.
Congress. Washington, DC: U.S. Department of
Washington, DC: U.S. Department of Commerce,
Health and Human Services, 1988.
1988.
2
The Alan Guttmacher Institute. Teenage Pregnancy:
9
Caspersen, C.J. Physical activity epidemiology:
The Problem that Hasn't Gone Away. New
Concepts, methods, and applications to exercise
York: the Institute, 1981.
science. Exercise and Sport Sciences Reviews
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17:423-473, 1989.
American Cancer Society. Cancer Facts and
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Figures 1989. New York: the Society, 1990.
Centers for Disease Control. Suicide Surveillance,
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1970-1980. Atlanta, GA: Center for Health
American School Health Association.
Promotion and Education, 1985.
5
American School Health Association, Association of
11
Center for Infectious Diseases, Centers for Disease
the Advancement of Health Education and
Control, Public Health Service, U.S. Department
Society for Public Health Education. National
of Health and Human Services, Atlanta, GA.
Adolescent Student Health Survey. Oakland, CA:
Third Party Press, 1989.
12 Center for Prevention Services, Centers for Disease
6
Control, Public Health Service, U.S. Department
Bachman, J.G.; Johnston, L.D.; O'Malley, P.M.; and
of Health and Human Services, Atlanta, GA.
Humphrey, R.H. Explaining the recent decline in
marijuana use: Differentiating effects of
13 Chasnoff, I.J. Drug use in women: Establishing a
perceived risks, disapproval, and general lifestyle
standard of care. Annals of New York Academy of
factors. Journal of Health and Social Behavior
Sciences 562:208, 1989.
29:92-112, 1988.
14 Chasnoff, I.J.; Landress, H.J.; and Barrett, M.E.
7
Behavioral Risk Factor Surveillance System, Centers
The prevalence of illicit drug and alcohol use
for Disease Control, Public Health Service, U.S.
during pregnancy and discrepancies in mandatory
Department of Health and Human Services,
reporting in Pinellas County, Florida. New
Atlanta, GA.
England Journal of Medicine 322:1202-6, 1990.
26
Conference Edition
2. The Nation's Health: Age Groups
15
Clarfield, A.M. The reversible dementias: Do they
30 Kleinman, J.C. and Madans, J.H. The effects of
reverse? Ann Intern Med 109:476-86, 1988.
maternal smoking, physical stature, and
educational attainment on the incidence of low
16 Clayton, R.R. The delinquency and drug use
birth weight. American Journal of Epidemiology
relationship among adolescents: A critical
121(6):832-55, 1985.
review. In: National Institute on Drug Abuse
(NIDA). Drug abuse and the American
31 Larson, E.B.; Reifler, B.V.; Featherstone, H.J.; et
adolescent, edited by Lettieri, D.J. and Ludford, J.
al. Dementia in elderly outpatients: A prospective
NIDA Research Monograph 31. Washington, DC:
study. Ann Intern Med 100:417-23, 1984.
U.S. Department of Health and Human Services,
32 National Cancer Institute. 1987 Annual Cancer
1981.
Statistics Review. DHHS Pub. No. (NIH)88-2789.
17 Division of Adolescent and School Health, Center
Bethesda, MD: U.S. Department of Health and
for Chronic Disease Prevention and Health
Human Services, 1988.
Promotion, Centers for Disease Control, Public
33 National Cancer Institute and the National Center
Health Service, U.S. Department of Health and
for Health Statistics. Unpublished data from the
Human Services, Atlanta, GA.
Cancer Control Supplement to the 1987 National
18 Doll, R. and Peto, R. The causes of cancer:
Health Interview Survey.
Quantitative estimates of avoidable risks of
34 National Center for Health Statistics. Health United
cancer in the United States today. Journal of the
States, 1989. DHHS Pub. No. (PHS)90-1232.
National Cancer Institute 66:1191-1308, 1981.
Hyattsville, MD: U.S. Department of Health and
19 Drug Abuse Warning Network, National Institute
Human Services, 1990.
on Drug Abuse, Alcohol, Drug Abuse, and
35 National Center for Health Statistics. Prevention
Mental Health Administration, Public Health
profile. Health, United States, 1989. DHHS Pub.
Service, U.S. Department of Health and Human
No. (PHS)90-1232. Hyattsville, MD: U.S.
Services, Rockville, MD.
Department of Health and Human Services, 1990.
20 Reference omitted.
36 National Center for Statistics and Analysis.
21 Fiore, M.C.; Novotny, T.E.; Pierce, J.P.;
Occupant Protection Facts. Washington, DC:
Hatziandreu, E.J.; Patel, K.M.; and Davis R.M.
U.S. Department of Transportation, 1989.
Trends in cigarette smoking in the United States:
37 National Health and Nutrition Examination Survey
The changing influence of race and gender.
(NHANES), National Center for Health Statistics,
JAMA 261:49-55, 1989.
Centers for Disease Control, Public Health
22 Hall, J.R. A decade of detectors: Measuring the
Service, U.S. Department of Health and Human
effect. Fire Journal :37-43, 1985.
Services, Hyattsville, MD.
23 Hollinshead, W.H. et al. Statewide prevalence of
38 National Health Interview Survey, National Center
illicit drug use by pregnant women Rhode
for Health Statistics, Centers for Disease Control,
Island. MMWR 39(14):225-7, 1990.
Public Health Service, U.S. Department of Health
and Human Services, Hyattsville, MD.
24 Institute of Medicine. Disability in America: A
National Agenda for Prevention. edited by Pope,
39 National Heart, Lung, and Blood Institute.
A. and Tarloff, A. Washington DC: National
Hypertension prevalence and the status of
Academy Press, in press.
awareness, treatment, and control in the U.S.:
Final report of the subcommittee on definition
25 Institute of Medicine. The Second Fifty Years:
and prevalence of the 1984 joint national
Promoting Health and Preventing Disability.
committee. Hypertension 7(3): 457-468, 1985.
Washington DC: National Academy Press, in
press.
40 National Heart, Lung, and Blood Institute. Report
of the Expert Panel on Detection, Evaluation, and
26 Institute of Medicine, National Academy of
Treatment of High Blood Cholesterol Adults.
Sciences. The Future of Public Health.
National Cholesterol Education Program.
Washington, DC: National Academy Press, 1988.
Washington, DC: U.S. Department of Health and
27 Jones, E.F. and Forrest, J.D. Contraceptive failure
Human Services, 1988.
in the United States: Revised estimates from the
41 National Heart, Lung, and Blood Institute. The
1982 National Survey of Family Growth. Family
1988 Report of the Joint National Committee on
Planning Perspectives 21(3):103-9, 1989.
Detection, Evaluation, and Treatment of High
28 Keith, L.G.; McGregor, S.N.; and Sciarra, J.J. Drug
Blood Pressure. Washington, DC: U.S.
abuse in pregnancy. In: Chasnoff, I.J. ed. Drugs,
Department of Health and Human Services, 1988.
Alcohol, Pregnancy and Parenting. Hingham,
42 National Heart, Lung, and Blood Institute, National
MA: Kluwer Academic Publishers, 1988.
Institutes of Health, Public Health Service, U.S.
29 Kleinman, J.C. and Kopstein, A. Smoking during
Department of Health and Human Services,
pregnancy, 1967-1980. American Journal of
Bethesda, MD.
Public Health 77:823-25, 1987.
Conference Edition
27
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43
National High School Seniors Survey, National
57
President's Committee on Mental Retardation.
Institute on Drug Abuse, Alcohol, Drug Abuse,
Preventing the New Morbidity: A Guide for State
and Mental Health Administration, Public Health
Planning for the Prevention of Mental
Service, U.S. Department of Health and Human
Retardation and Related Disabilities Associated
Services, Rockville, MD.
with Socioeconomic Conditions. Washington,
44 National Highway Traffic Safety Administration's
DC: U.S. Deaprtment of Health and Human
Services, 1988.
19 Cities Survey, Department of Transportation,
Washington, DC.
58 Public Health Service. The Surgeon General's
45 National Institute on Drug Abuse. National
Report on Health Promotion and Disease
Prevention. DHEW Pub. No.(PHS) 79-55071.
Household Survey on Drug Abuse: Population
Washington, DC: U.S. Department of Health,
Estimates, 1988. DHHS Pub. No.
Education and Welfare, 1979.
(ADM)89-1636. Washington, DC: U.S.
Department of Health and Human Services, 1989.
59 Public Health Service. Surgeon General's Report
46 National Institute on Drug Abuse. National Survey
on Nutrition and Health. Washington, DC: U.S.
Department of Health and Human Services, 1988.
Results from High School, College, and Young
Adult Populations, 1975-1988. DHHS Pub. No.
60 Report to Congress and the White House on the
(ADM)89-1638. Washington, DC: U.S.
Nature and Effectiveness of Federal, State, and
Department of Health and Human Services, 1989.
Local Drug Prevention/Education Programs.
47 National Institute of Health. Consensus
Washington, DC: U.S. Department of Education,
1987.
Development Conference Statement: Urinary
Incontinence in Adults, October 3-5, 1988.
61 Schoenborn, C.A. Health Promotion and Disease
48 National School Boards Association. Smoke-free
Prevention: United States, 1985. Public Health
Service. Vital and Health Statistics, Series 10,
Schools: A Progress Report. Alexandria, VA: the
No. 163. DHHS Pub. No. (PHS)88-1591, 1988.
Association, 1989.
62 Secretary's Task Force on Black and Minority
49 National Survey of Family Growth. National
Health. Report of the Secretary's Task Force on
Center for Health Statistics, Centers for Disease
Black and Minority Health. Washington, DC:
Control, Public Health Service, U.S. Department
U.S. Department of Health and Human Services,
of Health and Human Services, Hyattsville, MD.
1985.
50 National Vital Statistics, National Center for Health
63 Shapiro, S.; Venet, W.; Strax, L.; and Roeser, R.
Statistics, Centers for Disease Control, Public
Selection, follow-up, and analysis in the Health
Health Service, U.S. Department of Health and
Insurance Plan Study: A randomized trial with
Human Services, Hyattsville, MD.
breast cancer screening. National Cancer Institute
51 Office of Disease Prevention and Health
Monographs 67:65-74, 1985.
Promotion. Mass Communications and Health.
64
Shapiro S.; McCormick, M.C.; Starfield, B.H.;
Washington, DC: U.S. Department of Health and
Krischer, J.P.; and Bross, D. Relevance of
Human Services, 1990.
correlates of infant deaths for significant
52 Office of Disease Prevention and Health
morbidity at one year of age. American Journal of
Promotion. Prevention 89/90: Federal Programs
Obstetrics and Gynecology 136:363-373, 1980.
and Progress. Washington DC: U.S. Department
65 Sonnenstein, F.L.; Pleck, J.H.; and Ku, L.C. Sexual
of Health and Human Services, 1990.
activity, condom use, and AIDS awareness
53 Office on Smoking and Health. Reducing the
among adolescent males. Family Planning
Health Consequences of Smoking: 25 Years of
Perspectives 21(4):152-8, 1989.
Progress. A Report of the Surgeon General.
66 Taffel, S.M. Maternal Weight Gain and the
DHHS Publication No. (CDC)89-8411.
Outcome of Pregnancy. Vital and Health
Washington, DC: U.S. Department of Health and
Statistics, Series 21, No. 44, DHHS Pub. No.
Human Services, 1989.
(PHS)86-1922. Washington, DC: U.S.
54 Office of Technology Assessment. Healthy
Department of Health and Human Services, 1986.
Children: Investing in the Future. Washington,
67 U.S. Department of Health and Human Services.
DC: U.S. Congress, 1988.
National children and youth fitness study II.
55 Pierce, J.P.; Fiore, M.C.; Novotny, T.E.;
Journal of Physical Education, Recreation, and
Hatziandreu, E.J.; and Davis, R.M. Trends in
Dance 58:50-96, 1987.
cigarette smoking in the United States:
68 U.S. Preventive Services Task Force. Guide to
Projections to the year 2000 JAMA 261:61-65,
Clinical Preventive Services: An Assessment of
1989.
the Effectiveness of 169 Interventions. Baltimore,
56 Pirie, P.L.; Murray, D.M.; and Luepker, R.V.
MD: Williams and Wilkins, 1989.
Smoking prevalence in a cohort of adolescents,
69 Westat, Inc. Study Findings: Study of National
including absentees, drop outs, and transfers.
Incidence of Child Abuse and Neglect.
American Journal of Public Health 78:176-78,
Washington, DC: U.S. Department of Health and
1988.
Human Services, 1988.
28
Conference Edition
3. The Nation's Health: Special Populations
Progress toward a healthier America will depend substantially on improvements for cer-
tain populations that are at especially high risk. For that reason, Healthy People 2000
sets specific targets to narrow the gap between the total population and those population
groups that now experience above average incidences of death, disease, and disability.
These population groups include people with low incomes, people who are members of
some racial and ethnic minority groups, and people with disabilities. Likewise, it sets
specific targets for controlling some of the risk factors that contribute to the disease bur-
den of groups at highest risk. Special population groups often need targeted preventive
efforts, and such efforts require understanding the needs and the particular disparities ex-
perienced by these groups. General solutions cannot always be used to solve specific
problems.
This section provides profiles of the at-risk population groups addressed by Healthy
People 2000: low-income groups, minority groups, and people with disabilities. At the
outset, it is necessary to point to two caveats that limit these profiles and pose major
health challenges in themselves.
First, data are limited; sometimes, and for some groups, the data may be severely limited.
Without data, targets cannot be set, even though professional consensus exists that a
population group is at considerably higher risk than the total population. A challenge of
the coming years is to build better data systems, at national and State levels, in order that
the scope of health threats facing various groups within our society can be adequately
defined and appropriate preventive interventions can be effectively focused.
Second, the special populations themselves are extremely heterogenous. Whether the
group is defined as low income, black, Hispanic, Asian and Pacific Islander Americans,
American Indians/Alaska Natives, or people with disabilities, the variations within each
group are extensive. Generalizations, which characterize population profiles by defini-
tion, are dangerous because the exceptions are many. The challenge is to refine our
knowledge and our understanding even further, especially as basic health policies are
translated into community-based prevention programs and clinical preventive services.
With these two caveats in mind, profiles of special populations can be used, together with
those in the preceding section that address age groups, to provide the human context for
the health strategy laid out in this report.
People with Low Income
Nearly 1 of every 8 Americans lives in a family with an income below the Federal pover- 10
ty level. Nearly a quarter of children younger than 6 are members of such families.
Low income itself (or low socioeconomic status) is a shorthand label that encompasses
family groups with individuals who have poorly paid jobs or are unemployed, families
living in substandard housing, and families more likely to have only a single parent in
residence. Health disparities between poor people and those with higher incomes are al-
most universal for all dimensions of health.¹ Those disparities may be summarized by
the finding that people with low income have death rates that are twice the rates for
people with incomes above the poverty level.
For virtually all of the chronic diseases that lead the Nation's list of killers, low income is
a special risk factor. For example, the risk of death from heart disease is more than 25
percent higher for low income people than for the overall population.¹⁴ The incidence of
cancer increases as family income decreases, and survival rates are lower for low-income
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Healthy People 2000
cancer patients. The association of cancer and low income varies by cancer site; lung,
esophageal, oral, stomach, cervical, and prostate cancers are more frequent among the
poor, while breast and colorectal cancers are not. 1,24 Infectious diseases, like HIV infec-
tion and tuberculosis, are also often found disproportionately among the poor.
Similar vulnerability for low income people is found with some causes of traumatic in-
jury and death. These individuals, more than those with higher incomes, are the victims
of violent crime. Poverty appears to be a major predisposing factor associated with a
higher risk for murder of acquaintances and family members, as well as robbery-
motivated killings of strangers. Injuries and deaths among children from fires, drowning,
and suffocation are strongly related to low socioeconomic status.24
No single indicator of health status makes the connection between poverty and poor
health more clear than does infant mortality. Poor pregnancy outcomes including
prematurity, low birth weight, birth defects, and infant death are linked to low income,
low educational level, low occupational status, and other indicators of social and
economic disadvantage.²⁴
Poverty reduces a person's prospects for long life by increasing the chances of infant
death, chronic disease, and traumatic death; poverty is also often associated with sig-
nificant developmental limitations. For example, iron deficiency is more than twice as
common in low income children, aged 1 and 2, as it is among the total population of that
age.¹² Growth retardation affects 16 percent of low income children younger than age 6.
In the mid-1980s, an estimated 3 million children, virtually all of them from low income
families, had blood lead levels that exceeded 15 µg/dL, sufficient to place them at risk for
impaired mental and physical development. The rate of mental retardation is reported to
be higher among children in poverty. Poor children experience more sickness from infec-
tion and other debilitating conditions than the total population. Children in families with
incomes below $5,000 per year had an average of 9.1 disability days in 1980 compared to
only 4 days for children in families with incomes of $25,000 or more.¹³
The pattern of increased vulnerability to injury, disease, and death continues into
adulthood. People in families with incomes of less than $10,000 a year are twice as
likely as the total population to be limited in some activities of daily living. (Fig.3.1)
Activity limitations are four times more common among people with 8 years or less of
education than among those with 16 years or more. Bed disability days increase as
income decreases. 19
Income level
All persons
Fig. 3.1
Less than $13,000
Percentage of
people who
$13,000-18,999
experience limitation
of major activity, by
$19,000-24,999
income level (1988,
age adjusted)
$25,000-44,999
$45,000 or more
0
5
10
15
20
Source: National Health
Percent
Interview Survey
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3. The Nation's Health: Special Populations
Just as poor health is more likely among persons of low income, so are some, but not all,
of the major risk factors for poor health. Higher-than-average rates of obesity and high
blood pressure, which are major risks for heart disease and stroke, have been linked
directly with low income status. 24 Tobacco use, which has declined dramatically in the
past two decades for the population as a whole, has remained virtually constant since
1966 for those who completed less than 12 years of schooling. Smoking levels among
blue-collar workers are about 20 percent higher than among others. 20
Whereas in 1987 about 15 percent of people under age 65 had no health insurance either
by private or public forms of coverage, lack of health insurance coverage was a problem
for nearly twice as many who lived in families in which the principal wage earners made
$3.50 an hour or less. Two-thirds of children from families below the poverty level are
uninsured or insured only part of the year, and one-fourth of women aged 16 to 24 have
no health insurance. 19
In 1987 only 22 percent of low-income women over age 40 had ever received a clinical
breast examination and a mammogram, as compared to 36 percent of women in the total
population. 13 Relatively low survival rates for breast cancer among low-income women
point to the need for earlier diagnosis and treatment. While the benefits of prenatal care
for low-income women are well documented, with a savings-cost ratio on the order of 3-
to-1, low utilization rates are characteristic of groups at high risk of low birth weight and
other maternal and infant health problems.² Approximately 40 percent of children from
low-income families have untreated dental caries, another indicator of the lack of preven-
tive and primary health care. 18
For the coming decade, perhaps no challenge is more compelling than that of equity. The
disparities experienced by people who are born and live their lives at the lowest income
levels define the dimensions of that challenge. The relationships between poverty and
health are complex and cannot be reduced to a simple one-to-one relationship between
dollars available and level of health. Low income may, in fact, be a product of poor
health, just as poor health may be caused by environmental exposures, material deficien-
cies, and lack of access to health services that adequate income might correct or improve.
While, from a public health perspective, the leverage available to effect improvements is
limited largely to the availability and the quality of health services, improvements in
education, job training, and other social services are necessary to erase the health effects
of current income disparities.
Minorities
The United States has been called a "melting pot" of ethnic and racial groups. In recent
decades, it has become clearer that the image is no longer an appropriate one. Rather
than amalgamating into one single group, we have come to recognize and even celebrate
our diversity as a basis for national strength. Nevertheless, our health care programs are
characterized by unacceptable disparities linked to membership in certain racial and eth-
nic groups.
The predominant minority populations of the United States can be categorized as blacks,
Hispanics, Asian and Pacific Islander Americans, and American Indians/Alaska Natives.
From a total population perspective, the categories simplify the difficulties of assessing
health status and making plans to improve health. But they are gross simplifications.
Within each racial or ethnic category, significant subgroup differences exist. Demarca-
tions among minority populations are not absolute. There are black Hispanics. Many
nonblack Hispanics share historic roots and genetic endowments that are closely related
to those of many American Indian groups, while others have European roots and do not
share the genetic make-up which may predispose to adult-onset diabetes. Alaska Natives
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Healthy People 2000
may have more in common with some Asians than they do with American Indians in the
lower 48 States. In short, differences within the principal population groups must always
temper generalizations about their health needs.
The extent of disparities suffered by minority groups in America was documented in the
mid-1980s by the Report of the Secretary's Task Force on Black and Minority Health.
This report found that black Americans suffered nearly 60,000 excess deaths per year in
the period 1979-1980, with "excess deaths" defined as the difference between the number
of deaths observed in that minority population and the number of deaths that would have
been expected if that population had the same age- and gender-specific death rate as the
white population.
A compelling disparity of most minority populations in the United States is
socioeconomic. The discussion on low-income people describes a small portion of the
white American population. It applies to much larger portions of those from black,
Hispanic, Asian and Pacific Islander, and American Indian and Alaska Native com-
munities. Poverty and near-poverty appear as underlying elements of many health
problems experienced by these groups. But if the socioeconomic effects are set aside,
many disparities experienced by these population groups will still be observed. Simply
put, some differences in survival and health are not solely explained by poverty or other
environmental factors. 4 For that reason, Healthy People 2000 assesses disparities not
only in terms of income level and educational attainment, but also in terms of the
Nation's racial and ethnic population groups. Special population targets for improve-
ments to be achieved by 2000 are set for those groups with higher risks than the total
population, where data are available to establish such targets.
Black Americans
African Americans make up 12 percent of the United States population, thereby constitut-
ing the Nation's largest minority group. Members of this group live in all regions of the
country and are represented in every socioeconomic group. One-third of blacks live in
poverty, a rate three times that of the white population. Over half live in central cities, in
areas often typified by poverty, poor schools, crowded housing, unemployment, exposure
to a pervasive drug culture and periodic street violence, and generally high levels of
stress. Life expectancy for blacks has lagged behind that for the total population
throughout this century; since the mid-1980s the gap has actually widened, with the life
expectancy rising to 75 years for the overall population while falling slightly for blacks,
from a high of 69.7 years in 1984 to 69.4 years in 1987. 3 The leading chronic diseases as
causes of death for black Americans are the same as those for the majority population.
(Fig. 3.2) However, black men die from strokes at almost twice the rate of men in the
total population, and their risk of nonfatal stroke is also higher. Coronary heart disease
death rates do not show such disparate levels, although death rates are higher for black
women than for white women. On the other hand, when heart disease rates are compared
within income levels, black rates are lower than those for whites.24
Black men also experience a higher risk of cancer than nonblack men, with a 25-percent
higher risk of all cancers and a 45-percent higher incidence of lung cancer. Only 38 per-
cent of blacks with cancer survive 5 years after diagnosis, compared to 50 percent of
whites.24
32
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3. The Nation's Health: Special Populations
Heart disease
Cancer
Fig. 3.2
Stroke
Leading causes
Injuries
of death for blacks
Homicide
compared to whites
Pneumonia/influenza
(1987, age-adjusted
rates)
Diabetes
Perinatal conditions
Blacks
Chronic lung disease
Whites
HIV infection
0
50
100
150
200
250
300
Source: National Center
Rate per 100,000
for Health Statistics
Diabetes is 33 percent more common among blacks than whites. The highest rates are
among black women, especially those who are overweight. The complications of
diabetes-heart disease, stroke, kidney failure, and blindness-all are more prevalent
among blacks with diabetes than whites with diabetes. 24
Black babies are twice as likely as white babies to die before their first birthday. High
rates of low birth weight among black babies account for many of these deaths, but even
normal-weight black babies have a greater risk of death. Black infant mortality rates are
higher not only for babies in the first month of life, but also for those between 1 month
and 1 year of age. The major killer in this period is sudden infant death syndrome
(SIDS). Other causes of death that are more prevalent for black infants than for the total
population include respiratory distress syndrome, infections, and injuries. 17
Homicide is the most frequent cause of death for black men between the ages of 15 and
34. The homicide rate for those between ages 25 and 34 is 7 times that of whites. A
black man has a 1-in-21 lifetime chance of being murdered, and black women are more
than four times as likely to be homicide victims as white women.²⁴ Most young black
murder victims are killed with firearms in the course of an argument. It is estimated that
about half of all homicides in the United States are related to alcohol use and 10 percent
or more to the use of illegal drugs.
The rate of AIDS among blacks is more than triple that of whites. Among women and
children, the gaps are even wider. Black women face between 10 and 15 times the risk of
AIDS as compared to white women. Black children account for more than 50 percent of
all children with AIDS. The proportion of AIDS cases associated with intravenous drug
abuse is greater for blacks than for other AIDS victims, and higher rates of heterosexual
transmission of the HIV virus and transmission of the virus from mother to infant occur
as a consequence.25
Disparities in the experience of health risks mirror some of the most striking disparities in
health outcomes. High blood pressure is much more common among blacks of both
genders than among the total population. Severe high blood pressure is present 3 times
more often among blacks than among whites. 19 Overweight is a problem for 44 percent
of black women aged 20 and older, compared to 37 percent for low income women and
27 percent for all women. Poor nutrition, smoking, alcohol and drug abuse, and other
risk factors appear more commonly among blacks with low incomes. 24
Adolescent pregnancy is a major concern among the black population, for its social and
economic consequences as much as for its health effects. There are higher risks of infant
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Healthy People 2000
mortality and low birth weight, especially for very young pregnant girls. But even
greater risks indirectly threaten the health of both mother and baby because of the pat-
terns of poverty and low educational attainment that often become solidified as a result of
early childbearing. Actual rates of childbirth among black teenagers have dropped since
the 1960s, but because the number of girls in this population has risen by 20 percent, the
total number of births has increased. In 1987, births among girls aged 15 through 17 and
also among girls younger than age 15 were 3 times as likely among black girls as among
white girls. Birth rates among black girls younger than 15 were nearly 5 times higher,
than the rate for white girls. 24
Statistics demonstrate with sharp clarity that blacks do not receive enough early, routine,
and preventive health care. Early prenatal care can reduce low birth weight and prevent
infant deaths. Early detection of cancers can increase survival rates. Appropriate medi-
cal care can reduce the frequency and severity of the complications of diabetes, which
blacks experience at higher rates than others. Information about actual use of health care
services confirm these indications. Blacks make fewer annual visits to physicians than
whites, and black mothers are twice as likely as white mothers to receive no health care
or care only in the last trimester of their pregnancies. 24 Hospital emergency rooms and
clinics are a much more common source of medical care for blacks than for whites, and
20 percent of blacks compared to 13 percent of whites report no usual source of medical
care. 24 Though recent statistics are not available to assess immunization coverage by
race, children in central cities-many of whom are black Americans-lagged as much as
20 percent behind immunization rates for children living in other places. About 18 per-
cent of blacks have no private or public medical insurance, compared to 9 percent of
whites.24
Hispanic Americans
The Hispanic subgroups-Mexican Americans, Puerto Ricans, Cuban Americans,
Central and South American immigrants, and other Spanish surname/Spanish-speaking
communities-compose the second largest minority group in the United States. At the
beginning of the 1990s, they constitute about 8 percent of the total population and are the
fastest growing minority group. Over 70 percent of Hispanics were born in this country.
Within the Hispanic populations, Mexican Americans are nearly two-thirds of the total,
Puerto Ricans (excluding those who live in Puerto Rico) are 12 percent, Cuban
Americans are 5 percent, people of Central and South American origin are 11 percent,
and others (including Spanish-speaking immigrants from Caribbean islands) make up 9
percent. Eighty-seven percent of Hispanics live in urban areas. The largest concentra-
tions of Mexican Americans are in Western States, notably California and Texas. More
Puerto Ricans reside in East Coast States, led by New York. Cuban Americans more
often reside in Florida. 11
Hispanics experience perhaps the most varied set of health issues facing a single minority
population. Whereas Mexican Americans have low rates of cerebrovascular disease,
stroke rates among New York Puerto Ricans are high. Cuban Americans have high
utilization rates for prenatal care, but lower rates prevail among Mexican Americans and
Puerto Ricans. Infant mortality rates vary substantially from group to group. (Fig. 3.3)
In short, the Hispanic health profile is marked by diversity. This diversity is intertwined
with the ever-present effects of socioeconomic status, and with geographic and cultural
differences.
34
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3. The Nation's Health: Special Populations
Puerto Rican
Fig. 3.3
Infant mortality rates
Other and unknown
for selected Hispanic
Hispanic
groups
Mexican
Central and South
American
Cuban
Source: National Linked
0
2
4
6
8
10
12
14
16
Infant Birth and Death
Rate per 1,000 live births
Record File
Two related demographic facts are especially important for the health issues and
prospects of the Hispanic population: its youthfulness and its high birth rate. The
median Hispanic age is less than 26, compared to about 33 for the total population. Ap-
proximately 38 percent of all Hispanics are aged 19 and younger.2¹ The Hispanic birth
rate was 94 births per 1,000 women in 1987, while that of the total population was 69
births per 1,000 women.
The leading causes of death among Hispanic Americans document several differences be-
tween their health experience and that of the total population. (Fig. 3.4) Heart disease
and cancer lead the list, as is the case for other Americans, but death rates from these 2
causes are actually lower than for non-Hispanics.²⁴ Unintentional injuries, homicide,
chronic liver disease and cirrhosis, and AIDS rank higher on the Hispanic list; suicide,
stroke, and chronic obstructive pulmonary disease rank lower.¹¹ In the case of homicide,
the great majority of victims are young men. In the southwest, Hispanic men aged 20
through 24 have 4 times the homicide rate of their non-Hispanic, white counterparts. In
the case of AIDS, Hispanics' rate is nearly 3 times higher than for non-Hispanic whites,
with rates among Puerto Rican-born Hispanics as much as 7 times higher.2 The cumula-
tive incidence of AIDS among Hispanic women is about 8 times higher than among non-
Hispanic women, and the rate for HIV infection over 6 times higher for Hispanic
children. As with black Americans, HIV transmission among Hispanic women is primari-
ly linked to intravenous drug abuse by these women or their sexual partners. Diabetes
is especially prevalent among Mexican Americans.¹¹
Hispanics
Rank
White non-Hispanics
Fig. 3.4
Heart disease
25%
1
Heart disease
37%
Cancer
17%
2
Cancer
23%
Leading causes of
Injuries
9%
3
Stroke
7%
death for Hispanics
Stroke
6%
4
Chronic lung disease
4%
and white non-
Homicide
5%
5
Injuries
4%
Hispanics in 18
Liver disease
3%
6
Pneumonia/
4%
States and the Dis-
influenza
trict of Columbia, as
Pneumonia/
3%
7
Diabetes
2%
a percent of total
influenza
deaths (1987)
Diabetes
3%
8
Suicide
2%
HIV infection
3%
9
Atherosclerosis
1%
Source: Health, United
Perinatal conditions
3%
10
Liver disease
1%
States, 1989 and National
Center for Health Statistics
Note: National death rate data unavailable for Hispanics
Conference Edition
35
Healthy People 2000
Among the risks to health, smoking continues among 43 percent of Hispanic men, and
Hispanic teenagers of both genders smoke more than do either non-Hispanic black or non-
Hispanic white teenagers. 11 Likewise, Hispanic teenagers report heavy drinking of al-
coholic beverages more frequently than do white or black teenagers. 11 Puerto Ricans and
Cuban Americans aged 12 through 17 report higher rates of cocaine use than do either
whites or blacks, and Mexican Americans have higher rates of marijuana use. Cocaine-
related deaths tripled between 1982 and 1984 among Hispanics, while they were dou-
bling among non-Hispanic whites. 11
Overweight is common among Hispanics, especially among Mexican American women.
This disparity cannot be accounted for completely by socioeconomic differences.
Likewise, Mexican Americans participating in a San Antonio Heart Study were found to
have physical activity rates lower than those in the total population, even after differences
in socioeconomic status, residential location, and gender were taken into account. 11
Like black Americans, Hispanic Americans receive less preventive health care, including
prenatal care, than the total population. In 1987, 13 percent of Hispanic mothers had late
or no prenatal care compared to 4 percent of non-Hispanic whites. 11 Barriers to care in-
clude language differences between Spanish-speaking patients and English-speaking
health professionals, logistical barriers posed by rural residence of some Hispanic
families, and costs of services. In 1986, nearly 22 percent of Hispanics had no health in-
surance, either public or private, compared to 10 percent of blacks and less than 8 percent
of whites. 27
Migrant farmworkers, a small but important subset of Hispanic Americans, deserve spe-
cial attention. Migrant farmworkers may also belong to white, black, Haitian, or other
ethnic groups, but one of the largest sources is Hispanic. Their infant mortality rate is
about 25 percent greater than that of the national average; their life expectancy is 49
years rather than 75 years; the rate of parasitic infection among some sets of farm
workers approaches 50 times that of the total population. 16 The health care needs of
these farmworkers are particularly challenging, given their migratory patterns, low
incomes, poor education, and lack of health insurance.
Asian and Pacific Islander Americans
The diversity that characterizes the more than 11 million people who are Asian and
Pacific Islanders is striking. As a whole, they are the Nation's third largest minority
group, but this single label is an oversimplification. They speak over 30 different lan-
guages and bring with them a similar number of distinct cultures. Approximately three-
quarters of them are immigrants, mostly from Southeast Asia, and many of them are
refugees. A small proportion are either immigrants from South Pacific islands or Native
Hawaiians.
3
From the perspective of their health prospects, those born within the United States and es-
tablished here for generations are virtually undistinguishable from the population as a
whole. Indeed, their median income is higher than that of the overall United States
population, with Japanese families having annual incomes 38-percent higher than the na-
tional median income. Yet, some groups, particularly recent immigrants, are extremely
poor. For example, Laotian immigrants have one of the highest poverty rates of any
group in the Nation. Even within subgroups, diversity characterizes both socioeconomic
and health profiles. While Chinese Americans generally enjoy adequate incomes and
relatively good health, communities such as Chinatown in San Francisco have higher
poverty levels. Elimination of the disparities between Asian and Pacific Islander
Americans and the general population may parallel integration of the newer immigrants
into both the economy and the society of the United States.
36
Conference Edition
3. The Nation's Health: Special Populations
An adequate depiction of the health of Asian and Pacific Islander Americans is con-
strained by limited data. (Fig. 3.5) Many national data systems are unable to make es-
timates of this minority population because of its relatively small size. This prevents ac-
curate assessment of the leading causes of death, disease, and disability that it experien-
ces. Generalizations from local studies may be inaccurate and misleading due to the
profound differences among Asian and Pacific Islander American groups, for example
the difference in perinatal mortality among the groups. (Fig. 3.6) From those local
studies, however, it is possible to recognize certain diseases as posing higher than normal
risks for specific Asian and Pacific Islander Americans. Most of the studies are based in
California, which has the largest Asian and Pacific Islander American population.
Disparities in rates of cancer exist for several subgroups and selected cancer sites. For ex-
ample, the breast cancer incidence rate among Native Hawaiians is 111 per 100,000
women, as compared to 86 per 100,000 among whites. The lung cancer rate is 18 percent
higher among Southeast Asian men than for the white population. And the liver cancer
rate is more than 12 times higher among Southeast Asians than in the white popula-
tion. 2,23 Higher rates of high blood pressure have been found among Filipinos aged 50
and older living in California (61 percent for men and 65 percent for women) than among
the total California population (47 percent). 24
Asians and
Pacific Islanders
Rank
Whites
Heart disease
28%
1
Heart disease
35%
Fig. 3.5
Cancer
24%
2
Cancer
23%
Stroke
9%
3
Stroke
8%
Leading causes of
Injuries
7%
4
Chronic lung disease
5%
death for Asians and
Pneumonia/
4%
5
Pnuemonia/
4%
Pacific Islanders and
influenza
influenza
whites in California,
Chronic lung disease
3%
6
Injuries
4%
as a percent of total
Suicide
2%
7
Suicide
2%
deaths (1987)
Diabetes
2%
8
Liver disease
2%
Source: California State
Perinatal conditions
2%
9
Diabetes
1%
Department of Health and
Liver disease
1%
10
Atherosclerosis
1%
Asian American Health
Forum
Note: Asian and Pacific Islander category consists of 93 percent Asians and
7 percent Other (Native Americans, Eskimos, and Alaskan Aleuts.) National
death rate data are unavailable for Asians and Pacific Islanders. In 1980,
35.2 percent of all Asian Americans lived in California.
Laotion
Asian unspecified
Fig. 3.6
Cambodian
Other PI
Percent of deaths
Vietnamese
attributed to condi-
Cambodian
tions originating in
Asian Indian
the perinatal period,
Thai
for selected Asian
Samoan
Korean
groups
Filipino
Chinese
Japanese
Source: California State
Guamanian
Department of Health and
0
2
4
6
8
10
Asian American Health
Percent
Forum
Conference Edition
37
Healthy People 2000
The two infectious diseases that have followed immigrant Asian and Pacific Islander
population subgroups to this country are tuberculosis and hepatitis B. Tuberculosis is
still the leading cause of death in some Asian countries and has become a serious health
problem in some Asian communities in large American cities. Among Southeast Asian
immigrants, the incidence is 40 times higher than in the total population. Rates are par-
ticularly high among those over age 45.1 2 Higher rates of hepatitis B are also found
among Asian immigrants. This infection is associated with chronic liver disease, cir-
rhosis, and liver cancer. The overall carrier rate in the United States is estimated to be
0.3 percent of the population; among immigrants from Southeast Asia the estimated rate
is 4 percent. Infection is spread from mother to infant and from child to child. Refugee
transit camps now screen pregnant women and vaccinate infants of those who are carriers
of hepatitis B and all children under age 6. 5
Among the risk factors of greatest concern is smoking. Among California immigrant
groups, smoking rates among men are 92 percent for Laotians, 71 percent for Cam-
bodians, and 65 percent for Vietnamese, compared to 30 percent for the overall American
population.
2,24
Faced with western medicine and a health care system that is unfamiliar, Americans of
Asian and Pacific Island heritage experience unique access barriers to primary care. In
addition to linguistic and cultural differences, financial problems beset many subgroups,
especially recent immigrants and refugees.
American Indians and Alaska Natives
Descendants of the original residents of North America now number approximately 1.6
million and compose the smallest of the defined minority groups. Diversity characterizes
this group, too, encompassing numerous tribes and over 400 federally recognized nations,
each with its own traditions and cultural heritage. Eskimos, Aleuts, and Indians residing
in Alaska are referred to as Alaska Natives; those residing in other States are referred to
as American Indians. The Federal Government collects detailed data on American In-
dians and Alaska Natives in 33 States that include reservations; health care services are
provided through the Indian Health Service to those living in these reservation States.
Thus, it is possible to derive a composite profile of this population group. However, only
about one-third of this group lives on reservations or historic trust lands, while about 50
percent live in urban centers.
In general, the American Indian and Alaska Native population is youthful. The median
age of those living in the reservation States is about 23, compared to over 32 for the
United States population as a whole. Income and educational levels tend to be low, with
more than 1 in 4 living below the poverty level and fewer than 8 percent having college
degrees.
6
One reason for the youthfulness of the population is the large proportion of the popula-
tion who die before age 45. Most of the excess deaths-those that would not have oc-
curred if American Indian death rates were comparable to those of the total population-
can be traced to 6 causes: unintentional injuries, cirrhosis, homicide, suicide, pneumonia,
and complications of diabetes. 24 (Fig. 3.7) Heart disease and cancer are not among the
sources of excess deaths, perhaps because these are generally diseases of older age. 24
Cancer rates are lower overall, but are twice as high as the total population for lung can-
cer among Oklahoma Indians. Southwest Indians have high rates of gallbladder cancer,
and Alaska Natives suffer high rates of liver cancer.²⁴
38
Conference Edition
3. The Nation's Health: Special Populations
Heart disease
Cancer
Fig. 3.7
Injuries
Leading causes of
Stroke
death for American
Liver disease
Indians compared to
Diabetes
whites (1987, age ad-
justed rates)
Pneumonia/influenza
Suicide
American Indians
Homicide
Whites
Chronic lung disease
Source: Indian Health
0
50
100
150
200
Service and National
Rate per 100,000
Center for Health Statistics
The second leading cause of death among American Indian men, and the first cause for
those younger than age 44, is unintentional injuries, accounting for over one-fifth of all
their deaths each year. An estimated 75 percent of these injuries are alcohol-related,
and 54 percent involve motor vehicle crashes.¹ Alcohol is also a factor in a homicide
rate that is 60 percent higher than that of the total population. Suicide, the third of the
four alcohol-related causes of death among American Indians, occurs at an overall rate
that is 28 percent higher than the national rate, but among some tribes the suicide rate is
10 times higher than the total population rate.24
Cirrhosis and diabetes are the two chronic diseases that afflict American Indians more fre-
quently than other groups. Cirrhosis deaths occur at about three times the total popula-
tion rate, and cirrhosis is the fourth alcohol-related health effect contributing significantly
to death and disability among American Indians.²² Diabetes is now so prevalent that in
many tribes more than 20 percent of the members have this disease.24 Among two tribes
in Arizona, the rate is 40 percent of adults. Obesity contributes to the high incidence of
diabetes experienced by many American Indian communities, and it is also linked to hy-
pertension and cardiovascular disease. The increase in obesity among American Indians
in the last 50 years has paralleled the increasing rates of diabetes.
Alcohol and obesity are risk factors that stand out as problems for the American Indian
population. One estimate is that 95 percent of American Indian families are affected
either directly or indirectly by a family member's alcohol abuse.²² While American In-
dians living on reservations and tribal members with access to reservation health facilities
are served by the Indian Health Service, access to health care is still a problem for many.
Many live in rural areas where the availability of physicians is about half that of the na-
tional average and where the Indian Health Service may not provide health care services.
Health problems may appear especially intractable, but gains achieved among a number
of tribes in reducing infant mortality rates to levels below those of the population as a
whole provide testimony to the possibility of major improvement in the coming decade.
People With Disabilities
Throughout this document, the preventive actions implicit in targets to be achieved by
2000 seek not only to reduce unnecessary deaths and the immediate suffering and costs
of infectious and chronic diseases; they also seek to prevent the longer-term consequen-
ces of functional impairments that can severely affect the quality of one's life. As a
prevention plan for the 1990s, Healthy People 2000 addresses not only the prevention of
premature death and disease, but also with the prevention of disabilities. Even when data
Conference Edition
39
Healthy People 2000
are unavailable to define health outcomes except in terms of death, the thrust of objec-
tives for the year 2000 is aimed at the living consequences of unhealthy behaviors, unsafe
environments, and illness-causing infections. Disabilities may be defined, as distinct
from illness or disease, in terms of limited ability to function. Disabilities may be physi-
cal or mental; and they may include motor or sensory limitations. The focus is on effects,
rather than causes, since a similar functional limitation, such as a limitation in ability to
walk, may be caused by a congenital birth defect, an injury, or a leg amputation resulting
from complications of diabetes.
When the focus is on prevention of disabilities, another group of Americans who face spe-
cial health risks becomes evident: those who already experience serious and chronic dis-
ability. The health promotion and disease prevention needs of people with disabilities are
not nullified because they were born with an impairing condition or have experienced a
disease or injury that has long-term consequences. In fact, those needs for health promo-
tion are accentuated. People with disabilities are at higher risk of future problems that
can only increase the limitations that they experience. For that reason, Healthy People
2000 addresses people with disabilities as a special population, and where data are avail-
able, sets specific targets to address their needs and enhance their health.
Secondary conditions-health problems that arise from, or are related to, the main cause
of disability-are common among people with disabilities and are the principal targets of
health promotion and disease prevention efforts for this special population. Some, such
as decubitus ulcers (pressure sores) and genitourinary disorders, are associated with
living conditions linked to the disability, i.e., confinement to a wheel chair or bed. Immo-
bility or inactivity also increases the risk of metabolic, circulatory, respiratory, and mus-
culoskeletal problems. Other secondary health problems can be seen as a progression of
the original disabling condition. Diabetes, for example, can lead to serious foot problems
and vision impairment.
Many secondary health problems are preventable. For others, the risks can be reduced.
For example, pressure sores are a major health risk for all people with spinal cord injuries
yet can be prevented through improved health care, properly designed seating, and per-
sonal hygiene. Remediable genitourinary tract disorders are also a problem for people
whose major motor function is severely restricted. Inadequate health care is implicated in
the development of these disorders. Other factors include nutritional disorders, alcohol
and drug abuse, inadequate personal hygiene, and acute and chronic illness. Cardiovas-
cular disorders and stroke, brought on by hypertension, nutritional problems, smoking,
and lack of physical activity, may be particular problems for people with disabilities.
Musculoskeletal disorders caused by a lack of physical activity and injuries are especially
prevalent among people with disabilities. Many respiratory problems for people with dis-
abilities are thought to be preventable. They can result from tobacco use, lack of physi-
cal activity, and inadequate immunization.⁷
Alcohol and other drug abuse often are associated with emotional problems. For some
people with disabilities, special risks may stem from negative family and cultural at-
titudes.
As with minority populations, the elements of this report that explicitly call for improve-
ments for people with disabilities are limited by the availability of data with which to set
targets. Disabilities vary in their type and their intensity; those with disabilities include
all age, racial, and ethnic groups. One of the major challenges of the coming years is to
improve our understanding of the needs of the full range of people with disabilities by im-
proving the effectiveness of data systems.
Estimates of the number of people with chronic, significant disabilities vary from 34 mil-
lion to 43 million. These estimates include the almost 4 percent of the total population of
40
Conference Edition
3. The Nation's Health: Special Populations
the Nation who are unable to perform their major activity (play, school, work, self-care);
about 6 percent whose ability to perform major activities is limited in some fashion; and
over 4 percent who are limited in nonmajor activities. 8 Many more people, of course,
have impairments that are not yet, but could become, disabling; and still more have
chronic conditions, such as hypertension or alcoholism, that can lead to impairment and
disability. Many people have several disabling conditions. About 27 percent of people
with disabilities report more than one cause of their limited function and over 7 percent
report three or more.⁸
Activity limitations are most common among older people, the poor, and those
Americans who are less educated. In comparison to the total population, about twice as
many people in families with incomes of less than $10,000 a year report some activity
limitation. 15 Education too is clearly linked to disability; about 40 percent of people with
8 years or less of education have activity limitations compared to under 11 percent of
those with 16 years or more.¹⁵
The prevalence of disability increases with age, as one would expect. (Fig. 3.8) More
than one out of every five people aged 65 and older is limited in one or more of his or her
major activities, and nearly half of those aged 85 and older need assistance in activities of
daily living. On the other hand, people who are under age 65 and living in the com-
munity, i.e., not institutionalized, make up about 40 percent of those who need assistance
in activities of daily living. 8
Percent
30
Fig. 3.8
25
Percentage of
20
people experiencing
limitation of major
15
activity, by age
(1987)
10
5
0
Under 5
5-14
15-44
45-64
65-74
75+
Source: Health, United
Age group
States, 1989
The major causes of activity limitation vary with age. People under age 18 are most like-
ly to have disabilities associated with mental impairment, asthma, mental illness, deaf-
ness and other ear disorders, and speech impairments. Among young adults, orthopedic
impairments, such as spinal curvature and other back impairments, are most common,
while at older ages degenerative diseases, led by arthritis and heart disease, predominate.⁸
Among ethnic groups, American Indians have the highest rates of activity limitation and
Asian and Pacific Islander Americans the lowest. 15 Activity limitations are slightly
higher among blacks than among non-Hispanic whites, and both have higher rates of dis-
ability than Hispanics.
It is evident from this list that people with disabilities face many of the same risks as
other people-nutritional problems, physical inactivity, alcohol and other drug abuse,
and stress. But for people with disabilities reducing risks may be a particular challenge.
Physical activity, considered especially important in preventing secondary health
problems, offers a compelling example. To establish fitness regimens, people with
Conference Edition
41
Healthy People 2000
disabilities often need to learn new skills, have access to special equipment, and be part
of a support network that enables participation.⁷
Lack of adequate rehabilitation, maintenance therapies, and personal assistance increases
the risk of secondary health problems among people with disabilities. Inadequate health
insurance, especially among those without access to work-related group insurance, also
poses a significant problem for this group.
A clear opportunity exists for health promotion and disease prevention efforts to improve
the health prospects and functional independence of people with disabilities. Efforts to
adapt existing preventive services and programs are underway. For example, exercise
videotapes have been developed for people with paraplegia, quadriplegia, amputation,
cerebral palsy, and other physical impairments. Some fitness centers offer modified
aerobics, mild exercise in warm water, and other exercises designed to meet the needs of
individuals with disabilities. But fitness services are just one of many that are needed.
Preventing the occurrence of secondary health problems depends on the availability of a
variety of health and social services. Gaps, overlaps, inconsistencies, and inequities in ex-
isting programs require the effective coordination of existing services if the health of
people with disabilities is to be promoted.⁷
References
1
Amler, R.W. and Dull, H.B., Closing the Gap: The
11 National Coalition of Hispanic Health and Human
Burden of Unnecessary Illness. New York:
Services Organizations. Delivering Preventive
Oxford University Press, 1987.
Health Care to Hispanics: A Manual for
2
Asian American Health Forum. Year 2000 Strategic
Providers, Washington, DC: the Coaltion, 1988.
Health Development Program for Asian and
12 National Health and Nutrition Examination Survey
Pacific Islander Americans. April 1989.
(NHANES) II, National Center for Health
3
Bureau of the Census. U.S. Census of Population:
Statistics, Centers for Disease Control, Public
1980. Washington DC: U.S. Department of
Health Service, U.S. Department of Health and
Commerce.
Human Services, Hyattsville, MD.
13
4
Council on Ethical and Judicial Affairs. Black-white
National Health Interview Survey, National Center
disparities in health care. JAMA 263:2344-2346,
for Health Statistics, Centers for Disease Control,
1990.
Public Health Service, U.S. Department of Health
and Human Service, Hyattsville, MD.
5
Franks, A.L.; Berg, C.J.; Kane. M.A.; Browne, B.B.;
14 National Heart, Lung, and Blood Institute, National
et al. Hepatitis B virus infection among children
born in the United States to Southeast Asian
Cholesterol Education Program. Report of the
refugees, New England Journal of Medicine
Expert Panel on Population Strategies for Blood
321(9):1301-5,1989.
Cholesterol Reduction. Washington, DC: U.S.
Department of Health and Human Services, 1990.
6
Indian Health Service, Indian Health Service Chart
15 National Institute on Disability and Rehabilitation
Series Book, Washington, DC: U.S. Department
of Health and Human Services 1988.
Research, Chartbook on Disability in the United
States, Washington, DC: the Institute 1989.
7
Institute of Medicine. Disability in America: A
16 National Migrant Resource Program and the
National Agenda. edited by Pope, A. and Tarloff,
A. Washington, DC: National Academy Press, in
Migrant Clinicians Network. Migrant and
Seasonal Farmworker, Health Objectives for the
press.
Year 2000: Document in Progress, April 1990.
8
LaPlante, M.P., Data on Disability from the
Austin, TX: National Migrant Resource Program,
National Health Interview Survey, 1983-1985,
Inc., 1990.
Washington, D.C.: National Institute on
17 National Vital Statistics System, National Center
Disability and Rehabilitation Research, 1988.
for Health Statistics, Centers for Disease Control,
9
National Cancer Institute and National Center for
Public Health Service, U.S. Department of Health
Health Statistics. Unpublished data from the
and Human Services, Hyattsville, MD.
Cancer Control Supplement to the 1987 National
18 North Carolina Oral Health School Survey. North
Health Interview Survey.
Carolina Division of Dental Health, Raleigh,
10
National Center for Children in Poverty. A
North Carolina and the University of North
Statistical Profile of Our Poorest Young Citizens.
Carolina School of Public Health, Chapel Hill,
New York: The Center, 1990.
North Carolina.
42
Conference Edition
3. The Nation's Health: Special Populations
19
24
Office of Disease Prevention and Health
Secretary's Task Force on Black and Minority and
Promotion. Disease Prevention/Health
Health, Report of the Secretary's Task Force on
Promotion: The Facts. Washington, DC: U.S.
Black and Minority and Health, Washington, DC:
Department of Health and Human Services, 1987.
U.S. Department of Health and Human Services,
1985.
20 Office on Smoking and Health. Unpublished data
25
from the 1987 National Health Interview Survey.
Selik, R.M.; Castro, K.G.; and Papaionnou, M.
Racial/ethnic differences in the risk of AIDS in
21 Office of Substance Abuse Prevention (OSAP).
the United States. American Journal of Public
Communicating about alcohol and other drugs:
Health 78(12): 1539-1544, 1988.
Strategies for reaching populations at risk. OSAP
26
Prevention Monograph 4. Washington, DC: U.S.
Selik, R.M.; Castro, K.G.; Papaionnou, M.; and
Department of Health and Human Services, in
Ruehler, J.W. Birthplace and the risk of AIDS
press.
among Hispanics in the United States. American
Journal of Public Health 79(7):836-9, 1989.
22 Rhoades, E.R.; Hammond, J.; Welty, T.K.;
27
Handler, A.O.; and Amler, R.W. The Indian
U.S. House of Representatives, Select Committee
burden of illness and future health interventions.
on Children, Youth, and Families. A Key to Our
Public Health Reports 102(4):361-8, 1987.
Nation's Future: A Fact Sheet.
23
Schwartz, S.M. and Thomas, D.B. "Estimates of
Cancer Incidence Among Southeast Asian
Refugees in the United States." Paper presented at
the Annual Meeting of the American Public
Health Association, New Orleans, LA October
1987.
Conference Edition
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Healthy People 2000
44
Conference Edition
4. Goals for the Nation
The promise embodied in Healthy People 2000 involves people in all their variety: age,
gender, family relationships, racial and ethnic identity, income level, education, and oc-
cupation. It involves birth and death, two sentinel health events. Birth frames the poten-
tial for a healthy lifetime; death often summarizes how that potential was used. It invol-
ves the values of family, neighborhood, community, and Nation, enabling or undermin-
ing the health course that a life takes. It involves an array of risks-some posing ap-
parent, immediate danger and others invisible and delayed in their effects. Finally, it in-
volves medical science and medical care, with its ability to thwart infections, reverse the
course of some chronic diseases, and enhance ability to function where limitations exist.
Three overarching goals emerge from the complexity of the health challenge of the
1990s. They permeate the structure and the content of this report. They further define
the challenge, especially for health planners, policy-makers, and providers.
Goal I: Increase the Span of Healthy Life for Americans
A central purpose of Healthy People 2000 is to increase the proportion of Americans who
live long and healthy lives. The first goal underlying our strategy for the coming decade
clearly states this intention. It encompasses the essential elements of health promotion
and disease prevention: prevention of premature death, disability, and disease, and enhan-
cement of the quality of life.
From an individual perspective, healthy life extends into the final quarter of a full cen-
tury, free from chronic, disabling diseases and conditions, from preventable infections,
and from serious injury. It means a full range of functional capacity at each life stage,
from infancy through old age, allowing one the ability to enter into satisfying relation-
ships with others, to work, and to play. From a national perspective, healthy life means a
vital, creative, and productive citizenry contributing to thriving communities and a thriv-
ing nation.
In the course of this century, average life expectancy at birth has increased by almost 60
percent, from 47 years in 1900 to 75 years in 1987. (Fig. 4.1) This progress has been lar-
gely due to the advances of science and public health in conquering life-threatening com-
municable diseases. The aging of the population and the evolution from communicable
diseases to chronic diseases and injuries as the leading causes of death direct our atten-
tion to quality of life issues. Both chronic diseases and injuries can be measured by the
Life years
85
Fig. 4.1
Life expectancy at
80
birth, U.S. population
75.0
75
70
J
65
1970
1975
1980
1985
1990
1995
2000
Year
Source: Health, United
States, 1989
Conference Edition
45
Healthy People 2000
death certificates that they generate; but the numbers reflecting human suffering and
costs associated with heart disease, cancer, nonfatal strokes, diabetes, and lung diseases
far outstrip mortality statistics. The results of injury caused both by unintentional trauma
and by interpersonal violence are not limited to lives cut short; they also include lives
that must overcome brain damage, motor limitations, and other permanent impairments.
We can measure our progress in increasing the span of healthy life in several ways. One
measure offered here indicates the rate of deaths before age 75 per 100,000 people (Fig.
4.2), in 1990 the approximate average life expectancy at birth. Infant mortality, a tradi-
tional tool for judging the efficacy and compassion of health systems, can indicate nation-
al progress at the early end of the age spectrum. (Fig. 4.3) Another measure uses a for-
mula that combines death rates with acute and chronic illnesses, impairments, and hand-
icaps to define average years of healthy life. Using this measure, life expectancy can be
separated into two distinct measures. (Fig. 4.4) One is the average life expectancy at
birth that will be spent in a healthy state; these are years of healthy life. The other indi-
cates the average amount of time spent in a dysfunctional state due to either chronic or
acute limitation. One of the major indicators of dysfunction is defined as limitation of
major activity due to chronic conditions. (Fig. 4.5)
Years of healthy life uses a life expectancy model in which standard life table data are ad-
justed for level of well-being of a population. Measures of well-being represent in-
dividual functioning and include measures of mental, physical, and social functioning.
For example, social functioning may be measured in terms of an individual's limitation in
performing his or her usual social role, whether this be work, school, or housework;
physical functioning may be measured in terms of being confined to bed, chair, or couch
due to health reasons, or in terms of health-related limitation in mobility. Because years
of healthy life is a relatively new type of measure, both the baseline and target estimates
may change. Nonetheless it should prove an informative indicator as we track the
Nation's health progress.
Over the course of the decade, we will be able to use each of these measures as indicators
of our overall progress in increasing the span of healthy life. To explain the basis for
that progress, it is necessary to move beyond the broad goals that are proposed here and
look to the priorities for preventive action. Healthy life will be expanded to more years
and more Americans as a result of efforts to address the priorities defined in the next
chapter.
Rate per 100,000
1000
Fig. 4.2
800
Death rates for
people aged 74 and
600
younger, U.S.
392
population
400
200
0
1970
1975
1980
1985
1990
1995
2000
Year
Source: National Vital
Statistics System
46
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4. Goals for the Nation
Deaths per 1,000 live births
35
Fig. 4.3
30
Infant mortality rate,
25
U.S. population
20
15
10.1
10
5
0
1970
1975
1980
1985
1990
1995
2000
Year
Source: National Vital
Statistics System
Healthy life
Fig. 4.4
62 years
Years of healthy life
as a proportion of life
expectancy, U.S.
population (1980)
Dysfunctional life
11.7 years
Source: National Vital
Statistics System and Na-
Life expectancy
tional Health Interview
73.7 years
Survey
Percent
20
Fig. 4.5
15
Percentage of
people experiencing
9.4
limitation of major
10
activity, U.S. popula-
tion (crude rate)
5
0
1970
1975
1980
1985
1990
1995
2000
Year
Source: National Health
Interview Survey
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47
Healthy People 2000
Goal II: Reduce Health Disparities Among Americans
Achieving a healthier America depends on significant improvements in the health of
population groups that now are at highest risk of premature death, disease, and disability.
The particular health problems of those high risk groups were presented in the previous
two chapters. In some instances and for some health risks, they are age groups. In most
cases and for virtually all health risks, they are members of certain racial and ethnic
groups, people with low income, and people with disabilities. Special attention is needed
to close the gap that exists between the majority of the population and the various
minority populations. Whether the issue is chronic diseases, infectious diseases, uninten-
tional injuries, or violence-related injuries, the services and protection that might most ef-
fectively bring about improvements in their circumstances must be made available.
Although health statistics that take race and ethnicity into account are sparse, the ones
that do exist leave no doubt about disparities. The greatest opportunities for improve-
ment and the greatest threats to the future health status of the Nation reside in population
groups that have historically been disadvantaged economically, educationally, and politi-
cally. These must be our first priority.
Even as average life expectancy at birth edged into the upper 70s, the expected life span
for black American male babies born in 1986, 1987, and 1988 actually shrank. 1 The dis-
parities appear across the spectrum of health concerns, not just in average life expectan-
cy. (Fig. 4.6) One perspective on these differences is death rates before age 75. (Fig. 4.7)
A particularly sensitive and compelling measure of disparity is infant mortality. Al-
though America's infant mortality rate is at an all-time low, a persistent racial gap
remains. Black babies continue to die at twice the rate of white babies (Fig. 4.8).
Another is potential years of life lost before age 65 among white and black men from
chronic diseases, calculated as years lost per 1,000 population. Rates for black men are
55 percent higher for heart disease, 26 percent higher for cancer, 180 percent higher for
stroke, and 100 percent higher for lung disease. For homicide, years of potential life lost
are 630 percent higher for black men than for white men. Among women of both races,
death rates for all causes are lower, but comparisons of premature death of white and
black women are equally startling. Lost years of life before age 65 are 134 percent
higher among black women for heart disease, 166 percent higher for stroke, and 360 per-
cent higher for homicide. 1 Statistics are scarce for other racial and ethnic populations, for
low income groups, and for people with disabilities, but analyses of local data from small
area studies confirm disparities among these groups as well.
Life years
80
Fig. 4.6
75.6
Whites
75
Life expectancy at
birth, blacks and
69.4
whites
70
Blacks
65
60
1970
1975
1980
1985
1990
1995
2000
Year
Source: Health, United
States, 1989
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4. Goals for the Nation
Deaths per 1,000 live births
35
Blacks
Fig. 4.7
30
Infant mortality rates,
25
blacks and whites
20
17.9
15
Whites
8.6
10
5
Source: National Vital
0
1970
1975
1980
1985
1990
1995
2000
Statistics System and Na-
tional Linked Infant Birth
Year
and Death Record File
Rate per 100,000
1000
Blacks
Fig. 4.8
800
Death rates for
628
people aged 74 and
600
younger, blacks and
367
whites (1987)]
400
Whites
200
0
1970
1975
1980
1985
1990
1995
2000
Year
Source: National Vital
Statistics System
Contrasting death rates are mirrored by statistics that depict disability outcome, as well as
death. Statistics on years of healthy life reflect the gap between our racial and ethnic
groups in the United States. (Fig. 4.9) Similarly, rates of disability, measured in terms of
limitation of major activity, confirm the fact of inequity in health. The most striking
aspect of these comparative rates is the great gap between low-income people and all
other groups. (Fig. 4.10)
Healthy People 2000 thus calls for special attention to reducing-and finally eliminat-
ing-disparities among population groups of Americans. In the priorities for preventive
action, this report sets separate, challenging targets when baseline data are available.
Usually the targets are sufficient to narrow the gap between the death, disease, or dis-
ability rates for population groups and the total population; where trends have been wor-
sening for population groups, targets may appear less challenging but may, in fact, be dif-
ficult to achieve because of recent setbacks. In many instances, targets cannot be set in
1990 because measurement tools are not available to provide baselines from which to set
realistic, achievable targets for 2000. For this reason, the health status of black
Americans, for whom data are most readily available, is used to provide proxy measures
of our progress in moving toward the basic goal of equity in health for all our Nation's
people.
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49
Healthy People 2000
Years
100
Fig. 4.9
80
74.4
75
68
63
62
Life expectancy and
56
60
years of healthy life,
whites, blacks, and
40
Hispanics (1980)
20
0
Whites
Blacks
Hispanics
Source: National Vital
Statistics System and Na-
Life expectancy
Years of healthy life
tional Health Interview
(preliminary estimates)
Survey
Percent
25
Fig. 4.10
Low income
18.9
20
Percentage of
people experiencing
15
American Indians
13.4
limitations of major
Blacks
11.2
activity, by race and
10
Whites
ethnicity (crude rates)
9.3
Hispanics
5
6.6
0
1970
1975
1980
1985
1990
1995
2000
Year
Source: National Health
Interview Survey
Goal III: Achieve Access to Preventive Services for All
Americans
Healthy People 2000 calls for a comprehensive strategy to support the improvements in
health that are possible through prevention. This report defines the major parts of that
strategy as Health Promotion, Health Protection, and Preventive Services. The priorities
for prevention are grouped under these three categories. They are not precise or mutually
exclusive categories, but they serve to underscore an important point. Major improve-
ments depend on all three approaches to prevention, not just one. We cannot rely solely
on success in persuading people to change their health-related behaviors through health
promotion efforts, any more than we can rely solely on environmental improvements or
expanded and enhanced clinical interventions.
A health strategy for the 1990s, however, must put particular emphasis on the arena
where health professionals in both the private and public sectors have most respon-
sibility, namely the arena of preventive services. Those services, made available to all
Americans, can provide the foundation for achievement of other parts of our health
strategy. An example, which we will use to track our effectiveness in moving toward this
goal, relates to the birth of healthy babies. Prenatal health care is a vital, fundamental in-
gredient in attaining this sentinel health event. (Fig. 4.11) Early and regular prenatal
visits to qualified health care providers can ensure greater likelihood that low birth
50
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4. Goals for the Nation
weight and other perinatal complications will be prevented. Prenatal health care services
can also serve as a resource and a reinforcer for health promotion efforts that are equally
important to healthy pregnancies. The role of prenatal preventive services in education
and counseling about parental behaviors, including nutrition, abstinence from tobacco, al-
cohol, and other drugs, and, even before conception, behaviors that involve risks of
sexually transmitted diseases, including HIV infection, is crucial. Likewise, preventive
services for pregnant women can serve as the means of monitoring protection against
toxic exposures, such as lead, dangerous prescription medications, and radiation.
Other preventive services are equally fundamental to our national prevention plan. Basic
monitoring of child growth and development; immunization against childhood diseases
(Fig. 4.12); appropriate immunization for vulnerable adults against pneumonia and in-
fluenza; screening to detect high blood pressure and high blood cholesterol, breast, cervi-
cal, oropharyngeal, and colorectal cancers; counseling on nutrition, smoking cessation,
and injury prevention; all these services are indispensable parts of prevention. Achieve-
ment of this goal clearly requires that health care providers offer, and patients receive,
these services. Objectives throughout this report focus on increasing the proportion of
primary care providers who routinely offer preventive services to their patients.
Percent of live births
100
Fig. 4.11
90
Percentage of
Whites
79
pregnant women
80
receiving first
70
trimester prenatal
61
Blacks
care, blacks and
60
whites
50
40
1970
1975
1980
1985
1990
1995
2000
Year
Source: National Vital
Statistics System
Percent vaccinated
100
Fig. 4.12
80
Percentage of
children receiving
60
school entry
immunizations
40
20
0
1970
1975
1980
1985
1990
1995
2000
Year
Source: Center for
Prevention Services, CDC
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51
Healthy People 2000
Access to preventive services involves more than just availability of services. Preventive
services cannot, and should not, be separated from basic primary health care. Ap-
proximately 18 percent of all Americans and 31 percent of those without either private or
public health insurance have no source of primary health care. (Fig. 4.13) Thus, tracking
of progress to achieve access to preventive services over the coming decade must focus
on increases in the number of people who have a source of primary health care and those
who have adequate insurance coverage (Fig. 4.14), with particular attention to the exten-
sion of health insurance and managed health care systems to cover preventive services
such as immunizations, screening, and patient education and counseling.
Percent
35
30
Fig. 4.13
25
Percentage of
people who lack a
20
source of primary
care (1986)
15
10
5
0
All
People
Hispanics
Blacks
Low-income
Source: Robert Wood
w/o insurance
Johnson Foundation
Private insurance
Fig. 4.14
77%
Health insurance
coverage for people
aged 64 and
Other/unknown
younger, by type of
2%
Medicaid
coverage
6%
Not covered
15%
Source: Health, United
States, 1989
Note: Percent distribution approximate due to overlap among categories
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4. Goals for the Nation
These three goals-healthy lives for more Americans, elimination of disparities among
population groups, access to necessary preventive services for everyone-are our broad
national aspirations for health improvements. They can serve as a shared set of values
that underpin all of our health promotion and disease prevention work. They can inform
our public policy, whether at the Federal, State, or local levels. But taken alone, they do
not provide us with adequate direction to guide actual decisions about programs, resource
allocation, or professional and personal commitments. The goals are insufficient, unless
they are buttressed by a framework of specific and substantive preventive actions that
will move us steadily in the direction of their achievement. The next chapter lays out the
specifics of the Healthy People 2000 plan and gives substance to the goals for the Nation.
Reference
1
National Center for Health Statistics. Health United
States, 1989. DHHS Pub. No. (PHS)90-1232.
Hyattsville, MD: U.S. Department of Health and
Human Services, 1990.
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Healthy People 2000
54
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5. Priorities for Health Promotion and
Disease Prevention
Healthy People 2000 is a platform for action. The information it contains may be interest-
ing; the statistical data on which it is based may be analytically useful; and the objectives-
oriented structure that it employs may serve as a practical model for other planning
endeavors. But its value must finally be judged by how well it helps to shape what we do
to improve the health of the Nation in the coming decade.
This chapter summarizes the priorities for preventive action. Organized in three basic
categories-Health Promotion, Health Protection, and Preventive Services-it moves to
specific behavioral risks, disease conditions, and health outcomes that must be effectively
addressed if in the coming years we are to take advantage of our opportunities for better
health. In addition, a cross-cutting priority that supports each of the others is improve-
ment of our surveillance and data systems to foster more effective decision-making.
Each specific priority is summarized in the following pages, together with representative
health objectives drawn from Part II of Healthy People 2000. These representative objec-
tives serve as abbreviated examples of the measurable targets that are more fully stated
and discussed in greater detail in Part II. While they cannot completely summarize all
aspects of the health improvements, risk reductions, and service enhancements that are
contained in the chapters of Part II, these examples demonstrate the magnitude and impor-
tance of the change envisioned in Healthy People 2000.
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Healthy People 2000
Health Promotion
Physical Activity and Fitness
Nutrition
Tobacco
Alcohol and Other Drugs
Family Planning
Mental Health and Mental Disorders
Violent and Abusive Behavior
Educational and Community-Based Programs
56
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5. Priorities for Health Promotion and Disease Prevention
Physical Activity and Fitness
Regular physical activity increases life expectancy,⁷² can help older adults maintain func-
tional independence, and enhances quality of life at each stage of life. 32 The beneficial
impact of physical activity touches widely on various diseases and conditions. Regular
physical activity can help to prevent and manage coronary heart disease, hypertension,
diabetes, osteoporosis, and depression.²⁶ It has also been associated with a lower rate of
colon cancer⁷⁵ and stroke⁸¹, and may be linked to reduced back injury.⁸ It is an essential
component of weight loss programs.
Physical activity is a complex behavior and its relationship with health is multifaceted.
Regular vigorous physical activity promotes cardiorespiratory fitness and helps prevent
coronary heart disease. 5,73 Activity that builds muscular strength, endurance, and
flexibility may protect against injury and disability. And any activity that expends ener-
gy is important in weight control. Physical activity can also produce changes in blood
pressure, blood lipids, clotting factors, and glucose tolerance, that may help prevent and
control high blood pressure, coronary heart disease and diabetes.³⁷
While activity should be habitual, it need not be unduly strenuous. People who engage
daily in light to moderate exercise, equivalent to sustained walking for about 30 minutes
a day, can achieve substantial health gains. Increasing evidence suggests that even small
increases in light to moderate activity by those who are least active will produce
measurable health benefits. 38,80
Of particular importance is the role of physical activity in preventing coronary heart dis-
ease, the leading cause of death in the United States. A sedentary lifestyle appears to be
an independent risk factor for coronary heart disease, nearly doubling a person's risk. 76
Its effect on coronary heart disease risk is almost as great as the better known risk factors,
such as cigarette smoking and high blood pressure. Because more people are at risk of
coronary heart disease due to physical inactivity than to any other single risk factor, it has
an especially great public health impact.
Few Americans engage in regular physical activity despite the potential benefits. Current-
ly, only 22 percent of adults engage in at least 30 minutes of light to moderate physical
activity 5 or more times per week, and only 12 percent report that they are this active 7 or
more times a week. Less than 10 percent of the population exercises 3 or more times a
week at the more vigorous level necessary to improve cardiorespiratory fitness. Nearly
25 percent of adults report no leisure-time physical activity, and the prevalence of seden-
tary behavior increases with advancing age.
To increase physical activity and fitness, by the year 2000
1.3 Increase moderate daily physical activity to at least 30% of people
(a 36% increase)
1.5 Reduce sedentary lifestyles to no more than 15% of people
(a 38% decrease)
Other objectives target development of sustained combined changes in diet/activity
patterns for those who are overweight; physical education in schools; sponsorship by
employers of worksite physical activity programs; increasing accessibility of
community resources like trails and pools; and a stronger focus by primary care
providers on the physical activity patterns of their patients.
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Healthy People 2000
Nutrition
In ways often interrelated with patterns of physical inactivity, dietary factors are as-
sociated with 5 of the 10 leading causes of death in the United States: coronary heart dis-
ease, some types of cancer, stroke, noninsulin-dependent diabetes mellitus, and
atherosclerosis. The 1988 Surgeon General's Report on Nutrition and Health⁷⁷ found
that for the 2 out of 3 Americans who neither smoke nor drink, eating patterns may shape
their long-term health prospects more than any other personal choice. In general, exces-
ses and imbalances of some food components in the diet have replaced once-prevalent
nutrient deficiencies as the principal concern.
While many dietary components are involved in diet and health relationships, chief
among them is the disproportionate consumption of foods high in fats (especially
saturated fats), often at the expense of foods high in complex carbohydrates and dietary
fiber that may be more conducive to health. 77 To help promote health and prevent
chronic disease, the Dietary Guidelines for Americans,⁹⁰ issued by the United States
Departments of Health and Human Services and Agriculture, recommend eating a variety
of foods; maintaining healthy weight; choosing a diet low in fat, saturated fat, and
cholesterol; choosing a diet with plenty of vegetables, fruits, and grain products; using
sugars only in moderation; using salt and sodium only in moderation; and, if alcoholic
beverages are consumed, do so in moderation.
Overweight affects about 26 percent of the population. It is a particular problem for poor
and minority populations, affecting 44 percent of black women over age 20 and 37 per-
cent of all women below the poverty level. Obesity has been linked to increased risk for
diabetes mellitus, high blood pressure and stroke, coronary heart disease, some types of
cancer, and gallbladder disease. 77
Dietary fat contributes more than twice as many calories per unit weight as carbohydrate
or protein, and currently constitutes over 36 percent of the calories in the average
American diet. Considerable evidence associates diets high in fat with increased risk of
obesity, some types of cancer, and possibly gallbladder disease. 77 Strong and consistent
evidence relates saturated fat intake to high blood cholesterol and increased risk for
coronary heart disease. Moreover, Americans eat only about half of the dietary fiber
recommended by the National Cancer Institute to help reduce the risk for some types of
cancer. Dietary fiber is readily available from a variety of foods such as vegetables,
fruits, and grains, which are also low in fat.
To improve nutrition, by the year 2000
2.3
Reduce overweight to a prevalence of no more than 20% of people
(a 23% decrease)
2.5 Reduce dietary fat intake of an average of 30% of calories
(a 17% decrease)
Other objectives target increasing consumption of vegetables, fruits, and grain
products; decreasing sodium consumption; increasing calcium intake, in particular for
young people and pregnant or lactating women; increasing breastfeeding; reducing
iron deficiency in children; useful and uniform nutrition labeling for all food products;
increasing availability of low-fat food products; better identification of low-fat choices
in restaurants; more attention to nutrition education and food choices in schools; better
use of worksites for nutrition education and services; and a stronger focus by primary
care providers on the nutritional practices of their patients.
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5. Priorities for Health Promotion and Disease Prevention
Tobacco
Tobacco use is the single most important preventable cause of death in the United States,
accounting for one of every six deaths, or some 390,000 deaths annually.⁷¹ It is a major
risk factor for diseases of the heart and blood vessels; chronic bronchitis and emphysema;
cancers of the lung, larynx, pharynx, oral cavity, esophagus, pancreas, and bladder; and
other problems such as respiratory infections and stomach ulcers.⁷¹ Cigarette smoking is
responsible for an estimated 21 percent of all coronary heart disease deaths (40 percent of
those under age 65), 30 percent of all cancer deaths, and 87 percent of lung cancer deaths
in the United States. The risk of dying from lung cancer is 22 times higher for men and
12 times higher for women who smoke as for lifetime nonsmokers. Passive or involun-
tary smoking causes lung cancer and other diseases in healthy nonsmokers and severe
respiratory problems in children. Middle ear infections in children have been linked to
passive smoking.
Cigarette smoking during pregnancy is a risk factor for low birth weight, prematurity,
miscarriage, sudden infant death syndrome, and other maternal and infant health
problems. Between 20 and 30 percent of the incidence of low birth weight,35 up to 14
percent of preterm deliveries, and about 10 percent of all infant deaths are attributable to
maternal cigarette smoking.⁷ Yet 25 percent of pregnant women smoke throughout their
pregnancy.⁴⁹
Cigarette smoking has declined dramatically since 1964, when the first Surgeon
General's report on smoking appeared. In 1987, 29 percent of adults smoked compared
to 40 percent in 1965. Nearly half of all living adults who ever smoked have quit. Never-
theless, smoking rates remain high in certain populations, including blacks, blue collar
workers, and people with fewer years of education. In 1987, 34 percent of blacks
smoked. It is a special problem for workers with exposure to hazardous substances that
may compound the risk of smoking.
Among youth, more than half of 8th graders and nearly two-thirds of 10th graders report
having tried cigarettes. More than a fourth of 10th graders report having smoked a
cigarette during the preceding month and nearly one in five reports smoking a pack or
more in the previous month.
To reduce use of tobacco, by the year 2000
3.4 Reduce cigarette smoking prevalence to no more than 15% of adults
(a 48% decrease)
3.5 Reduce initiation of smoking to no more than 15% by age 20
(a 50% decrease)
Other objectives target increasing smoking cessation during pregnancy; reducing use
of smokeless tobacco; prevention education and tobacco-free environments in
schools; restrictions on smoking in the workplace and other public places;
enforcement of prohibition of sales of tobacco products to youth; restrictions on
tobacco advertising and promotion targeting youth; State plans to reduce tobacco use;
and more smoking cessation assistance to patients by primary care providers.
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Healthy People 2000
Alcohol and Other Drugs
Approximately two-thirds of American adults drink alcohol at least occasionally. Of
these, it is estimated that about 18 million currently experience problems as a result of al-
cohol use, and about 7 percent of drinkers experience moderate levels of dependence
symptoms. 63 Alcohol is a factor in approximately half of all homicides, suicides, and
motor vehicle fatalities. 74 With fetal alcohol syndrome affecting as many as 3 infants per
1,000 live births in some hospital reports, it is the leading preventable cause of birth
defects. 63 Alcohol is also responsible for numerous deaths due to liver disease. Of spe-
cial concern are the problems for young people. Nine out of ten high school seniors
report using alcohol at least once.
Drug use is also a dominant societal concern. Surveys in 1988 found that 21 million
Americans had ever used cocaine at least once, and 21 million also had used marijuana in
the last year. 61 Among high school seniors, almost 44 percent report having tried
marijuana, and 10 percent report ever using cocaine.⁴⁴ It has been estimated that one in
four American adolescents is at very high risk of alcohol and other drug problems, and
their consequences.20 The data may underestimate the problem because existing surveys
fail to count high risk youth who have dropped out of school. Drug abuse is linked to
high rates of violent crime in the Nation, to transmission of the HIV virus, and to develop-
mental problems in infants.
These are the immediate health problems posed by alcohol and other drugs. Their abuse,
however, is closely related to a host of other social and health problems, such as early un-
wanted pregnancy, delinquency, and school failure. The economic cost of problems at-
tendant to alcohol abuse was estimated in 1983 to be $116 billion, and another $60
billion for drug problems. 27 Alcohol and other drug abuse appears to be declining across
the total population. Use of crack cocaine, however, is on the rise, especially in some
urban centers. Homeless people are at special risk of alcohol abuse. 62
In the past decade, public awareness of this problem grew, uniting diverse groups in the
common goal. Businesses, schools, parent groups, and minority organizations have
developed ways to fight the pervasive dangers of alcohol and other drugs. A changing so-
cial climate has been accompanied by legislative and policy actions, particularly concern-
ing drinking and driving.
To reduce alcohol and other drug abuse, by the year 2000
4.1
Reduce alcohol-related motor vehicle crash deaths to no more than 8.5 per
100,000 people
(a 12% decrease)
4.6 Reduce alcohol use by school children aged 12 to 17 to less than 13%;
marijuana use by youth aged 18 to 25 to less than 8%; and cocaine use
by youth aged 18 to 25 to less than 3%
(50% decreases)
Other objectives target increasing the average age of first use of addictive substances;
reducing occasions of heavy drinking by young people; reducing aggregate per capita
alcohol consumption nationally; increasing awareness of the harmful effects of
addictive substances; better access to treatment programs; stronger and better
enforced laws related to driving under the influence of intoxicants; better access of
workers to assistance for problems; policies to reduce minors' access to alcohol; and
greater involvement of primary care providers in dealing with these problems.
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5. Priorities for Health Promotion and Disease Prevention
Family Planning
Families are the bedrock of our society. Decisions about forming a family are of critical
importance. Decisions made today may have long-term consequences. Safe and health-
ful childbearing both contributes to, and is a result of, effective family planning. Miscar-
riage, stillbirth, and infant mortality are tragic examples of problems more frequently
associated with unwanted pregnancies. Family planning is therefore defined here as the
process of establishing the preferred number and spacing of children in one's family and
selecting the means by which these preferences are achieved. It presupposes the impor-
tance of family and the importance of planning. It requires that fundamental questions be
addressed concerning an individual's relationship to the lives, health, and well-being of
others.
Successful implementation of family planning choices requires mature, thoughtful
decisions accompanied by motivation to carry out those decisions. It requires the exer-
cise of personal responsibility. There are many effective means by which family plan-
ning choices can be implemented. Childbearing, adoption, abstinence from sexual
activity outside of a monogamous relationship, use of contraception methods, natural
family planning, and treatment of infertility are all means of reaching desired family plan-
ning goals.
Despite the fundamental importance of these decisions to each individual and to society
as a whole, problems attendant to poor family planning choices exert a tremendous toll
on our Nation. In 1988, nearly half of American women surveyed reported that their
pregnancies in the last 5 years had been mistimed or unwanted-56 percent if adjustment
is made for unreported abortions. 67
The problem is most pressing among young people. More than three out of four young
women and 85 percent of young men have had sexual intercourse by age 20. 67,85 Each
year, one out of ten young women in this age group becomes pregnant. By age 20, ap-
proximately 40 percent of women have been pregnant while 63 percent of black women
have been pregnant. An estimated 84 percent of these pregnancies were unintended, 31
and abortion rates among American teenagers are considerably higher than for many
other countries.
To improve family planning, by the year 2000
5.1
Reduce teenage pregnancies to no more than 50 per 1,000 girls 17 and
younger
(a 30% decrease)
5.2
Reduce unintended pregnances to no more than 30% of pregnancies
(a 46% decrease)
Other objectives target reducing sexual intercourse among teenagers; reducing
nonuse of contraceptives among those who are unmarried and sexually active;
increasing effectiveness with which contraceptives are used; improving
communication between adolescents and parents on human sexuality; increasing
availability of appropriate preconception counseling; increasing referral rates to
appropriate services; increasing availability of information on adoption for unmarried
pregnant patients; and reducing rates of infertility.
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Healthy People 2000
Mental Health and Mental Disorders
Mental health refers to an individual's ability to negotiate the daily challenges and social
interactions of life, without experiencing undue emotional or behavioral incapacity. It
can be affected by numerous factors ranging from exogenous stresses presenting in ways
that may be difficult to manage to organic disease or genetic defects that impair brain
function. An estimated 23 million noninstitutionalized adults in the United States have
cognitive, emotional, or behavioral disorders, not including alcohol and other drug abuse.
Schizophrenic disorders most often result in functional disabilities, but depression is the
most common of the major disorders, affecting about 5 percent of the population at any
one time.
Suicide is clearly the most serious of the potential outcomes of these disorders and it
claims more than 30,000 lives each year. 68 Injuries from firearms are directly responsible
for a majority of suicidal deaths, and much of the increase in suicide that has taken place
since the 1950s is specific to firearm deaths. 6,45 There has been a steady increase in
deaths from suicide among youth aged 15 to 19 and by the mid-1980s suicide was the
second leading cause of death in this age group.
A variety of approaches have been proposed to reduce the impact of mental health
problems. Stress, whether stemming from life events, chronic strain, or environmental
pressures, is associated with biological changes linked to cognitive, emotional, and be-
havioral dysfunctions. Healthful habits, such as good nutrition and adequate amounts of
exercise, and relaxation techniques may be useful in helping to relieve stress. Because
people with low levels of control over their environment (actual or perceived) appear to
be at greater risk, interventions have also been directed at increasing individuals' resour-
ces and coping skills through education and social support. For those needing more ag-
gressive attention, medical interventions are available that include antidepression drugs,
psychotherapeutic agents, and biofeedback.
Childhood developmental delays and specific skill disorders have also been linked to
learning and adjustment problems in adolescence and early adulthood. Early interven-
tions with parents and children that address prenatal care, parental skills, and remedial
help in early school programs may help prevent developmental problems and their
progression to mental health problems.
To improve mental health and prevent mental disorders, by the year 2000
6.1
Reduce suicides to no more than 10.5 per 100,000 people
(a 10% decrease)
6.5
Reduce adverse effects of stress to less than 35% of people
(an 18% decrease)
Other objectives target reducing prevalence of mental disorders; increasing utilization
of community support programs; increasing treatment for those with major depressive
disorders; increasing use of broad social support mechanisms for those with trouble
coping; more attention by employers to services related to managing employee stress;
better access to mutual-help clearinghouses; and more attention by primary care
providers to the cognitive, emotional, and behavioral needs of their patients.
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5. Priorities for Health Promotion and Disease Prevention
Violent and Abusive Behavior
Violent and abusive behavior (intentional injury) exacts a large toll on the physical and
mental health of Americans. Child abuse, spouse abuse, and other forms of intrafamilial
violence continue to threaten the health of thousands of American families. Homicide
and suicide account for over one-third of the more than 145,000 injury deaths that occur
in the United States each year. Because of its growing prominence as a source of the
leading health problems experienced by Americans, violent and abusive behavior has
been increasingly recognized as an important public health problem.
Homicide is the 11th leading cause of death in the United States, accounting for nearly
21,000 deaths in 1986. 50 Men, teenagers, young adults, and minority group members,
particularly blacks and Hispanics, are most likely to be murder victims. It is the leading
cause of death for blacks between the ages of 15 and 34.¹³ Overall homicide rates for
blacks have declined since 1970, while the rates for whites have increased. 13 Most
homicides are committed with a firearm, occur during an argument, and occur among
people who are acquainted with one another. Homicide rates in the United States far ex-
ceed those of any other developed country.
Assault injuries are another consequence of interpersonal violence. Each year between
1979 and 1986 more than 2.2 million people suffered nonfatal injuries from violent and
abusive behavior. Of these injured victims, 1 million received medical care and 500,000
were treated by emergency medical facilities. More than 25 percent of the Nation's
10,000 to 15,000 spinal cord injuries each year are the result of assaultive violence.
Firearms account for 60 percent of all homicides and suicides, and a substantial propor-
tion of all traumatic spinal cord injuries. 43
Intrafamily violence is more prevalent than often recognized. In 1986 an estimated 1.6
million children nationwide experienced some form of abuse or neglect. 86 Physical abuse
accounted for the greatest portion of abuse incidents, followed by emotional and then
sexual abuse. Studies also suggest that between 2 and 4 million women are physically
battered each year by partners including husbands, former husbands, boyfriends, and
lovers. Between 21 and 30 percent of all women in the United States are estimated to
have been beaten by a partner at least once. More than 1 million women seek medical as-
sistance for injuries caused by battering each year, and the vast majority of domestic
homicides are preceded by episodes of violence. 54
To reduce violent and abusive behavior, by the year 2000
7.1
Reduce homicides to no more than 7.2 per 100,000 people
(a 15% decrease)
7.6 Reduce assault injuries to no more than 10 per 1,000 people
(a 10% decrease)
Other objectives target reducing weapon-related injury deaths; reducing child and
spouse abuse, reducing rape; reducing weapon-carrying by adolescents; reducing
inappropriate storage of weapons; improving emergency treatment, housing, and
referral services for battered women, children, and older people; improving school
programs for conflict resolution; and strengthening State-based efforts in violence
prevention.
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Healthy People 2000
Educational and Community-based Programs
A supportive social environment may be the most important factor in changing behaviors
that contribute to many of today's leading health threats. Consequently activity and
leadership at the community level is fundamental to progress. Educational and com-
munity-based programs, developed to reach people outside of traditional health care set-
tings, may address one risk factor in one setting, but increasingly they use multiple
interventions in a variety of settings.
Many involve various sectors and levels of society. Changes in the social and physical
environment call for the involvement of social institutions, businesses, legislative and
judicial bodies, the media, and other parts of the community. Because comprehensive,
communitywide programs aim to draw upon and become involved in as many aspects of
community life as possible, they require a high degree of cooperation and coordination
between groups that are often not traditional partners: environmental citizen groups and
manufacturers, health professionals and churches, employers and hospitals. Important to
the success of these partnerships are information networks and coordinating mechanisms,
both of which can help streamline services and interventions.
Schools offer a natural locus for the provision of crosscutting educational interventions in
health, and studies have now shown that school health education is an effective means of
helping children improve their health knowledge and develop attitudes that facilitate heal-
thier behaviors. Yet only 25 States currently mandate comprehensive school health
education programs, and implementation is spotty in even these States.
Similarly, the workplace can be an excellent site for health promotion programs. More
than 85 percent of adult Americans spend much of their day at their workplace.
Numerous studies have shown the benefits of worksite health promotion programs in im-
proving employee health, reducing insurance claims, improving morale, reducing absen-
teeism and reducing employee turnover. Among workplaces with more than 50
employees, about two-thirds report offering at least one health promotion activity 69 A
much smaller share offers a comprehensive package to employees, and even fewer in-
clude special activities for family members or retirees.
To enhance educational and community-based programs, by the year 2000
8.5
Provide quality K-12 school health education in at least 75% of schools
8.7
Provide employee health promotion activities in at least 85% of work-
places with 50 or more employees
(a 31% increase)
Other objectives target increasing reading levels and high school graduation rates;
increasing child development programs for low-income preschool children;
improving the school environment as well as health education; increasing
accessibility of health promotion programs for older people; development of broad
State-based strategies for health promotion; stronger focus on the health promotion
needs of minorities; and involvement of religious institutions in health promotion
efforts.
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5. Priorities for Health Promotion and Disease Prevention
Health Protection
Unintentional Injuries
Occupational Safety and Health
Environmental Health
Food and Drug Safety
Oral Health
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Healthy People 2000
Unintentional Injuries
Unintentional injuries are the fourth leading cause of death in the United States, killing
about 100,000 people a year, and are a major cause of disability.⁵⁰ Nonfatal injuries are
responsible for one of every six hospital days and one of every 10 hospital discharges. 79
Nearly two-thirds of all injury deaths and 84 percent of all injuries resulting in
hospitalization involve unintentional injuries. Motor vehicle crashes account for ap-
proximately one-half of the deaths from unintentional injuries. Deaths from falls rank
second, followed by deaths from poisoning, drowning, and residential fires. 17
At highest risk are the young and older adults. During the first four decades of life in-
juries account for more deaths than either chronic or infectious diseases, taking more than
2 million potential years of life from Americans every year. Males are more than twice
as likely to die from unintentional injuries than females, and blacks have higher death
rates than whites. 50
American Indian and Alaska Natives have disproportionately higher
injury death rates. 29
Injuries have been estimated to cost the United States more than $100 billion annually
due to lost productivity and medical care, with a third of these costs attributable to falls
and 28 percent to motor vehicle crashes. 79
About 46,000 people die and 3,500,000 people are injured annually in motor vehicle
crashes. By themselves, motor vehicle crashes rank as the fifth leading cause of death in
the United States, and approximately half of these are alcohol-related. Alcohol-related
traffic crashes are the leading cause of death and spinal cord injury for young
Americans.
58
Although use of automobile safety restraints has increased in recent years, only 42 per-
cent of people currently report using them. Increasing this share to 85 percent could save
about 10,000 lives per year. Given the fact that almost 30 percent of motor vehicle
fatalities are related to motorcycle, pedestrian, and bicycle causalities, increasing helmet
use could also prove of substantial benefit.59,60
Many injuries are multifactorial in nature. Alcohol use is a factor in numerous uninten-
tional injuries, including about half of all motor vehicle fatalities and a sizable share of
drownings. Of the 33,000 firearm-related deaths in 1987, nearly 3,400 were children
aged 1 to 19. Of these, about 15 percent were unintentional and often due to improper
handling, accessibility to children, and lack of safety mechanisms. Progress in reducing
unintentional injuries will require full participation of the fields of education, transporta-
tion, law, engineering, architecture, and safety sciences.
To reduce unintentional injuries, by the year 2000
9.1
Reduce unintentional injury deaths to no more than 29.3 per 100,000
people
(a 15% decrease)
9.12 Increase automobile safety restraint use to at least 85% of occupants
(a 102% increase)
Other objectives target death from motor vehicle crashes, falls, drownings, and
residential fires; occurrence of hip fractures, poisonings, head injuries, and spinal
cord injuries; use of protective helmets; extension of safety belt and motorcycle
helmet use laws; handgun design; expanded installation of fire sprinklers and smoke
detectors; better roadway design and markers; injury prevention instruction in
schools; and involvement of primary care providers in counseling on safety.
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5. Priorities for Health Promotion and Disease Prevention
Occupational Safety and Health
Approximately 110 million people make up the American workforce, with most spending
major portions of their days in their work environments. Of the estimated 10 million in-
juries that occur annually among workers, about 3 million are severe and include some
3,400 to 11,000 deaths. Although the number of fatal occupational injuries has gradually
declined in recent years, work-related illnesses and nonfatal injuries appear to be increas-
ing. During 1987, permanent impairments suffered on the job grew from 60,000 to
70,000, total disabling injuries numbered 1.8 million, and combined occupational ill-
nesses and injuries in the manufacturing industries increased by 12 percent.⁷
Approximately 40 percent of fatal injury victims were between 25 and 44 years old.
More than 20 percent of fatal occupational injuries in the mid-1980s involved highway
vehicles, which were the leading cause of death in seven of eight industry divisions.
Other causes included falls (13 percent), nonhighway industrial vehicular injuries (11 per-
cent), blows other than by vehicles or equipment (8 percent), and electrocutions (7 per-
cent). Other leading work-related problems include occupational lung diseases,
musculoskeletal injuries, and occupational cancers.⁷
Those occupations with relatively higher rates of injury include mining, agriculture, con-
struction, manufacturing, trucking, and warehousing. The largest numbers (as opposed to
rates) of injuries occur in industries with large total workforces such as eating and drink-
ing establishments, grocery stores, hospitals, trucking companies, nursing homes, depart-
ment stores, and hotels/motels. While employees in occupations related to these
enterprises comprise about one-fifth of the total workforce, they report one-fourth of the
injuries.⁷
Prevention of occupational health hazards rests on the basic principles of control technol-
ogy: engineering controls, work practices, personal protective equipment, and monitor-
ing of the workplace for emerging hazards. Despite the number of occupational injuries,
effective prevention is practiced in many workplaces, and approximately 48 percent of all
establishments report no injuries in a given year.
To improve occupational safety and health, by the year 2000
10.1 Reduce work-related injury deaths to no more than 4 per 100,000 workers
(a 33% decrease)
10.2 Reduce work-related injuries to no more than 6 per 100 workers
(a 22% decrease)
Other objectives target reductions in cumulative trauma disorders (e.g., from
repetitive motion, pressure, or noise), occupational skin disorders, and, among health
workers, hepatitis B infection; use of occupant protection systems by workers;
reducing workplace exposure to lead; State implementation of plans for identification
and control of major work-related illnesses and injuries; State standards to prevent
work-related lung disease; increasing worksites with formal plans for worker health
and safety; including back injury prevention programs; expanded State assistance to
small businesses in implementation of worker health and safety programs; and greater
attention by primary health care providers to occupational health exposures.
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Healthy People 2000
Environmental Health
Environmental Measures Have Long Been A Mainstay Of Public health. State and local
efforts to assure safe supplies of food and water, to manage sewage and municipal was-
tes, and to control or eliminate vector-borne illnesses have contributed substantially to
public health improvements in the United States. The most difficult challenges for en-
vironmental health today come from uncertainties about the toxic and ecologic effects of
the use of fossil fuels and synthetic chemicals in modern society. An estimated 82 per-
cent of major industrial chemicals have not been tested for their toxic properties and links
to specific diseases, and only a small proportion of chemicals have been adequately
tested for their ability to cause or promote cancer. 66 Still, enough is known to target im-
provement in several areas.
Exposure to lead, air pollutants, and radon are good examples. Exposure to high levels of
lead is toxic to the central nervous system and can be fatal. Even low levels of exposure
can result in persistent impairments in central nervous system function, especially in
children, including delayed learning, impaired hearing, and growth deficits. Yet an es-
timated 2 out of 3 poor inner-city black children aged 6 months through 5 years have
blood lead levels above 15 ug/dl and 1 out of 10 has levels above 25 ug/dl. For the Na-
tion as a whole, nearly 3 million children are at some risk from elevated lead levels. 1
Decreased levels of lead in gasoline, air, and food and releases from industrial sources
have resulted in lower mean blood lead levels. However, lead in paint, dust, and soil in
inner-city urban areas has been lowered only to a limited extent. A strong national effort
is needed to reduce lead in the home environment.
Airborne pollutants have been shown to contribute to lung diseases, bronchial asthma,
cancer, neural disorders, and eye irritation. 21 Standards have been set by the Environmen-
tal Protection Agency for ozone, carbon monoxide, particulates, sulfur dioxide, nitrogen
dioxide, and lead. Air quality has improved greatly since 1970, but in 1988 less than 50
percent of Americans lived in counties that met all the EPA standards for air quality for
the previous 12 months. 22 Additional measures are necessary to reduce contamination
from motor vehicles and other sources.
Radon comes from rock and soil, enters buildings through cracks in foundations or base-
ments, and when inhaled releases ionizing radiation that can damage lung tissue and lead
to lung cancer. Along with tobacco smoke, it is a leading indoor air hazard, and as many
as an estimated 8 million homes may have radon at a level requiring correction. 21 Low-
cost test kits are available to identify exposures, but only about 5 percent of homes have
been tested. 70
To improve environmental health, by the year 2000
11.4 Eliminate blood lead levels above 25 µg/dL in children under age 5
11.5 Increase protection from air pollutants so that at least 85% of people live
in counties that meet EPA standards
(a 72% increase)
11.6 Increase protection from radon so that at least 40% of people live in homes
tested by homeowners and found to be/made safe
(a 700% increase)
Other objectives target reducing infectious agent and chemical contamination of
drinking water supplies and surface water; reducing human exposure to toxic agents
released into the air, water, and soil; reducing environmental burden of solid waste
contamination; eliminating immediate risks from hazardous waste sites; improving
household management of recyclable materials and toxic waste materials; and better
State-based systems to track environmental exposures and diseases.
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5. Priorities for Health Promotion and Disease Prevention
Food and Drug Safety
American consumers currently benefit from extensive food and drug safety assurance sys-
tems. Microbial contamination of food in the production process is rare. Inspections of
foods for pesticide residues consistently find that between 96 and 98 percent of foods
tested do not contain pesticides in excess of legal limits-and those limits are typically
set with a wide margin for error, 100 to 1,000 times lower than a level causing toxic ef-
fects in animals. 23 Similarly, careful procedures are established to test new drugs and
each year FDA officials inspect one-third of 18,000 drug and biologics establishments in
the United States to ensure proper manufacture and handling.2⁴
Nevertheless, outbreaks of foodborne disease and incidents involving drugs continue to
occur and cause illness or death. Some problems are caused by failures in the protective
systems established at the Federal, State, and local levels. In many cases, problems are
caused by foods improperly handled by consumers, the misuse of a prescribed drug, and
drug interactions that occur when different health care providers unknowingly prescribe
different drugs for the same patient.9
Based on the number and severity of cases that occur, Salmonella, Campylobacter, Es-
cherichia coli, and Listeria are four of the most important foodborne pathogens in the
United States-largely related to time and temperature abuse of foods. One problem that
has increased markedly over the decade of the 1980s is illness due to infection with Sal-
monella enteritidis. This foodborne disease is often traced to contaminated eggs and
results in severe diarrhea, fever, vomiting, and can even cause death. The 77 outbreaks
occurring in 1989 involved nearly 2,400 cases and 14 deaths. 14 Expanded efforts are
needed both to reduce source exposure (e.g., sale of contaminated eggs) and to improve
food preparation and handling techniques that can protect against this problem.
The principal drug safety issue of the coming years is related to polypharmacy, the use of
multiple prescription and over-the-counter medications, especially by older people with
chronic health problems. This problem calls for a coordinated prevention approach, in-
volving care on the part of those who prescribe medications to ensure that they will not
adversely interact with previously prescribed drug regimens still in use; attentiveness on
the part of pharmacists to spot potential medication problems as their customers purchase
new prescription drugs; and education for consumers to help them comply with
prescribed pharmacologic therapies.
To ensure food and drug safety, by the year 2000
12.2 Reduce salmonella infection outbreaks to fewer than 25 yearly
(a 68% decrease)
Other objectives target reductions in the incidences of foodborne diseases; improving
food handling techniques on the part of consumers; better pharmacy-based systems to
provide alerts to customers of potential adverse drug interactions; and more regular
review by primary care providers of all medications used by their older patients.
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Healthy People 2000
Oral Health
Although the prevalence of dental caries or cavities among children has declined steadily
since the 1940s, oral diseases remain a prevalent health problem in the United States. On
average, among adults 40 through 44, about 1 out of 4 tooth surfaces have been affected
by decay. 64 Currently 53 percent of children aged 6 to 8 and 78 percent of 15 year olds
have caries. 65 Tooth loss is a major problem among people aged 65 and older, with near-
ly 40 percent of those aged 65 and older having no natural teeth in 1986. 52 Periodontal
diseases, especially gingivitis, also affects many adults. The total cost of dental care to
the Nation was more than $27 billion in 1988. 78
Regular care is a factor in maintaining oral health. However, nearly half the population
in the United States does not obtain regular oral health care, and among low-income
people the proportion not receiving care is higher. 52 The proportions of black and
Hispanic adolescents with untreated decay is approximately 65 percent higher than for
the total population. 55,65 One out of every four American Indians/Alaska Natives aged 35
to 44, and nearly three out of four age 55 and older, has fewer than 20 natural teeth.
Among preventive measures, community water fluoridation is the single most effective
and efficient means of preventing dental caries in children and adults, regardless of race
or income level. Yet more than one-third of people with community water systems do
not have adequate fluoride, and only about half of those without fluoridated water receive
fluoride from other sources. 10 Improvements are needed. Other factors that can improve
oral health include regular self-care, avoiding foods that promote caries, and not using
tobacco. Excessive alcohol consumption also may affect oral health.
Oral cancer is also a serious problem, with 30,000 new cases and 8,600 deaths a year. 68
In fact, oral cancer deaths are more numerous than deaths from cervical cancer. Because
75 percent of oral cancers can be attributed to tobacco and alcohol use, it is preventable.
Moreover, because early treatment can reduce mortality, attention is needed for its early
detection.
To improve oral health, by the year 2000
13.1 Reduce the incidence of dental caries to no more than 35% of children by
age 8
(a 44% decrease)
13.5 Reduce edentulism to no more than 20 percent in people aged 65 and older
(a 44% decrease)
Other objectives target expanding treatment of dental caries; reducing periodontal
disease and tooth loss; increasing use of protective sealants on permanent teeth in
children; improving parental practices that prevent baby bottle tooth decay; and
improving use of oral health screening and follow-up services for all age groups.
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5. Priorities for Health Promotion and Disease Prevention
Preventive Services
Maternal and Infant Health
Heart Disease and Stroke
Cancer
Diabetes and Chronic Disabling Conditions
HIV Infection
Sexually Transmitted Diseases
Immunization and Infectious Diseases
Clinical Preventive Services
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Healthy People 2000
Maternal and Infant Health
Of every 1,000 babies born in the United States each year, about 10 die before they reach
their first birthday. 68 Although the infant mortality rate in the United States is declining
and has reached an all-time low, the pace of progress has slowed. Mortality is also
higher for black infants, who die at twice the rate of white infants, and data from the Na-
tional Birth Cohort Study of 1983 indicate that other minorities may have higher rates
than had been estimated previously. Leading causes of deaths among infants are congeni-
tal anomalies, sudden infant death syndrome (SIDS), respiratory distress syndrome, and
disorders relating to short gestation.
The most prominent risk factor for infant death, low birth weight (less than 2,500 grams),
occurred among nearly 7 percent of all births in 1987 and was associated with more than
half of all infant deaths. Black babies have twice the risk of having low birth weight.
Low birth weight is also linked to a variety of nonfatal disorders, including neurodevelop-
mental conditions, learning and behavior problems, and lower respiratory tract infections.
In 1985, approximately 11,000 low-birth-weight infants were born with moderate to
severe disabilities. From 1970 to 1981 low birth weight declined about 1.3 percent per
year, but has since been stagnant.⁶⁸ A number of risk factors have been identified for low
birth weight, including: younger and older maternal age, high parity, poor reproductive
history (especially history of low birth weight), low socioeconomic status, low level of
education, late entry into prenatal care, low pregnancy weight gain, smoking, and other
substance abuse. 34 Smoking is estimated to be associated with from 20 to 30 percent of
all low-birth-weight births in this country.3 Illicit drug use as a contributor to low birth
weight has increased in some urban areas.
An expectant mother with no prenatal care is three times more likely to have a low-birth-
weight baby. Despite the importance of early prenatal care in protecting against low
birth weight and infant deaths, nearly one of every four pregnant women in the United
States received no care in the first trimester of her pregnancy. 68 A disproportionate share
of these mothers were low income, had less than a high school education, or were very
young. 84 Between 1970 and 1980 there was a significant trend toward increasing early
entry into prenatal care, but that trend has since plateaued. 68 Contributing to this problem
is the fact that an estimated 14 million women of reproductive age have no insurance to
cover maternity care.²
To improve maternal and infant health, by the year 2000
14.1 Reduce infant mortality to no more than 7 deaths per 1,000 births
(a 31% decrease)
14.5 Reduce low birth weight to no more than 5% of live births
(a 28% decrease)
14.11 Increase first trimester prenatal care to at least 90% of live births
(an 18% increase)
Other objectives target reducing rates of fetal death, maternal mortality, and fetal
alcohol syndrome; increasing abstinence from tobacco, alcohol, cocaine, and
marijuana during pregnancy; increasing the proportion of mothers who gain enough
weight during their pregnancies, as well as increasing the number who breastfeed
their babies; reducing severe complications of pregnancy and cesarean delivery rates;
increasing the availability of preconception care and counseling, as well as of genetic
services and counseling; improving the management of high risk cases; and
increasing the proportion of babies who receive the recommended primary care
services.
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5. Priorities for Health Promotion and Disease Prevention
Heart Disease and Stroke
Despite dramatic declines in mortality from heart disease and stroke in the past two
decades, about 7 million Americans have symptomatic coronary artery disease, and car-
diovascular diseases still cause more deaths in the United States than all other diseases
combined. 50 Reductions in major risk factors-high blood pressure, high blood
cholesterol, and smoking-are having a significant impact on cardiovascular mortality.
Approximately 30 percent of adults in America have high blood pressure. 56 People with
uncontrolled high blood pressure are at 3 to 4 times the risk of developing coronary heart
disease and as much as 7 times the risk of developing a stroke as do those with normal
blood pressures. 18 Overall, blacks have a higher prevalence of high blood pressure than
whites (38 percent versus 29 percent). 56 Although surveys indicate that 54 percent of
adults with high blood pressure are aware of their condition, only about a quarter to a
third have their blood pressure under control. 55 This remains a problem despite the fact
that many can reduce their blood pressure to normal through programs of physical ac-
tivity and weight loss, reduced sodium and alcohol intake, and stress management; and
medications are available for those who cannot.
The National Heart, Lung, and Blood Institute regards a blood cholesterol level below
200 mg/dL as desirable. 56 Yet the mean cholesterol level for Americans is 213 mg/dL, 53
and about 60 million adults in this country are estimated to have blood cholesterol levels
that place them at high risk for coronary heart disease. 82 The Coronary Primary Preven-
tion Trial showed that men at high risk were able to reduce coronary heart disease by
about 2 percent for every 1 percent lower blood cholesterol level. 39 Most people can
lower their high blood cholesterol by reducing their intake of saturated fat, total fat, and
dietary cholesterol, and by normalizing their weight and increasing physical activity.
Medications are available for those whose blood cholesterol levels remain significantly
elevated despite diet modification.
Tobacco use, which may account for as much as 40 percent of heart disease deaths
among people under age 65, is discussed elsewhere. Other contributors to cardiovascular
disease include obesity, physical inactivity, and diabetes mellitus.
To reduce heart disease and stroke, by the year 2000,
15.1 Reduce coronary heart disease deaths to no more than 100 per 100,000
people
(a 26% decrease)
15.2 Reduce stroke deaths to no more than 20 per 100,000 people
(a 34% decrease)
15.4 Increase control of high blood pressure to at least 50% of people with HBP
(a 108% increase)
15.6 Reduce blood cholesterol to an average of no more than 200 mg/dL
(a 6% decrease)
Other objectives target increasing awareness of their condition by those with high
blood cholesterol and high blood pressure; reducing dietary fat intake; reducing
overweight and increasing physical activity; reducing tobacco use; increasing
numbers of adults who have recently been screened for high blood pressure or high
blood cholesterol; better use of worksites for detection and followup programs; and
improving adherence to recommended protocols and standards for primary care
providers and laboratories involved in cholesterol testing and management.
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Healthy People 2000
Cancer
Cancer accounts for about one of every five deaths in the United States each year.³
About 75 million Americans now living, nearly one in three, will eventually have cancer.
While the incidence of cancer has increased in the past two decades, death rates for those
under 55 have fallen. 46 More people are surviving cancer now than several decades ago.
However not everyone has benefitted equally from this trend. Blacks are less likely than
whites to survive 5 years from the time of diagnosis. The five-year survival rate for all
cancer sites combined is 50 percent for white patients and 37 percent for black patients.
Once surrounded by fear and fatalism, cancer has been the focus of nationwide education-
al campaigns to inform the public that the risk of cancer can be significantly reduced
when adequate preventive measures are taken. Tobacco has been estimated to account
for 30 percent of cancers, and dietary factors another 35 percent.⁴⁷ For example, the lead-
ing cause of cancer deaths, lung cancer, can be prevented by not smoking, and
epidemiological research suggests that diets relatively low in fat and higher in foods con-
taining fiber may help prevent colon, rectal, breast, prostate, and other cancers. High
levels of alcohol use have been linked to esophageal and oral cancers. Limiting sun ex-
posure, use of sunscreens and protective clothing when exposed to sunlight, and
avoidance of sun lamps and tanning booths can reduce the risk of skin cancer.
Early detection also can have an important impact on cancer death rates. Procedures
such as mammography and clinical breast examination, the Pap test, sigmoidoscopy, and
oral, skin, and digital rectal examinations make it possible to treat cancers before they
spread. For example, research suggests than breast cancer deaths could be reduced by 30
percent among women aged 50 and older through the use of mammography and clinical
breast examination.
83,88,92 Yet in 1987 only 25 percent of such women had these tests
within the preceding 2 years. 52 A Pap test could reduce cervical cancer deaths by an es-
timated 75 percent, but one out of every five women with family incomes less than
$10,000 has never had a Pap test and relatively few have had the test within the most
recent 3 years. Despite the fact that fecal occult blood testing and sigmoidoscopy are im-
portant to facilitate early diagnosis of colorectal cancer, especially among those at high
risk, only 27 percent of people aged 50 and older report receiving a fecal occult blood
test within the preceding 2 years.
To prevent and control cancer, by the year 2000
16.1 Reverse the rise in cancer deaths no more than 130 per 100,000 people
16.11 Increase clinical breast exams and mammography every 2 years to at
least 60% of women aged 50 and older
(a 140% increase)
16.12 Increase Pap tests every 1-3 years to at least 85% of women aged 18 and
older
(a 13% increase)
16.13 Increase fecal occult blood testing every 1-2 years to at least 50% of
people aged 50 and older
(an 85% increase)
Other objectives target reducing dietary fat intake; increasing consumption of
vegetables, fruits, and grain products; reducing tobacco use; decreasing sun exposure;
more counseling by primary care providers on diet and tobacco use and offering of
screening procedures according to established protocols; and improving the quality of
Pap tests and mammograms.
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5. Priorities for Health Promotion and Disease Prevention
Diabetes and Chronic Disabling Conditions
As the population of the United States grows older, the problems posed by chronic and
disabling conditions increasingly demand the Nation's attention. Chronic conditions
such as heart disease, cancer, stroke, and lung and liver disease are joined in importance
by other chronic and disabling conditions, such as diabetes, arthritis, deformities or or-
thopedic impairments, hearing and speech impairments, and mental retardation.
Chronic and disabling conditions have a profound effect not only on mortality rates but
also on quality of life. Disability, defined by its impact on the kinds and level of ac-
tivities one is able to perform, affected more than 13 percent of Americans in 1988. 49
About 33 million people have functional limitations that interfere with their daily ac-
tivities, and more than 9 million have limitations that prevent them from working, attend-
ing school, or maintaining a household. The underlying conditions most often
responsible for these conditions are arthritis, heart disease, back conditions (including
spinal curvature), lower extremity problems, and intervertebral disk disorders. 36 For
those under aged 18 the most frequent causes of activity limitation are asthma, mental
retardation, mental illness, and hearing and speech impairments.
Diabetes is one of the most prevalent chronic conditions among Americans. Ap-
proximately 7 million people in the United States have been diagnosed with diabetes and
each year some 650,000 new cases are identified. In 1987, diabetes was the underlying
cause of death for more than 37,000 Americans and contributed to over 100,000 addition-
al deaths. In addition to death, diabetes is accountable for 30 percent of kidney failure
cases, is the second leading cause of blindness in aged 45 to 74, causes half of all non-
traumatic amputations, and causes a threefold increase in risk for congenital malforma-
tions and perinatal mortality among babies of diabetic mothers. Insulin-dependent
diabetes mellitus (IDDM, or Type I) is the most severe form, but comprises no more than
10 percent of all cases of diabetes. Noninsulin-dependent diabetes mellitus (NIDDM, or
Type II), while serious, has less severe consequences, usually appears after age 40, is
often associated with obesity, and may often be controlled by diet and exercise, some-
times in combination with oral hypoglycemic agents. Careful control of diabetes is criti-
cal to prevention of its complications. Diet and physical activity are important to the
management of both types of diabetes, and NIDDM can often be prevented through these
measures.
To reduce diabetes and chronic disabling conditions, by the year 2000,
17.2 Reduce disability from chronic conditions to no more than 8% of people
(a 15% decrease)
17.9 Reduce diabetes-related deaths to no more than 34 per 100,000 people
(an 11% decrease)
Other objectives target reducing reducing complications of diabetes; reducing
disability from asthma, chronic back conditions, osteoporosis, hearing impairment,
vision impairment, and mental retardation; increasing physical activity; reducing
overweight; improving early diagnosis and referral for disabling conditions among
the very young and older people; improving community and self-help resources for
people with chronic and disabling conditions; and improving employer policies
related to the needs of people with disabilities.
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75
Healthy People 2000
HIV Infection
The human immunodeficiency virus (HIV) epidemic is a multifaceted national and inter-
national problem. People with HIV infection can develop acquired immunodeficiency
syndrome (AIDS), including severe opportunistic infections, Kaposi's sarcoma, and mul-
tiple-system medical complications. Without treatment about 50 percent of people
develop AIDS within 10 years of becoming infected with HIV, and another 40 percent or
more develop other clinical illnesses associated with HIV infection. 28 By the end of
1989, reported cases of AIDS had reached 115,000 12 but the projected figure is expected
to more than triple or quadruple by the end of 1993. It has become the seventh leading
cause of potential years of life lost in the United States. 14 By the end of 1993, a projected
total of 390,000 to 480,000 cases of AIDS will have been diagnosed in the United States
and 285,000 to 340,000 people will have died from the disease. 14 Annual costs of AIDS
are projected to climb as high as $5 to $13 billion by 1992 42
An estimated 1 million people in the United States are infected with HIV and of these ap-
proximately 40,000 became infected in 1989. Groups at special risk have been identified
and include: intravenous drug abusers and their sex partners; people with large numbers
of sex partners; men who have sex with men, and their female partners; and people who
exchange sex for money or drugs. Of current AIDS patients, more than three-fourths are
male, and two-thirds are male homosexuals and bisexuals;¹² but the most rapid increases
are occurring among intravenous drug-abusers, women, and babies born to women in
high risk groups. An estimated 20 to 35 percent of infants of infected mothers develop
HIV infection. Approximately 60 percent of AIDS patients are white, 25 percent are
black, and 15 percent are Hispanic. 12
Although some therapeutic agents may extend survival, there is currently no available
treatment to prevent death among people with AIDS. The survival rate in the early 1980s
was only about 15 percent, before the licensure of antiviral drugs, such as zidovudine
(AZT). AZT has been shown to slow replication of the virus and improve survival
prospects, as have selected other agents now under study.
The development of a safe and effective HIV vaccine is a high priority for the coming
decade, although the prospects for the availability of such a vaccine are uncertain. Other
prevention and control strategies are vital to stopping the spread of HIV infection. Most
HIV-infected people in the United States do not know they harbor the virus, and in-
creased counseling, testing, and follow-up services are needed. Public education efforts
on risks and precautions are essential to slowing the spread of the disease.
To prevent and control HIV infection, by the year 2000
18.2 Confine HIV infection to no more than 800 per 100,000 people
Other objectives target reducing experience with sexual intercourse among
adolescents; increasing use of condoms among sexually active, unmarried people;
increasing outreach and access to treatment programs for intravenous drug abusers;
expanding testing and counseling for people at risk of HIV infection, including
improved skills among primary care providers; increasing education in schools and
colleges about HIV infection and its prevention; and extension of regulations to
protect workers at risk for occupational transmission of HIV.
76
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5. Priorities for Health Promotion and Disease Prevention
Sexually Transmitted Diseases
Sexually transmitted diseases affect almost 12 million Americans each year, 86 percent
of whom are aged 15 through 29.¹¹ About one-fifth of all young people, by the time they
reach 21, have needed treatment for a sexually transmitted disease. Because only some
teenagers are sexually active, this amounts to an effective rate of at least 25 percent
among those who are.⁹³ The sexually transmitted diseases encompass more than 50
recognized organisms and syndromes, including, in addition to syphilis and gonorrhea,
chlamydia trachomatis infections, genital herpes, hepatitis B, chancroid,
cytomegalovirus, and human immunodeficiency virus (HIV). After AIDS, the most
serious complications of sexually transmitted diseases are pelvic inflammatory disease
(PID), sterility, ectopic pregnancy, blindness, cancer associated with human papil-
lomavirus, fetal and infant death, birth defects, and mental retardation. The total societal
cost of sexually transmitted diseases exceeds $3.5 billion annually, with the cost of PID
and PID-associated ectopic pregnancy and infertility alone exceeding $2.6 billion.93
Gonorrhea is the most frequently reported communicable disease in the United States. In
1989, some 733,000 cases were reported and the incidence was an estimated 300 per
100,000 people. Youth, low-income, and minority populations are at particular risk. In
1989, adolescents aged 15 to 19 had an infection rate of 1,125 per 100,000 and blacks a
rate of 1,990 per 100,000. Despite the fact that since 1981, cases of gonorrhea in males
have declined 29 percent and declined 24 percent in females, the rates have not declined
among racial and ethnic minorities or among teenagers. Furthermore, the percent of all
gonorrhea organisms that are antibiotic-resistant grew from less than 1 percent in 1985 to
7 percent in 1989. 10
In 1989, nearly 45,000 cases of syphilis were also reported. Syphilis is the first sexually
transmitted disease for which control measures were developed and tested. Since the in-
itiation of Federal assistance for syphilis control in the 1940s, reported cases of all stages
of syphilis declined from an all-time high of 575,600 cases in 1943 to fewer than 68,000
cases in 1985. In recent years, however, the number of syphilis cases has increased
dramatically, due in part to an increase in the exchange of sex for drugs, to an increased
number of crack cocaine users, and to increased sexual activity among adolescents. Be-
tween 1986 and 1989, the number of reported syphilis cases increased over 55 percent, to
the highest level in the United States since the early 1950s. 10
To reduce sexually transmitted diseases, by the year 2000
19.1 Reduce gonorrhea infection to no more than 225 per 100,000 people
(a 25% decrease)
19.3 Reduce syphilis infection to no more than 10 per 100,000 people
(a 45% decrease)
Other objectives target reducing infections with chlamydia trachomatis, genital
herpes and genital warts, and hepatitis B; reducing occurrence of pelvic inflammatory
disease; increasing use of condoms among sexually active, unmarried people; fuller
availability of comprehensive sexually transmitted disease-related services in clinics
and centers that provide family planning, maternal and child health care, drug
treatment, and primary care to low income families; increasing partner tracing and
notification; improving primary care provider management of STD cases; and
inclusion of instruction on STD transmission and prevention as part of school health
education for middle and secondary school students.
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77
Healthy People 2000
Immunization and Infectious Diseases
The reduction in incidence of infectious diseases is the most significant public health
achievement of the past 100 years. This success is most notably embodied in the global
eradication of smallpox, achieved in 1977. Other gains in control of infectious diseases
are nearly as striking, however, including the virtual elimination of diphtheria and
poliomyelitis in the United States. Much of the progress made has been a result of im-
provements in basic hygiene, food production and food handling, and water treatment.
The development and use of antimicrobial drugs have reduced the morbidity and mor-
tality of a number of infectious diseases. The other major factor in reducing the toll from
infectious diseases has been the development and widespread use of vaccines, which are
among the safest and most effective measures for the prevention of infectious diseases.
Nevertheless, infectious diseases still cause many preventable illnesses and deaths. Flu
and pneumonia, for example, shorten the lives of many older adults despite the
availability of vaccines. Approximately 80 to 90 percent of all influenza-associated
deaths in the United States occur in people 65 years or older. 68 The childhood diseases,
although they have declined dramatically due to new vaccines, remain problems among
certain high-risk, under-immunized groups. Moreover, newly recognized diseases, such
as Legionnaire's disease, toxic shock syndrome, Lyme disease, and the many diseases as-
sociated with human immunodeficiency virus, have emerged as threats to public health.
The occurrence of measles in the United States is an example of an infectious disease
problem that ought to be readily controlled. A viral infection that in countries with poor
nutritional status and intense crowding may be associated with death rates in children of
5 percent or higher, measles is a disease for which a vaccine has been available since
1963. Use of that vaccine helped to reduce the number of reported measles cases in this
country to an all-time-low of under 1,500 in 1983. However, due to inadequate im-
munization of low income preschool children, as well as of young people, the disease has
had something of a resurgence, with over 16,000 cases reported in 1989, including 41
deaths. 41 In response, the measles immunization protocol recommended by the Im-
munization Practices Advisory Committee has called for a two-dose schedule of measles
vaccine, but effective control will also require better outreach in low income com-
munities, strong enforcement of school entry laws, and efficient identification and inter-
vention in disease outbreaks.
To increase immunization and prevent infectious diseases, by the year 2000
20.1 Eliminate measles
20.2 Reduce epidemic-related pneumonia and influenza deaths to no more than
7.3 per 100,000 people aged 65 and older
(a 20% decrease)
20.11 Increase childhood immunization levels to at least 90% of 2 year-olds
(a 20% increase)
Other objectives target eliminating diphtheria, tetanus, polio, and rubella; reducing
viral hepatitis, tuberculosis, bacterial meningitis; reducing infectious diarrhea among
children in licensed child care centers; reducing middle ear infections; increasing
immunization levels for pneumococcal pneumonia and hepatitis B; expanding
immunization laws for schools, preschools, and day care settings; eliminating
financial barriers to immunizations; full involvement of primary care providers in
meeting the immunization needs of their patients; and expanding laboratory
capabilities for rapid viral diagnosis of influenza.
78
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5. Priorities for Health Promotion and Disease Prevention
Clinical Preventive Services
Clinical preventive services refer to those disease prevention and health promotion ser-
vices-immunizations, screening, and counseling-delivered to individuals in a health
care setting. The effectiveness of preventive services in reducing disease, disability, and
premature death is now well documented. The dramatic declines observed for childhood
infectious diseases and early death from strokes and cervical cancer are largely attributed
to the widespread application of three preventive services: childhood immunizations,
high blood pressure detection and control, and Pap tests. Several other preventive ser-
vices, such as screening mammography, have also been shown to be effective. In 1989,
the U.S. Preventive Services Task Force reported on its review of the scientific evidence
on 169 clinical preventive services for 60 target conditions. Based on well-established
criteria, it published in the Guide to Clinical Preventive Services⁹¹ its recommendations
on the basic services that should be provided.
Despite their proven effectiveness, clinical preventive services are rarely covered under
health insurance or delivered as recommended. The few studies that have examined the
receipt of clinical preventive services have found the delivery to be less than optimal.
For example, although 93 percent of newborns studied had received at least one well-
child examination, less than half had received three or more doses of diphtheria-pertussis-
tetanus (DPT) vaccine and three or more doses of polio vaccine by age 18 months. 40 The
National Health Interview Survey found an increase in the use of eight routine preventive
services among adults and children between 1973 and 1982, but low-income people,
people with low levels of education, and people of Hispanic origin were among the least
likely to have ever received all eight procedures. 19 A related study found that only 42
percent of women had adequately received a blood pressure check, clinical breast ex-
amination, Pap test, and glaucoma screening.⁹⁴ Screening was less adequate among the
poor, the less educated, and those living in rural areas, with only 33, 34, and 38 percent,
respectively, screened for all four conditions.
Barriers specific to the delivery or use of preventive services include uncertainty among
health care providers about which services to offer, practice organization characteristics
that are not conducive to delivery of preventive services (e.g., lack of time, too few allied
health professionals, and limited access to medical record systems organized for preven-
tion), and inadequate knowledge among consumers to create the necessary demand.
Another important barrier is the lack of reimbursement or financing. In addition to the
fact that few insurance plans cover preventive services, a substantial proportion of
Americans-some 30 to 37 million-are without any form of health insurance. And
many more are underinsured or are covered by insurance programs with requirements
and payments that providers are increasingly reluctant to accept.
To expand access and use of clinical preventive services, by the year 2000
21.4 Eliminate financial barriers to clinical preventive services
Other objectives target increasing the proportion of people with a specific source of
primary care; increasing the number of people who receive recommended clinical
preventive services; increasing delivery of preventive services to patients of publicly
funded providers of primary care; increasing focus by primary care providers on the
delivery of recommended preventive services; and increasing representation of
minorities among primary care providers.
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79
Healthy People 2000
Surveillance and Data Systems
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5. Priorities for Health Promotion and Disease Prevention
Surveillance and Data Systems
Systematically collecting, analyzing, interpreting, disseminating, and using health data is
essential to understanding the health status of a population and to planning effective
prevention programs. Public health surveillance and data systems collect information on
morbidity, mortality, disability, injuries, risk factors, services, and costs. Systems used in
the United States include vital statistics and disease reporting systems as well as sample
surveys, such as the continuous National Health Interview Survey (NHIS).
Although the United States Public Health Service takes the lead role in national public
health data collection, it is only one partner within the larger structure necessary to col-
lect national public health data. Surveillance often requires active cooperation among
Federal, State, and local agencies. For example, the National Vital Statistics System ob-
tains information on births, deaths, marriages, and divorces from all 50 States, New York
City, the District of Columbia, Puerto Rico, the United States Virgin Islands, and Guam.
Programs in each State collect vital information from many sources in local communities,
including funeral directors, medical examiners, coroners, hospitals, religious authorities,
and justices of the peace. Other surveys, like the National Health Interview Survey, are
based on interviews with thousands of individual citizens nationwide. Still others, like
the Centers for Disease Control's Behavioral Risk Factor Surveillance System, are based
on State reports of telephone interviews with individual citizens.
The Institute of Medicine's report, The Future of Public Health, recognized the impor-
tance of surveillance and data system for guiding public health into the 21st century, in
recommending the creation and use of methods for the collection of national data that
will permit comparison of local and State health data with those of the Nation and of
other States and localities and that will facilitate progress towards the national health ob-
jectives.
,,30
A set of indicators and methods, arrived at through a consensus process,
would facilitate comparability of data on health status within and among State and local
areas and would permit the valid comparison of local and State health data with national
data. Further, the use of a minimum set of indicators would facilitate communication
among public health officials and with others involved in programs and activities that af-
fect the Nation's health (e.g., employers and school administrators). Though complete
comparability across data systems is not possible given the differences in purposes and
approaches (e.g., direct interviews V. telephone V. mail), differences can be minimized.
To improve surveillance and data systems, by the year 2000.
22.1 Develop and implement common health status indicators for use by
Federal/State/local health agencies
Other objectives target creation of data sources to track the year 2000 objectives;
expanded State-based activity to track the progress of the population toward the year
2000 objectives; improvement of related data for blacks, Hispanics, American Indians
and Alaska Natives, Asian Americans, and people with disabilities; improvement of
information transfer capabilities among Federal, State, and local agencies; and more
speedy processing of survey and surveillance data.
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81
Healthy People 2000
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tsville, Maryland.
Adults. National Cholesterol Education Pro-
gram. Bethesda, MD: U.S. Department of
69 Office of Disease Prevention and Health
Health and Human Services, 1988.
Promotion. National Survey of Worksite Health
Promotion Activities: A Summary.
58 National Highway Traffic Safety Administra-
Washington, DC: U.S. Department of Health
tion. The Economic Cost to Society of Motor
and Human Services, 1987.
Vehicle Accidents. Technical Report DOT HS
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Office of Radiation Programs, U.S. Environ-
ment of Transportation, 1987.
mental Protection Agency, Washington, DC.
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National Highway Traffic Administration. The
Office on Smoking and Health. Reducing the
Effectiveness of Motorcycle Helmets in Prevent-
Health Consequences of Smoking: 25 Years of
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Progress. A Report of the Surgeon General.
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DHHS Publication No. (CDC)89-8411.
Transportation, 1989.
Washington, DC: U.S. Department of Health
and Human Services, 1989.
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tion. Motorcycle Accident Cause Factors and
72 Paffenbarger, R.S.; Hyde, R.T.; Wing, A.L.; and
Identification of Countermeasures. Technical
Hsieh, C.C. Physical activity, all-cause mor-
Report DOT HS 805-862. Washington, DC:
tality, and longevity of college alumni. New
U.S. Department of Transportation, 1981.
England Journal of Medicine 314:605-613, 1986.
61
National Household Survey of Drug Abuse,
73 Paffenbarger, R.S.; Wing, A.L.; and Hyde, R.T.
National Institute on Drug abuse, Alcohol,
Physical activity as an index of heart attack
Drug Abuse, and Mental Health Administra-
risk in college alumni. American Journal of
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Epidemiology 108:161-175, 1978.
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Epidemiologic perspectives on drunk driv-
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coholism. Seventh Special Report to the U.S.
Driving: Background Papers. Washington,
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75 Powell, K.E.; Caspersen, C.J.; Koplan, J.P.; and
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National Institute on Alcohol Abuse and Al-
Ford, E.S. Physical activity and chronic dis-
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gress on Alcohol and Health. Washington, DC:
49:999-1006, 1989.
U.S. Department of Health and Human Ser-
vices, 1987.
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5. Priorities for Health Promotion and Disease Prevention
76
Powell, K.E.; Thompson, P.D.; Caspersen, C.J.;
85
Sonnenstein, F.L.; Pleck, J.H.; Ku, L.C. Sexual
and Kendrick, J.S. Physical activity and the
activity, condom use, and AIDS awareness
incidence of coronary heart disease. Annual
among adolescent males. Family Planning
Review of Public Health 8:253-287, 1987.
Perspectives 21(4):152-158, 1989.
77 Public Health Service. The Surgeon General's
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Study of the National Incidence of Child
Report on Nutrition and Health. DHHS Pub.
Abuse and Neglect, National Center on Child
No. (PHS)88-50210. Washington, DC: U.S.
Abuse and Neglect, Administration for
Department of Health and Human Services,
Children, Youth, and Families, Office of
1988.
Human Development Services, DHHS,
78 Reisine, S., and Miller, J. A longitudinal study
Washington, DC.
of work loss related to dental diseases. Social
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Surveillance, Epidemiology, and End Results
Science and Medicine 21(12):1309-1314, 1985.
Program, 1987. National Cancer Institute,
79
National Institutes of Health, Public Health
Rice, D.P.; MacKenzie, E.J.; Jones, A.S.; Kauf-
Service, U.S. Department of Health and
man, S.R.; deLissovoy, G.V.; Max, W.; Mc-
Human Services, Bethesda, MD.
Loughlin, E.; Miller, T.R.; Robertson, L.S.;
Salkever, D.S.; and Smith, G.S. Cost of Injury
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in the United States: A Report to Congress,
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Wood, P.D.; and Vranizan, K.M. Moderate-
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Tanfer, K., and Horn, M.C. Contraceptive use,
intensity physical activity and cardiovascular
pregnancy, and fertility patterns among
risk factors: The Stanford five-city project.
single American women in their 20s. Family
Preventive Medicine 15:561-568, 1986.
Planning Perspectives 17(1):10-19, 1985.
81 Salonen, J.T.; Puska, P.; and Tuomilehto, J.
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Physical activity and risk of myocardial in-
Department of Health and Human Services.
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Dietary Guidelines for Americans. Washington,
gitudinal study in Eastern Finland. American
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Journal of Epidemiology 115:526-537, 1982.
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N.E. Reduction of breast cancer mortality
Selection, Followup, and Analysis in the
through mass screening with modern mam-
Health Insurance Plan Study: A Randomized
mography: First results of the Nijmegan
Trial With Breast Cancer Screening. National
Project, 1975-1981. Lancet 1:1222-1224, 1984.
Cancer Institute Monographs 67:65-74, 1985.
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Washington, A.E.; Arno, P.S.; and Brooks,
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Singh, S.; Torres, D.; and Forrest, J.D. The need
M.A. The economic costs of pelvic inflam-
for prenatal care in the United States:
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Evidence from the 1980 national natality sur-
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Woolhandler, S., and Himmelstein, D.U.
1985.
Reverse targeting of preventive care due to
lack of health insurance. JAMA 259:2872-
2874, 1988.
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6. Shared Responsibilities
The challenge set out through Healthy People 2000 is one directed to people throughout
the Nation. Each of us, whether acting as an individual, an employee or employer, a
member of a family, community group, professional organization, or government agency,
has both an opportunity and an obligation to contribute to the effort to improve the
Nation's health profile. To arrive at the established goals and objectives, we must chart a
common course that depends upon commitment and action from every level of our
society. Then, together, the challenge can be met.
Personal Responsibility
The individual is both the starting point and the ultimate target of the campaign towards
Healthy People 2000. Through the many roles that each of us fulfills in our daily lives,
we are afforded numerous opportunities for promoting health and preventing disease.
With these opportunities, though, comes responsibility, and the first role we must all un-
dertake is responsibility for our own personal health habits. Improving personal health
behavior can count among the most potent means to prevent disease and promote health.
Measurable decreases in risks to health can result from changes in diet, exercise, tobacco
use, alcohol and other drug use, injury prevention behavior, and sexual habits, but each of
us must choose to make these changes a personal priority.
Our worksites can provide a smoking cessation program and a fitness center, for ex-
ample, but we have to enroll. Fast food chains can offer salads, but we have to choose
them. Legislators can mandate food labeling, but we must care enough to read the labels.
Our health care providers can provide the necessary screening tests and immunizations,
but we must take the initiative to obtain them.
While the responsibility for change lies with each of us, it also lies with all of us, and in-
dividuals cannot be expected to act alone.
The Family
The family is the primary context in which health promoting activities occur and is there-
fore potentially the most immediate source of health-related support and education for the
individual. It is in the context of the family that attitudes and behaviors regarding diet,
physical activity, hygiene, smoking, and alcohol and other drug use are often learned and
maintained. Therefore, the family offers the primary opportunity for change in these
areas. Parents can teach children healthy habits and offer the supportive environment
necessary to sustain them. In addition, parents can ensure that their children receive
needed preventive services-immunizations, screening tests, as well as counseling and
education about health risks and behaviors.
Although the family plays a key role in meeting the challenge of Healthy People 2000,
the family also should not be expected to assume these responsibilities in isolation.
Families need and deserve the support of their communities in achieving and maintaining
standards of good health. When families experience stresses that can result in self-
destruction through abuse, neglect, and addiction, the community's responsibility be-
comes increasingly urgent. Single-parent homes, children in poverty, and an aging
society are all factors that threaten the family's viability. As the burdens of a family in-
crease, its very spirit is threatened and the need for community support becomes still
more crucial, not only to the well-being of its members but also to its survival.
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Healthy People 2000
Community
In today's society, a supportive community can make a vital difference in the well-being
of its members. Accordingly, there is evidence that community-based health programs
can play a strong role in improving the health status of their citizens. Multiple oppor-
tunities exist for community health promotion efforts on the part of government, volun-
tary and self-help groups, businesses, and schools. Such local community programs can
often deliver services more efficiently than centralized programs managed far from the
point of delivery. Furthermore, indigenous programs maintain the sensitivity to family
and neighborhood values that is vital to encourage change successfully towards healthier
lifestyles within the community.
Local health officials can contribute to the challenge of Healthy People 2000 by work-
ing to ensure that health department clinics provide appropriate preventive and health
promotion services for the people they serve-in addition to their historic roles of provid-
ing and monitoring traditional community health services related to public sanitation,
clean water, and water fluoridation. Local governments can form partnerships with
grassroots organizations, such as neighborhood associations and tenant councils, in a
cooperative effort to reach specific populations on topics of special local concern.
Voluntary organizations have long worked to improve health through research, public
education, and other program activities. In fact, the spirit of volunteerism is the essence
of our national traditions. Groups that have not traditionally been involved in reducing
health risks should now begin to define their role in community health education. For ex-
ample, local organizations serving their youth can collaborate on alcohol and other drug
abuse-reduction programs or on discouraging the use of tobacco. Groups representing
special populations-people with disabilities, racial and ethnic minorities, older people-
can work together to achieve needed changes both within their memberships and in the
community at large.
Business, community leaders, and labor can work together for mutual benefit to en-
hance the well-being of employees and the community. Management, unions, and
employee groups can sponsor wellness and employee assistance programs; coverage for
effective preventive services can be sought in contract negotiations; and employees can
work to make community health promotion services available at the worksite for themsel-
ves, their dependents, and retirees. Many important disease prevention and health promo-
tion activities, such as smoking cessation, diet modification, and physical conditioning,
can be accomplished at the worksite in an effective and efficient manner. Company
policies can help create a healthy work and living environment and contribute to the ecol-
ogy of the communities in which they are based. From enforcing safety procedures, to
mandating smoke-free workplaces, to ensuring that healthful food choices are available
in employee cafeterias, employers have multiple opportunities to improve the health
prospects of their employees. Companies also have a responsibility to contribute to the
community leadership in maintaining a healthy environment through responsible waste
disposal policies.
Schools have a special role in enhancing and maintaining the health of their community's
children, since roughly one-quarter of a young person's time is spent in this environment.
School health education can foster healthful behaviors and help prevent hazardous ones,
particularly in the areas of physical fitness, smoking, and nutrition. Standard course cur-
ricula can be modified to include health promotion, as, for example, through the addition
of environmental health components to science classes. Provision of healthy meals, safe
work and play areas, and physical education courses that stress the acquisition of lifetime
exercise habits can be instituted as well to foster the long-term health of our youth. In
partnership with parents and other community groups, schools can help to create health
promotion programs and enhance health education curricula. Schools can, in addition,
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6. Shared Responsibilities
open their facilities and health curricula to the adults of the community, thereby serving
as an even greater local resource.
Churches and other religious institutions may also offer important resources for enhanc-
ing access to health promotion and disease prevention services, especially for populations
that may otherwise be difficult to reach. Churches are often strong in the same com-
munities where the health care system is weak and overburdened. In poor black com-
munities, for example, the church has met not only the spiritual but also the educational,
physical, and social needs of its members and their families and friends. Increasingly,
religious institutions are sponsoring health fairs and establishing blood pressure educa-
tion, screening, and control programs. They offer individual and family counseling and
are often involved in adolescent pregnancy prevention efforts. These are important con-
tributions.
Health Professionals
Responsibility also falls to physicians and other health care providers, who are for many
Americans the primary sources of health information. Their professional training gives
them the skill to translate science into practice. Practice can take the form of partnerships
with nonprofessionals in the pursuit of individual, family, and community health care.
The effectiveness and efficiency of preventive services-screening tests, immunizations,
and counseling-will be enhanced by such partnerships.
Health education and counseling, in particular, provide opportunities for interdisciplinary
consulting among educators, administrators, social workers, health and other profes-
sionals in order to integrate healthy practices into the daily lives of individuals, their
families, and communities. Professional associations can facilitate dissemination of the
health promotion and disease prevention knowledge base through their established infor-
mation exchange and professional education networks. A special opportunity and respon-
sibility exists for the teachers of health professionals to select students, design curricula,
and allocate educational resources which will equip the profession with prevention exper-
tise and with the skills to share their knowledge with the public.
America's physicians, dentists, nurses, pharmacists, medical technicians and other health
professionals must be not only knowledgeable in the basic and clinical sciences; they also
must be life-long learners, excellent communicators, good team players, managers of
scarce resources, health care visionaries, and community leaders. The day of the solo
practitioner, dealing with the patient in isolation from other professionals is past.
Media
The day of the print and electronic media is, however, very much here, and these media
can contribute to the exchange of health information between health professionals and
the public, as well as among health professionals themselves. The average American is
exposed to many different kinds of health-related messages, some explicit in news, public
affairs, and documentaries, and some buried in the plots and characters seen in entertain-
ment programs through the mass media. In partnerships with the media, voluntary and
professional organizations can expand the reach of their programs while performing an
important service to the community.
Partnerships can also be created between community groups and the increasing number
of cable television stations, radio stations, and regional magazines that are aimed at very
specific audiences and therefore have a unique opportunity to tailor their messages direct-
ly to the target audience. New opportunities will also unfold through the evolving in-
tegration of telecommunications media-telephone, television, computer-to make cus-
tomized health information more accessible than ever before.
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Healthy People 2000
Government
Policy decisions are made regularly that can assist health professionals and the public in
reaching our national health goals. These decisions range from health care legislation to
legislation that bears on the environment, business, farming, production, energy, housing,
information dissemination, education, and the economy. The health interests of
Americans are directly and indirectly shaped by such policy decisions. Local, State, and
Federal governments can ensure that health promotion and disease prevention activities
receive adequate attention and support. The accomplishment of this task can be effective-
ly bridged through partnerships with each other and with the private sector.
With the increasing decentralization of government health services, the States have taken
on new roles as conveners, fostering alliances and common interests among many poten-
tial participants in disease prevention and health promotion activities. These alliances
can occur both horizontally, among statewide organizations, and vertically, among com-
munity, State, and national groups. Particularly important is their role in maintaining sur-
veillance systems on the occurrence of disease, exposure to risks, and delivery of ser-
vices. They are in this respect the keepers of the tools most important to charting our
progress.
The Federal Government supports basic biomedical research on disease prevention and
sponsors demonstration projects to help identify effective health promotion strategies. It
provides financial support for many State and local government initiatives in health
promotion and disease prevention, and directly serves some of the population groups
most in need. On issues of particular prominence, it sponsors the development of nation-
al educational campaigns and the formation of coalitions for action. In order to address
public health issues that are in flux with changing social, behavioral, and economic en-
vironments, sustained Federal leadership is necessary to improve the health of the
American people.
Healthy People: The Vision
Clearly, to meet the challenge of the Healthy People 2000 goals and objectives, we must
work both individually and collectively. Alone, no one person, family, business, or-
ganization, or government has the resources to bring about the changes needed to imple-
ment this broad program, and yet the program cannot succeed unless each of us con-
tributes individually. In essence, Healthy People 2000 offers hope that through coopera-
tive efforts all Americans can live longer, healthier lives.
There are existing examples of cooperative programs which, if replicated, could propel us
toward our health goals for the year 2000. Promising efforts are emerging in programs
that have taken deep roots in neighborhoods across America and focus upon the early
developmental needs of children. In many areas, these programs are the chief, if not the
only, agents of family and community. Through these efforts, parents can both receive
support and become active participants and leaders within the community. Where such
programs are successful, they demonstrate that by working together-by mobilizing
families, neighborhoods, schools, businesses, churches, the media, and government-we
can make great strides toward helping Americans become healthier, more productive, and
more fulfilled.
Thus, the final message of this report is one of shared responsibility-among the many
partners in prevention, but most importantly among ourselves individually. It is what we
do, the steps that we take not only collectively, but personally, that will move us as in-
dividuals and as a Nation towards a healthier future.
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Appendices
Contents
A. Healthy People 2000
Consortium
B.
Priority Area Lead
Agencies
A. Healthy People 2000 Consortium
National Organizations
Academy of General Dentistry
American College of Health Care
Aerobics and Fitness Association of
Administrators
America
American College of Healthcare Executives
Alcohol and Drug Problems Association of
American College of Nurse-Midwives
North America
American College of Nutrition
Alliance for Aging Research
American College of Occupational Medicine
Alliance for Health
American College of Physicians
Amateur Athletic Union
American College of Preventive Medicine
American Academy of Child and
American College of Radiology
Adolescent Psychiatry
American College of Sports Medicine
American Academy of Ophthalmology
American Council on Alcoholism, Inc.
American Academy of Orthopaedic
American Dental Association
Surgeons
American Dental Hygienists' Association
American Academy of Pediatric Dentistry
American Diabetes Association, Inc.
American Academy of Pediatrics
American Federation of Teachers
American Alliance for Health, Physical
American Heart Association
Education, Recreation, and Dance
American Home Economics Association
American Association for Clinical
Chemistry
American Hospital Association
American Association for Dental Research
American Indian Health Care Association
American Association for Marriage and
American Institute for Preventive Medicine
Family Therapy
American Institute of Nutrition
American Association for Respiratory Care
American Kinesiotherapy Association
American Association for the Advancement
American Lung Association
of Science
American Meat Institute
American Association of Certified
American Medical Association
Orthoptists
American Medical Student Association
American Association of Colleges of
American Nurses' Association, Inc.
Pharmacy
American Nutritionists Association
American Association of Dental Schools
American Optometric Association
American Association of Homes for the
American Orthopaedic Society for Sports
Aging
Medicine
American Association of Occupational
American Osteopathic Academy of Sports
Health Nurses
Medicine
American Association of Pathologists'
American Osteopathic Association
Assistants
American Association of Public Health
American Osteopathic Hospital Association
Dentistry
American Pharmaceutical Association
American Association of Public Health
American Physical Therapy Association
Physicians
American Podiatric Medical Association
American Association of Retired Persons
American Psychiatric Association
American Association of School
American Psychiatric Nurses Association
Administrators
American Psychological Association
American Association of Suicidology
American Public Health Association
American Association of University
American Red Cross
Affiliated Programs
American Rehabilitation Counseling
American Association on Mental
Association
Retardation
American School Food Service Association
American Cancer Society
American School Health Association
American College of Cardiology
American Social Health Association
American College of Clinical Pharmacy
American Society for Microbiology
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Healthy People 2000
American Society for Parenteral and Enteral
Association of Teachers of Preventive
Nutrition
Medicine
American Society of Acupuncture
Association of Technical Personnel in
American Society of Addiction Medicine
Ophthalmology
American Society of Allied Health
Black Congress on Health, Law, and
Professions
Economics
American Society of Hospital Pharmacists
Blue Cross and Blue Shield Association
American Society of Human Genetics
Boys Scouts of America
American Society of Ocularists
Camp Fire, Inc.
American Society for Psycoprophylaxis in
Cardiovascular Credentialing International
Obstetrics
Children's National Medical Center
American Speech-Language-Hearing
College of American Pathologists
Association
Council for Responsible Nutrition
American Spinal Injury Association
Council of Medical Specialty Societies
American Statistical Association
Dairy and Food Nutrition Council of the
American Thoracic Society
Southeast
Arthritis Foundation
Emergency Nurses Association
Asian American Health Forum, Inc.
Eye Bank Association of America
Association for Applied Psychophysiology
Federation of American Societies for
and Biofeedback
Experimental Biology
Association for Fitness in Business
Federation of Nurses and Health
Association for Hospital Medical Education
Professionals
Association for Practitioners in Infection
Food Marketing Institute
Control
Future Homemakers of America
Association for Retarded Citizens of the U.S.
Girl Scouts of the United States of America
Association for the Advancement of
Great Lakes Association of Clinical
Automotive Medicine
Medicine, Inc.
Association for the Advancement of Health
Grocery Manufacturers of America, Inc.
Education
Group Health Association of America, Inc.
Association for Vital Records and Health
Health Industry Manufacturers Association
Statistics
Health Insurance Association of America
Association of Academic Health Centers
Highway Users Federation for Safety and
Association of American Indian Physicians,
Mobility
Inc.
Institute of Food Technologists
Association of American Medical Colleges
International Association for Enterostomal
Association of Clinical Scientists
Therapy, Inc.
Association of Community Health Nursing
International Lactation Consultant
Educators
Association
Association of Food and Drug Officials
International Patient Education Council
Association of Maternal and Child Health
La Leche League International
Programs
Learning Disabilities Association of
Association of Pediatric Oncology Nurses
America
Association of Rehabilitation Nurses
March of Dimes Birth Defects Foundation
Association of Schools of Public Health
Maternal and Child Health Network
Association of State and Territorial
Maternity Center Association
Directors of Nursing
Midwives' Alliance of North America
Association of State and Territorial
Migrant Clinicians Network
Directors of Public Health Education
Mothers Against Drunk Driving
Association of State and Territorial Health
Officials
NAACOG-The Association of Obstetric,
Gynecologic, and Neonatal Nurses
Association of State and Territorial Public
Health Laboratory Directors
NARD-formerly National Association of
Retail Druggists
Association of State and Territorial Public
National AIDS Network
Health Nutrition Directors
National Alliance of Black School Educators
Association of State and Territorial Public
Health Social Work
National Association for Hispanic Elderly
National Association for Home Care
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A. Healthy People 2000 Consortium
National Association for Human
National Extension Homemakers Council,
Development
Inc.
National Association for Music Therapy
National Family Planning and Reproductive
National Association for Sport and Physical
Health Association, Inc.
Education
National Federation of State High School
National Association of Biology Teachers
Associations
National Association of Childbearing
National Food Processors Association
Centers
National Head Injury Foundation, Inc.
National Association of Community Health
National Health Council, Inc.
Centers, Inc.
National Health Lawyers Association
National Association of Counties
National Hearing Aid Society
National Association of County Health
National Institute for Fitness and Sport
Officials
National Kidney Foundation
National Association of Elementary School
National League for Nursing
Principals
National Lesbian and Gay Health
National Association of Governors Council
Foundation, Inc.
on Physical Fitness and Sports
National Medical Association
National Association of Neonatal Nurses
National Mental Health Association
National Association of Optometrists and
National Museum of Health and Medicine
Opticians, Inc.
National Association of Pediatric Nurse
National Nurses Society on Addictions
Associates and Practitioner
National Organization for Women
National Association of RSVP Directors
National Organization on Adolescent
National Association of School Nurses, Inc.
Pregnancy and Parenting, Inc.
National Association of Social Workers, Inc.
National Osteoporosis Foundation
National Pest Control Association, Inc.
National Association of State Alcohol and
Drug Abuse Directors
National Pressure Ulcer Advisory Panel
National Association of State Boards of
National Recreation and Park Association
Education
National Safety Council
National Association of State NET Program
National School Boards Association
Coordinators
National Society of Allied Health
National Black Nurses' Association, Inc.
National Society to Prevent Blindness
National Board of Medical Examiners
National Strength and Conditioning
National Center for Health Education
Association
National Coalition of Hispanic Health and
National Stroke Association
Human Services Organization
National Wellness Institute, Inc.
National Commission Against Drunk
National Women's Health Network
Driving
NEA Health Information Network
National Committee for Adoption
Nursing Network on Violence Against
National Committee for Prevention of Child
Women
Abuse
Oncology Nursing Society
National Conference of State Legislatures
Paralyzed Veterans of America
National Consumers League
People's Medical Society
National Council for International Health
Pharmaceutical Manufacturers Association
National Council for the Education of
Planned Parenthood Federation of America,
Health Professionals in Health Promotion
Inc.
National Council on Alcoholism and Drug
Population Association of America
Dependence
Produce Marketing Association, Inc.
National Council on Disability
Salt Institute
National Council on Health Laboratory
Services
Society for Nutrition Education
National Council on Patient Information and
Society for Public Health Education, Inc.
Education
South Cove Community Health Center
National Council on Self-Help and Public
State Family Planning Administrators
Health
The American Academy of Family
National Dairy Council
Physicians
National Environmental Health Association
The American Art Therapy Association, Inc.
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Healthy People 2000
The American College Health Association
The National Council on the Aging, Inc.
The American College of Obstetricians and
The National PTA
Gynecologists
The Salvation Army
The American Dietetic Association
The Society of Behavioral Medicine
The American Geriatrics Society
The Society of Hospital Epidemiologists of
The American Occupational Therapy
America
Association, Inc.
The Society of Prospective Medicine
The American Physiological Society
The Society of State Directors of Health,
The American Society for Clinical Nutrition
Physical Education, and Recreation
The Association of State and Territorial
The United States Conference of Mayors
Dental Directors
United States Chamber of Commerce
The Business Roundtable
United Way of America
The Catholic Health Association of the
Visiting Nurse Associations of America
United States
Voluntary Hospitals of America, Inc.
The Gerontological Society of America
Washington Business Group on Health
The National Alliance for the Mentally Ill
Wellness Councils of America-WELCOA
The National Alliance of Nurse Practitioners
Western Consortium for Public Health
The National Association of Secondary
Women's Sports Foundation
School Principals
State and Territorial Health Departments
Alabama
Missouri
Alaska
Montana
American Samoa
Nebraska
Arizona
Nevada
Arkansas
New Hampshire
California
New Jersey
Colorado
New Mexico
Connecticut
New York
Delaware
North Dakota
District of Columbia
Ohio
Florida
Oklahoma
Georgia
Oregon
Guam
Pennsylvania
Hawaii
Puerto Rico
Idaho
Rhode Island
Illinois
South Carolina
Indiana
South Dakota
Iowa
Tennessee
Kansas
Texas
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96
Conference Edition
B. Priority Area Lead Agencies
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Physical Activity and Fitness
President's Council on Physical
Fitness and Sports
2.
Nutrition
National Institutes of Health
Food and Drug Administration
3.
Tobacco
Centers for Disease Control
4.
Alcohol and Other Drugs
Alcohol, Drug Abuse, and Mental
Health Administration
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Family Planning
Office of Population Affairs
6.
Mental Health and Mental Disorders
Alcohol, Drug Abuse, and Mental
Health Administration
7.
Violent and Abusive Behavior
Centers for Disease Control
8.
Educational and Community-Based Programs
Centers for Disease Control
Health Resources and Services Administration
9.
Unintentional Injuries
Centers for Disease Control
10.
Occupational Safety and Health
Centers for Disease Control
11.
Environmental Health
National Institutes of Health
Centers for Disease Control
12.
Food and Drug Safety
Food and Drug Administration
13.
Oral Health
National Institutes of Health
Centers for Disease Control
14.
Maternal and Infant Health
Health Resources and Services Administration
15.
Heart Disease and Stroke
National Institutes of Health
16.
Cancer
National Institutes of Health
17.
Diabetes and Chronic Disabling Conditions
National Institutes of Health
Centers for Disease Control
18.
HIV Infection
National AIDS Program Office
19.
Sexually Transmitted Diseases
Centers for Disease Control
20.
Immunization and Infectious Diseases
Centers for Disease Control
21.
Clinical Preventive Services
Health Resources and Services Administration
Centers for Disease Control
22.
Surveillance and Data Systems
Centers for Disease Control
97
Conference Edition
Healthy People 2000
98
Conference Edition
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