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2
HEALTHY
PEOPL
E
National Health Promotion and
Disease Prevention Objectives
HEALTHY
PEOPLE
2000
National Health Promotion and
Disease Prevention Objectives
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.
SERVICES
HUMAN
VSN
HEALTH
DEPARTMENT OF HEALTH & HUMAN SERVICES
Public Health Service
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
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 alco-
hol 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 lower 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.
V
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
addresses 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
national 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, Defense, Edu-
cation, Interior, Labor, and Transportation and the Environmental Protection Agency par-
ticipated generously in the development of the national objectives. In regional and na-
tional hearings, 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
nation of healthy people.
Louis W. Sullivan, M.D.
Secretary
September 1990
vi
Contents
Foreword
V
Acronyms and Abbreviations
viii
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
43
5. Priorities for Health Promotion and Disease Prevention
53
6.
Shared Responsibilities
85
Appendices
A. Summary List of Objectives
91
B. Contributors to Healthy People 2000
127
C. Priority Area Lead Agencies
141
Index to Summary List of Objectives
143
Contents of the Full Report
Part I
Healthy People 2000
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
Adolescents and Young Adults
Adults
Older Adults
Special Population Objectives
People with Low Income
Blacks
Hispanics
Asians and Pacific Islanders
American Indians and Native Americans
People with Disabilities
Additional Appendices
D.
Mortality Objectives Technical
E.
Recommendations of the U.S.
Appendix
Preventive Services Task Force
Acronyms and Abbreviations
ADAMHA
Alcohol, Drug Abuse, and Mental Health Administration
AHCPR
Agency for Health Care Policy and Research
ATSDR
Agency for Toxic Substances and Disease Registry
CDC
Centers for Disease Control
DOD
Department of Defense
DoEd
Department of Education
DOI
Department of the Interior
DOL
Department of Labor
DOT
Department of Transportation
EPA
Environmental Protection Agency
FDA
Food and Drug Administration
FSA
Family Support Administration
HCFA
Health Care Financing Administration
HRSA
Health Resources and Services Administration
IHS
Indian Health Service
NIH
National Institutes of Health
OHDS
Office of Human Development Services
PHS
Public Health Service
SSA
Social Security Administration
USDA
Department of Agriculture
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. Scien-
tific 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 in this country stopped entirely today, 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 ac-
tivity no more strenuous than sustained walking for 30 minutes a day, additional 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 Prevention⁷ and expanded with
publication in 1980 of Promoting Health/Preventing Disease: Objectives for the Na-
tion⁸, 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-
1
Healthy People 2000
ganizations and all the State health departments (see Appendix B). The Healthy People
2000 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 testimony from over 750 individuals and organizations. This testimony be-
came the primary resource material for working groups of professionals to use in crafting
the health objectives. 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. One particularly fast-growing population group will be Hispanics, some es-
timates 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 racial groups, including American Indians and Alaska Natives and Asians
and 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,
Asians and Pacific Islanders, and American Indians and 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
1. Introduction
By the year 2000, the American population may increase by up to 6 million people
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 unintentional injuries.
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
Injuries
Leading causes of
Stroke
death, U.S. popula-
Chronic lung disease
tion (age-adjusted)
Pneumonia/influenza
Suicide
Diabetes
1987
Liver disease
1977
Source: Health, United
Atherosclerosis
States, 1989 and Preven-
tion Profile and National
0
50
100
150
200
250
Center for Health Statis-
Rate per 100,000
tics (CDC)
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 to 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 65-percent decline since
1950. Preventable childhood diseases, such as mumps, measles, and rubella, are now un-
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
Fig. 1.2
Children
20% lower death rate
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
Source: Health, United
* Relative to baseline (1977 data)
States, 1989 and Preven-
tion Profile
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 Disease: 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. 5 Among the 15 priority areas that were the focus of the 1990 objectives,
areas in which progress seemed to lag included pregnancy and infant health, nutrition,
physical fitness and exercise, family planning, sexually transmitted diseases, and occupa-
tional safety and health. On the other hand, priority areas related to high blood pressure
control, immunization, control of infectious diseases, unintentional injury prevention and
control, smoking, and alcohol and drugs showed substantial progress. 5
4
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, cancer over $70 billion, and cardiovascular dis-
ease $135 billion. 3,9
Sophisticated technology for the diagnosis and treatment of disease conditions has out-
stripped society's ability to pay for it. But many of these expenses are avoidable (Fig.
1.3). 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 coronary
Overall
Avoidable
Cost per
Condition
magnitude
intervention
1
patient 2
Heart
7 million with coronary
Coronary bypass surgery
$30,000
disease
Fig. 1.3
artery disease
500,000 deaths/yr
Costs of
284,000 bypass
procedures/yr
treatment
for selected
Cancer
1 million new
Lung cancer treatment
$29,000
cases/yr
preventable
510,000 deaths/yr
Cervical cancer treatment
$28,000
conditions
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 drug-
$63,000
abuse
1-3 million, cocaine
affected 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)
Source: Data
20-30%, aged 2 and
compiled from
younger
various sources
3%, aged 6 and older
by the Office of
1 Examples (other interventions may apply).
Disease Pre-
²Representative first-year costs, except as noted. Not indicated are non-
vention and
medical costs, such as lost productivity to society.
Health Promo-
tion
5
Healthy People 2000
bypass procedures performed each year is approaching 300,000, each one of these proce-
dures at a cost of approximately $30,000. 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 cirrhosis 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 virtual-
ly all of these conditions are preventable. Mobilizing the considerable energies and
creativity of the Nation in the interest of disease prevention and health promotion is an
economic imperative.
Healthy People 2000: The Challenge and Goals
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 suf-
fering, illness, and disability. It comes as well from an improved 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 challenge of Healthy People 2000 is to use the combined strength of scientific know-
ledge, professional skill, individual commitment, community support, and political will
to enable people to achieve their potential to live full, active lives. It means preventing
premature death and preventing disability, preserving a physical environment that sup-
ports 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 main-
tain a maximum level of functioning.
The purpose of Healthy People 2000 is to commit the Nation to the attainment of three
broad goals that will help bring us to our full potential (Fig. 1.4). We have a broad array
of opportunities to achieve our goals. 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. 1.5).
Increase the span of healthy life for Americans
Fig. 1.4
Reduce health disparities among Americans
Healthy People 2000
Achieve access to preventive services for all
Goals
Americans
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 mental disorders, and violent and abusive be-
havior. Educational and community-based programs can address lifestyle in a crosscut-
ting 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
6
1. Introduction
Health Promotion
1. Physical Activity and Fitness
2. Nutrition
Fig. 1.5
3. Tobacco
4. Alcohol and Other Drugs
Healthy People 2000
5. Family Planning
Priority Areas
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
not exclusively protective in nature-there may be a substantial health promotion ele-
ment as well-but the principal approaches involve a communitywide rather than in-
dividual focus.
Preventive services 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 disa-
bling 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, chapters are included for each of
four age groups: children, adolescents and young adults, adults, and older adults. Objec-
tives 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 accord-
ing 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
7
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 2000 and includes all of the national objec-
tives 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
8
Bureau of the Census. Projections of the Numbers
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
9
Health Care Financing Administration, Office of the
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
Center, The Johns Hopkins University, 1989.
3
Hodgson, T.A., and Rice, D.P. Economic impact of
10
cancer in the United States. In: Schottenfeld, D.,
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
Breast Cancer Screening. National Cancer
4
Kutscher, R.E. Projections 2000: Overview and
Institute Monographs 67:65-74, 1985.
implications of the projections to 2000. Monthly
11
Labor Review September, 1987.
Spencer, G. Projections of the Hispanic Population:
1983-2080. Current Population Reports,
5
National Center for Health Statistics. Health, United
Population Estimates and Projections. Series
States, 1989 and Prevention Profile. DHHS Pub.
P-25, No. 995. Washington, DC: U.S.
No. (PHS)90-1232. Hyattsville, MD: U.S.
Department of Commerce, Bureau of the Census,
Department of Health and Human Services, 1990.
1986.
6
Passel, J.E., and Woodrow, K.A.' Immigration to
12
Spencer, G. Projections of the population of the
the United States." Paper presented to the Census
United States, by age, sex, and race: 1988 to
Table, August 1986.
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
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 later 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. 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. 38
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
considerably higher than for white infants. 38
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. 38 Four causes account for more than half of all infant deaths:
disorders 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. 38 This dangerous condition has been linked
to several preventable risks, including lack of prenatal care, maternal smoking, use of
9
Healthy People 2000
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
Source: Health, United
0
50
100
150
200
250
States, 1989 and Preven-
Deaths per 100,000 live births
tion Profile
alcohol and other drugs, and pregnancy before age 18. 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. Black infants are more than twice as likely as white babies to be born
weighing less than 2,500 grams.³⁸
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. Low-birth-weight babies are nearly twice as likely
to have severe developmental delay or congenital anomalies. 68 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. In 1985, about 11,000 babies were
born with moderate to severe impairments.⁴ 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 impor-
tant factors. Fetal alcohol syndrome (FAS) affects as many as 1 to 3 infants per 1,000
live births. 38 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. 59 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. 14 The long term consequences of these alarming trends are inestimable.
10
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. 66
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. 32 Maternal cigarette smoking has been linked with from 20 to 30 percent of
all low-birth-weight births in the United States. 33 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 use. 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.³⁰ Reliable data on the prevalence of
substance abuse by pregnant women is also difficult to obtain. Extrapolations of local
studies suggest that mothers of as many as 10 percent of babies born each year have used
one or more illicit substances during their pregnancy. 14,15,25
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.⁷¹ 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. 58 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, an important element 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. 31 Similarly,
11
Healthy People 2000
poor pregnancy outcomes have been linked to other indicators of lower socioeconomic
status such as lack of health insurance and poor nutrition.
Congenital anomalies may be caused by environmental factors such as viruses, chemi-
cals, 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, however, are still uncer-
tain and controversial.
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. 27,58
About 76 percent of women receive prenatal care, but rates are considerably lower for
many minority groups. 73
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
38
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
findings 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. 58
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 1970, the rate of childhood deaths from motor vehicle
crashes has declined 41 percent for children aged 1 through 4, and 31 percent for those
aged 5 through 14, primarily due to the use of car seats and seatbelts. 38 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 pover-
ty, often in inner cities, than among those at higher socioeconomic levels. 62 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.
12
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
(1987)
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 (CDC)
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 1984.⁴⁷ However, many States still do not mandate
child restraints for children over age 5, and in some States there is no requirement 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.48
Drownings and fires account for most other injury-related deaths among children. Drown-
ings 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.²⁴
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 in fall-related injuries in children.
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.
Some infections and respiratory illnesses remain problems for children. For example,
influenza 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, has raised concern in recent years.³⁸
13
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. 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. 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.⁷⁵
Developmental Problems
Psychological, emotional, and learning disorders are on the rise among children, as are
chronic physical conditions such as hearing and speech impairment. Low-income
children are at a significantly higher risk for such problems. 62
One contributor to developmental problems in children is lead poisoning. In 1984, an
estimated 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. Severe lead poisoning can lead to pro-
found 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. Child-
hood 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. 17 While most smokers start when they are
young teenagers, many start even earlier. 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. Although cigarette smoking is declining
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 be-
havior, lack of knowledge and understanding of health consequences, advertising and
promotion, and the easy availability of cigarettes in unsupervised vending machines. 57
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.
51
14
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. 72 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; 54
63 percent of school districts and private schools provide some instruction concern-
ing alcohol and other drugs and 39 percent provide related counseling;64
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;72
25 States require comprehensive school health education programs and 9 States
recommend that local school districts implement such programs. 18
Appropriate educational strategies vary according to community and age group, but age-
appropriate 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.
15
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 60 percent and cancer by 40 per-
cent.³⁸ 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, Supple-
Deaths per 100,000 youth
ment, September 26, 1989
Motor Vehicle Crash Injuries
Unintentional injuries account 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 fatal
motor vehicle crashes among people in this age group 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.³⁸
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. 38 The raised speed limit on rural interstate high-
ways may be a factor in this trend. 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. 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.
16
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 rate is substantially
higher. Over half of all homicide victims are relatives or acquaintances of the perpetrators.
Most are killed with firearms. 11
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
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 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. Three-fourths of high school seniors who smoke report that
they smoked their first cigarette by grade 9. 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.⁵⁷
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 whom smoking is
more prevalent. 61 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. 65
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. Alcohol is
a major contributor to both motor vehicle crashes and violence, two of the leading 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 oc-
casions 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.⁴⁹
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.⁵ Among young people aged 18 to 24,
drinking is more prevalent than in any other age group. In 1988, more than 65 percent of
this group reported alcohol use during the past month.³⁸
The use of illicit drugs among adolescents has been declining since the late 1970s, at
least among young people who remain in school. 51 The number of high school seniors
17
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. 49
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. 5
Sexual Behavior
An estimated 78 percent of adolescent girls and 86 percent of adolescent boys have
engaged in sexual intercourse by age 20. 53,69 The risks of early sexual activity include
not only unwanted pregnancy, but also infection by sexually transmitted diseases. Of the
approximately 1.1 million girls aged 15 through 19 who become pregnant each year, an
estimated 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.
23,29
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.
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.
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,
including 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 pro-
grams are needed to provide positive alternatives to alcohol and other drug abuse,
teenage pregnancy, and lifestyles conducive to violence.
18
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 contributed 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 (Fig. 2.4). These and the other top causes of death between
the ages of 25 and 65-unintentional injuries, stroke, and chronic liver disease and cir-
rhosis-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 (CDC)
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. 19
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.⁵⁷
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
19
Healthy People 2000
colorectal cancer. Since 1969, death rates from these cancers have fallen among
white men and women, remained about the same for black women, and increased
markedly for black men. 36 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. 67 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
cervical 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. 70
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 25 and 65, and most
are between 55 and 64.³⁸ 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.³⁸
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. 46 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.⁴³ 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. 46
Weight control, physical activity, lower intake of alcohol and sodium, and if necessary,
medication are means of controlling blood pressure.⁴⁵
Health Habits
Several major health risk factors, sometimes alone and sometimes in combination, are
associated 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.
20
2. The Nation's Health: Age Groups
Certain eating patterns-especially excessive consumption of fats-are linked to a higher
risk of heart disease, breast and colon cancer, and gallbladder disease. 63 Total dietary fat,
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. 63 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.⁴¹ 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. 41
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. 66 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. 10 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. 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. 57
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. 60 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). In general, smoking rates are higher among blacks,
Hispanics, blue-collar workers, and people with fewer years of education. 22
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.
21
Healthy People 2000
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
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. 50
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. 56
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. 38 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. 20 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. 39 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. 74
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. In 1987, just 75 percent of women aged 18 and over had received a
22
2. The Nation's Health: Age Groups
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.³⁷
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. 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. 37
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
28
age.
People who reach the age of 65 can now expect to live into their eighties. 38 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 21,38 (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.
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
Source: Health, United
0
Men
Women
States, 1989 and Preven-
tion Profile
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.²⁶
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. 57
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. 28
Physical Activity
A key ingredient to healthy aging is physical activity. Often physiological decline associ-
ated 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 ac-
tivity 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. 10
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
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 pre-
ventive 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. 67 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 42 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. Only about 10 percent of older adults living in the
community receive pneumococcal vaccine and 20 percent receive influenza vaccines. 13
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 preva-
lence 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 hy-
perthyroidism-may be reversible. 16,34
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 osteo-
porosis 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. 52 The risk of incontinence increases with age but it often is a sign of
25
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. 28 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.
12
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.
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15
Department of Health and Human Services,
Chasnoff, I.J.; Landress, H.J.; and Barrett, M.E.
Atlanta, GA.
The prevalence of illicit drug and alcohol use
8
during pregnancy and discrepancies in mandatory
Boyd, J.H and Moscicki, E.K. Firearms and youth
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76:1240-1242, 1986.
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16
Clarfield, A.M. The reversible dementias: Do they
33
Kleinman, J.C. and Madans, J.H. The effects of
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maternal smoking, physical stature, and
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educational attainment on the incidence of low
17
Clayton, R.R. The delinquency and drug use
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relationship among adolescents: A critical
121(6):832-55, 1985.
review. In: Lettieri, D.J. and Ludford, J. eds.
34 Larson, E.B.; Reifler, B.V.; Featherstone, H.J.; et
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18 Division of Adolescent and School Health, Center
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36 National Cancer Institute. 1987 Annual Cancer
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20 Drug Abuse Warning Network, National Institute
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on Drug Abuse, Alcohol, Drug Abuse, and
Cancer Control Supplement to the 1987 National
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Service, U.S. Department of Health and Human
38 National Center for Health Statistics. Health,
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United States, 1989 and Prevention Profile.
21 Erikson, P. Unpublished analysis of vital statistics
DHHS Pub. No. (PHS)90-1232. Hyattsville, MD:
and National Health Interview Survey data, 1990.
U.S. Department of Health and Human Services,
22 Fiore, M.C.; Novotny, T.E.; Pierce, J.P.;
1990.
Hatziandreu, E.J.; Patel, K.M.; and Davis R.M.
39 National Center for Statistics and Analysis.
Trends in cigarette smoking in the United States:
Occupant Protection Facts. Washington, DC:
The changing influence of race and gender.
U.S. Department of Transportation, 1989.
JAMA 261:49-55, 1989.
40 National Commission to Prevent Infant Mortality.
23 Furstenberg, F.F., Jr. Unplanned Parenthood: The
Indirect Costs of Infant Mortality and Low
Social Consequences of Teenage Childbearing.
Birthweight. Washington, D.C: the Commission,
New York: Free Press, 1976.
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24 Hall, J.R. A decade of detectors: Measuring the
41
National Health and Nutrition Examination Survey
effect. Fire Journal 79:37-43, 1985.
(NHANES), National Center for Health Statistics,
25
Hollinshead, W.H. et al. Statewide prevalence of
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Island. Morbidity and Mortality Weekly Report
Services, Hyattsville, MD.
39(14):225-7, 1990.
42
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26 Institute of Medicine. Disability in America: A
for Health Statistics, Centers for Disease Control,
National Agenda for Prevention. edited by Pope,
Public Health Service, U.S. Department of Health
A. and Tarloff, A. Washington DC: National
and Human Services, Hyattsville, MD.
Academy Press, in press.
43 National Heart, Lung, and Blood Institute.
27
Institute of Medicine. Preventing Low Birthweight.
Hypertension prevalence and the status of
Washington, DC: National Academy Press, 1985.
awareness, treatment, and control in the U.S.:
Final report of the subcommittee on definition
28 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
44 National Heart, Lung, and Blood Institute. Report
press.
of the Expert Panel on Detection, Evaluation, and
29 Jones, E.F. and Forrest, J.D. Contraceptive failure
Treatment of High Blood Cholesterol in Adults.
in the United States: Revised estimates from the
National Cholesterol Education Program.
1982 National Survey of Family Growth. Family
Washington, DC: U.S. Department of Health and
Planning Perspectives 21(3):103-9, 1989.
Human Services, 1988.
30 Keith, L.G.; McGregor, S.N.; and Sciarra, J.J. Drug
45
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1988 Report of the Joint National Committee on
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MA: Kluwer Academic Publishers, 1988.
Blood Pressure. Washington, DC: U.S.
31
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46 National Heart, Lung, and Blood Institute, National
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Public Health 77:823-25, 1987.
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49
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Nature and Effectiveness of Federal, State, and
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51 National Institute on Drug Abuse. National Survey
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52 National Institute of Health. Consensus
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Shapiro, S.; Venet, W.; Strax, L.; and Roeser, R.
Incontinence in Adults, October 3-5, 1988.
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68 Shapiro S.; McCormick, M.C.; Starfield, B.H.;
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American Journal of Public Health 78:176-78,
1988.
28
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 and Alaska Natives, or people with disabilities, the variations within
each group are extensive. Generalizations, which characterize population profiles by
definition, 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-
ty level. Nearly a quarter of children younger than 6 are members of such families. 11
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. 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. 1
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. 16 The incidence of
cancer increases as family income decreases, and survival rates are lower for low-income
29
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. 1,30 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
injury and death. These individuals, more than those with higher incomes, are the vic-
tims 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. 11
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.⁸
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.¹⁴ 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.¹⁵
The pattern of increased vulnerability to injury, disease, and death continues into adult-
hood. People in families with incomes of less than $13,000 a year are twice as likely as
the total population to be limited in major activities because of their health (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 in-
come decreases. 17
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
Income level
All persons
Fig. 3.1
Percentage of
Less than $13,000
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 (CDC)
30
3. The Nation's Health: Special Populations
blood pressure, which are major risks for heart disease and stroke, have been linked
directly with low income status. 23 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
21
blue-collar workers are about 20 percent higher than among others.
Whereas in 1986 over 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 37 percent of families with incomes below $10,000 a year. 12
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. 15 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. 8 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. 20
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.
People in Minority Groups
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 and Alaska Na-
tives. From a total population perspective, the categories simplify the difficulties of as-
sessing health status and making plans to improve health. But they are gross simplifica-
tions. Within each racial or ethnic category, significant subgroup differences exist.
Demarcations among minority populations are not absolute. For example, there are both
black and nonblack 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 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.
31
Healthy People 2000
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. 30 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 ob-
served 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 socio-
economic. 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 communities. Pover-
ty and near-poverty appear as underlying elements of many health problems experienced
by these groups. But if the socioeconomic effects are set aside, disparities experienced
by these population groups will still be observed. Simply put, some differences in sur-
vival 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 improvements to be achieved by 2000 are set for
those groups with higher risks than the total population, where data are available to estab-
lish 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 through-
out this century; since the mid-1980s the gap has actually widened, with the life expectan-
cy 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 popula-
tion, 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.
Heart disease
Cancer
Fig. 3.2
Stroke
Leading causes
Injuries
of death for blacks
Homicide
compared to whites
Pneumonia/influenza
(1987, age-adjusted
Diabetes
rates)
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 (CDC)
32
3. The Nation's Health: Special Populations
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.
30
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. 30
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. 19
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. 30 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.²⁶
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 4 times
more often among black men than among white men.²⁹ 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. 30
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
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
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. 12
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
33
Healthy People 2000
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.³⁾ 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.³⁰ 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. In 1986, about
23 percent of blacks had no private or public medical insurance, compared to 14 percent
of whites.¹²
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 Ameri-
cans 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 per-
cent. Eighty-seven percent of Hispanics live in urban areas. The largest concentrations
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. 13
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.
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
Puerto Rican
Fig. 3.3
Other and unknown
Infant mortality rates
Hispanic
for selected Hispanic
groups (1983-84)
Mexican
Central and South
American
Cuban
Source: National Linked
0
2
4
6
8
10
12
14
16
Birth and Infant Death
Rate per 1,000 live births
Data Set (CDC)
34
3. The Nation's Health: Special Populations
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. 3 The Hispanic birth
rate was 22.3 births per 1,000 women in 1987, while that of the total population was 15.7
births per 1,000 women. 19
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. 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. 13 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. 28 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. 27 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 primarily linked
to intravenous drug abuse by these women or their sexual partners. 27 Diabetes is especial-
ly prevalent among Mexican Americans. 13
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: Monthly Vital
Statistics Report, Supple-
Perinatal conditions
3%
10
Liver disease
1%
ment, September 26, 1989
Note: National death rate data unavailable for Hispanics.
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. Likewise, Hispanic teenagers report heavy drinking of
alcoholic beverages more frequently than do white or black teenagers. 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. 13
Overweight is common among Hispanics, especially among Mexican American women.
This disparity cannot be accounted for completely by socioeconomic differences. Like-
wise, 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. 13
Like black Americans, Hispanic Americans receive less preventive health care, including
prenatal care, than the total population. In 1987, 39 percent of Hispanic mothers had no
prenatal care during the first trimester of pregnancy compared to 21 percent of non-
Hispanic whites. 12 Barriers to care include language differences between Spanish-speak-
35
Healthy People 2000
ing patients and English-speaking health professionals, logistical barriers posed by rural
residence of some Hispanic families, and costs of services.
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 the largest group 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. 18 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
established 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
national median income. Yet, some groups, particularly recent immigrants, are extreme-
ly 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 Ameri-
cans and the general population may parallel integration of the newer immigrants into
both the economy and the society of the United States.
An adequate depiction of the health of Asian and Pacific Islander Americans is con-
strained because data cannot be stratified by subgroups. Many national data systems are
unable to make estimates of this minority population because of its relatively small size.
This prevents accurate assessment of the leading causes of death, disease, and disability
that it experiences. From local studies, however, it is possible to recognize certain dis-
eases as posing higher than normal risks for specific Asian and Pacific Islander Ameri-
cans. Most of the studies are based in California, which has the largest Asian and Pacific
Islander American population (Fig. 3.5). Generalizations from local studies may be inac-
curate 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).
Disparities in rates of cancer exist for several subgroups and selected cancer sites. For
example, the breast cancer incidence rate among Native Hawaiians is 111 per 100,000
women, as compared to 86 per 100,000 among whites.² The lung cancer rate is 18 per-
cent higher among Southeast Asian men than for the white population. And the liver can-
cer rate is more than 12 times higher among Southeast Asians than in the white popula-
tion.
2,25 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). 30
36
3. The Nation's Health: Special Populations
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: California's published data on the Asian and Pacific Islander popula-
tion includes 93 percent Asians and 7 percent Other (Native Americans, Es-
kimos, and Alaskan Aleuts.) National death rate data are unavailable for
Asians and Pacific Islanders.
Laotion
Asian unspecified
Fig. 3.6
Cambodian
Other Pacific Isl.
Percent of deaths
Vietnamese
attributed to condi-
Hawaiian
tions originating in
Asian Indian
the perinatal period,
Thai
Samoan
for selected Asian
Korean
groups
Filipino
Chinese
Japanese
Source: California State
Guamanian
Department of Health and
0
2
4
6
8
10
Asian American Health
Percent
Forum
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 45.2 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 Cambodians, and 65 percent for Vietnamese, compared to 30
percent for the overall American population.²
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
37
Healthy People 2000
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 (Fig. 3.7). Heart disease and cancer are not among the
sources of excess deaths, perhaps because these are generally diseases of older age. Can-
cer rates are lower overall, but are twice as high as the total population for lung cancer
among Oklahoma Indians. Southwest Indians have high rates of gallbladder cancer, and
Alaska Natives suffer high rates of liver cancer.³⁰
Heart disease
Cancer
Fig. 3.7
Injuries
Leading causes of
Stroke
death for American
Liver disease
Indians in Reserva-
tion States
Diabetes
compared to whites
Pneumonia/influenza
(1987, age-adjusted
Suicide
American Indians
rates)
Homicide
Whites
Chronic lung disease
Source: Indian Health
Service and National
0
50
100
150
200
Center for Health Statis-
Rate per 100,000
tics (CDC)
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. 19 An estimated 75 percent of these injuries are alcohol-related,
and 54 percent involve motor vehicle crashes. 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
38
3. The Nation's Health: Special Populations
28 percent higher than the national rate, but among some tribes the suicide rate is 10
times higher than the total population rate.⁶
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. 24 Diabetes is now so prevalent that in
many tribes more than 20 percent of the members have this disease. 6 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. 24 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 the prevention of disabilities. Even when data are
unavailable to define health outcomes except in terms of death, the thrust of objectives
for the year 2000 is aimed at the living consequences of unhealthy behaviors, unsafe en-
vironments, and illness-causing infections. Disabilities may be defined, as distinct from
illness or disease, in terms of limited ability to function. Disabilities may be physical 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
39
Healthy People 2000
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.
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
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. 9 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.⁹
Activity limitations are most common among older people, the poor, and those Ameri-
cans 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 major activity limita-
tion. 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.⁹
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 commu-
nity, i.e., not institutionalized, make up about 40 percent of those who need assistance in
activities of daily living. 9
40
3. The Nation's Health: Special Populations
Percent
30
Fig. 3.8
25
Percentage of
20
people experiencing
limitation of major
15
activity, by age
(1987)
10
5
0
Source: Health, United
Under 5
5-14
15-44
45-64
65-74
75+
States, 1989 and Preven-
Age group
tion Profile
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.⁹
Among ethnic groups, American Indians have the highest rates of activity limitation and
Asian and Pacific Islander Americans the lowest. 17 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 prob-
lems, offers a compelling example. To establish fitness regimens, people with 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
41
Healthy People 2000
References
1
17
Amler, R.W. and Dull, H.B., Closing the Gap: The
National Institute on Disability and Rehabilitation
Burden of Unnecessary Illness. New York:
Research, Chartbook on Disability in the United
Oxford University Press, 1987.
States, Washington, DC: the Institute 1989.
2
18
Asian American Health Forum. Year 2000 Strategic
National Migrant Resource Program and the
Health Development Program for Asian and
Migrant Clinicians Network. Migrant and
Pacific Islander Americans. April 1989.
Seasonal Farmworker, Health Objectives for the
3
Year 2000: Document in Progress, April 1990.
Bureau of the Census. U.S. Census of Population:
Austin, TX: National Migrant Resource Program,
1980. Washington DC: U.S. Department of
Inc., 1990.
Commerce.
19
4
Council on Ethical and Judicial Affairs. Black-white
National Vital Statistics System, National Center
for Health Statistics, Centers for Disease Control,
disparities in health care. JAMA 263:2344-2346,
Public Health Service, U.S. Department of Health
1990.
and Human Services, Hyattsville, MD.
5
Franks, A.L.; Berg, C.J.; Kane. M.A.; Browne, B.B.;
20
North Carolina Oral Health School Survey. North
et al. Hepatitis B virus infection among children
Carolina Division of Dental Health, Raleigh,
born in the United States to Southeast Asian
North Carolina and the University of North
refugees, New England Journal of Medicine
Carolina School of Public Health, Chapel Hill,
321(9):1301-5, 1989.
North Carolina.
6
Indian Health Service, Indian Health Service Chart
21
Office on Smoking and Health. Unpublished data
Series Book, Washington, DC: U.S. Department
from the 1987 National Health Interview Survey.
of Health and Human Services, 1988.
22
7
Office of Substance Abuse Prevention (OSAP).
Institute of Medicine. Disability in America: A
Communicating about alcohol and other drugs:
National Agenda. edited by Pope, A. and Tarloff,
Strategies for reaching populations at risk. OSAP
A. Washington, DC: National Academy Press, in
Prevention Monograph 4. Washington, DC: U.S.
press.
Department of Health and Human Services, in
8
Institute of Medicine. Preventing Low Birthweight.
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Washington, DC: National Academy Press, 1985.
23
Public Health Service. The Surgeon General's
9
LaPlante, M.P., Data on Disability from the
Report on Nutrition and Health. Washington, DC:
National Health Interview Survey, 1983-1985,
U.S. Department of Health and Human Services,
Washington, D.C.: National Institute on
1988.
Disability and Rehabilitation Research, 1988.
24
Rhoades, E.R.; Hammond, J.; Welty, T.K.;
10
National Cancer Institute and National Center for
Handler, A.O.; and Amler, R.W. The Indian
Health Statistics. Unpublished data from the
burden of illness and future health interventions.
Cancer Control Supplement to the 1987 National
Public Health Reports 102(4):361-8, 1987.
Health Interview Survey.
25
Schwartz, S.M. and Thomas, D.B. "Estimates of
11
National Center for Children in Poverty. A
Cancer Incidence Among Southeast Asian
Statistical Profile of Our Poorest Young Citizens.
Refugees in the United States." Paper presented at
New York: the Center, 1990.
the Annual Meeting of the American Public
12
Health Association, New Orleans, LA October
National Center for Health Statistics. Health,
1987.
United States, 1989 and Prevention Profile.
26
Hyattsville, MD: U.S. Department of Health and
Selik, R.M.; Castro, K.G.; and Papaionnou, M.
Human Services, 1990.
Racial/ethnic differences in the risk of AIDS in
13
the United States. American Journal of Public
National Coalition of Hispanic Health and Human
Health 78(12):1539-1544, 1988.
Services Organizations. Delivering Preventive
27
Health Care to Hispanics: A Manual for
Selik, R.M.; Castro, K.G.; Papaionnou, M.; and
Providers, Washington, DC: the Coaltion, 1988.
Ruehler, J.W. Birthplace and the risk of AIDS
14
among Hispanics in the United States. American
National Health and Nutrition Examination Survey
Journal of Public Health 79(7):836-9, 1989.
(NHANES) II, National Center for Health
28
Statistics, Centers for Disease Control, Public
Smith, J.C.; Mercy, J.A.; and Rosenberg, M.L.
Health Service, U.S. Department of Health and
Suicide and homicide among Hispanics in the
Human Services, Hyattsville, MD.
Southwest. Public Health Reports
15 National Health Interview Survey, National Center
101(3):265-270, 1986.
for Health Statistics, Centers for Disease Control,
29
Subcommittee on Definition and Prevalence, Joint
Public Health Service, U.S. Department of Health
National Committee on Detection, Evaluation,
and Human Service, Hyattsville, MD.
and Treatment of High Blood Pressure.
16
Hypertension prevalance and the status of
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Cholesterol Education Program. Report of the
7(3):460, 1985.
Expert Panel on Population Strategies for Blood
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Cholesterol Reduction. Washington, DC: U.S.
U.S. Department of Health and Human Services.
Department of Health and Human Services, 1990.
Report of the Secretary's Task Force on Black
and Minority Health. Washington, DC: the
Department, 1985.
42
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 occu-
pation. It involves birth and death, two sentinel health events. Birth frames the potential
for a healthy lifetime; death often summarizes how that potential was used. It involves
the values of family, neighborhood, community, and Nation, enabling or undermining the
health course that a life takes. It involves an array of risks-some posing apparent, imme-
diate danger and others invisible and delayed in their effects. Finally, it involves medical
science and medical care, with their 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 (Fig. 4.1).
Increase the span of healthy life for Americans
Fig. 4.1
Reduce health disparities among Americans
Healthy People 2000
Goals
Achieve access to preventive services for all
Americans
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 century,
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 relationships
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 thriving Na-
tion.
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. 4.2). 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 and disability
direct our attention to quality of life issues. Both chronic diseases and injuries can be
measured by the 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 unin-
tentional 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.
43
Healthy People 2000
Life years
85
Fig. 4.2
80
Life expectancy at
birth, U.S. population
75.0
75
70
65
1970
1975
1980
1985
1990
1995
2000
Source: Health, United
Year
States, 1989 and Preven-
tion Profile
We can measure our progress in increasing the span of healthy life in several ways. One
measure offered here indicates the rate of deaths per 100,000 people before age 75, the
approximate average life expectancy at birth in 1990 (Fig. 4.3). Infant mortality, a tradi-
tional tool for judging the effectiveness and compassion of health systems, can indicate
national progress at the early end of the age spectrum (Fig. 4.4).
Rate per 100,000
1000
Fig. 4.3
800
Death rates for
people aged 74 and
600
younger, U.S.
392
population (age-ad-
400
justed)
200
0
1970
1975
1980
1985
1990
1995
2000
Year
Source: National Vital
Statistics System (CDC)
Deaths per 1,000 live births
35
Fig. 4.4
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 (CDC)
44
4. Goals for the Nation
Another measure uses a formula that combines death rates with acute and chronic illnes-
ses, impairments, and handicaps to define average years of healthy life. Using this meas-
ure, time spent in a healthy state or years of healthy life can be compared to the average
life expectancy at birth. (Fig. 4.5) The difference between these two estimates indicates
the average amount of time spent in a dysfunctional state due to either chronic or acute
limitation. One major indicator of dysfunction is limitation of major activity due to
chronic conditions. (Fig. 4.6) Years of healthy life uses a life expectancy model in which
standard life table data are adjusted for level of well-being of a population. Measures of
well-being represent individual 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, the baseline
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.
Healthy life
62 years
Fig. 4.5
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 (CDC)
Percent
20
Fig. 4.6
15
Percentage of
people experiencing
limitation of major
9.4
10
activity, U.S. popula-
tion (crude rates)
5
0
1970
1975
1980
1985
1990
1995
2000
Year
Source: National Health
Interview Survey (CDC)
45
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 popu-
lations. Whether the issue is chronic diseases, infectious diseases, unintentional injuries,
or violence-related injuries, the services and protection that might most effectively 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
disparities appear across the spectrum of health concerns, not just in average life expec-
tancy. (Fig. 4.7) One perspective on these differences is death rates before age 75 (Fig.
4.8). 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. 4.9).
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. In 1987, 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 poten-
tial life lost were 630 percent higher for black men than for white men. Among women
of both races, death rates for all causes were lower, but comparisons of premature death
of white and black women are equally startling. Lost years of life before age 65 were
134 percent higher among black women for heart disease, 166 percent higher for stroke,
and 360 percent higher for homicide. 1 Statistics to compute years of potential life lost 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. 4.7
75.6
Whites
75
Life expectancy at
birth, blacks and
whites
69.4
70
Blacks
65
60
1970
1975
1980
1985
1990
1995
2000
Source: Health, United
Year
States, 1989 and Preven-
tion Profile
46
4. Goals for the Nation
Deaths per 1,000 live births
35
Blacks
Fig. 4.8
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 Birth and
Year
Infant Death Data Set
(CDC)
Rate per 100,000
1000
Blacks
Fig. 4.9
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 (CDC)
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. 4.10). 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. 4.11).
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 disabil-
ity rates for population groups and the total population; where trends have been worsen-
ing 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 Ameri-
cans, 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.
47
Healthy People 2000
Years
100
80
74.4
75
Fig. 4.10
68
63
62
Life expectancy and
60
56
years of healthy life,
whites, blacks, and
40
Hispanics (1980)
20
Source: Analysis based
0
on data from the National
Whites
Blacks
Hispanics
Vital Statistics System
(CDC), National Health In-
Life expectancy
Years of healthy life
terview Survey (CDC),
(preliminary estimates)
and the U.S. Census
Bureau
Percent
25
Fig. 4.11
20
Low income
18.9
Percentage of
people experiencing
15
American Indians
13.4
limitation of major ac-
Blacks
11.2
tivity, by race and
10
Whites
9.3
ethnicity (crude rates)
Hispanics
5
6.6
0
1970
1975
1980
1985
1990
1995
2000
Year
Source: National Health
Interview Survey (CDC)
48
4. Goals for the Nation
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 responsi-
bility, 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, fundamen-
tal ingredient in attaining this sentinel health event (Fig. 4.12). Early and regular prenatal
visits to qualified health care providers can ensure greater likelihood that low birth 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 im-
portant to healthy pregnancies. The role of prenatal services in education and counseling
about parental behaviors, including nutrition, abstinence from tobacco, alcohol, 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.
Percent of live births
100
Fig. 4.12
90
Percentage of
Whites
79
80
pregnant women
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 (CDC)
49
Healthy People 2000
Other preventive services are equally fundamental to our national prevention plan. Basic
monitoring of child growth and development; immunization against childhood diseases
(Fig. 4.13); appropriate immunization for vulnerable adults against pneumonia and in-
fluenza; screening to detect high blood pressure and high blood cholesterol and breast,
cervical, oropharyngeal, and colorectal cancers; counseling on nutrition, smoking cessa-
tion, and injury prevention; all these services are indispensable parts of prevention.
Achievement of this goal clearly requires that health care providers offer, and patients
receive, these services. Objectives throughout this report focus on increasing the propor-
tion of primary care providers who routinely offer preventive services to their patients.
Percent vaccinated
100
Fig. 4.13
80
Percentage of
children immunized
60
by time of school
entry
40
20
0
1970
1975
1980
1985
1990
1995
2000
Year
Source: Center for
Prevention Services, CDC
Access to preventive services involves more than just availability of services. Preventive
services cannot, and should not, be separated from basic primary health care. Approxi-
mately 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. 4.14) 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 primary source of health care and those
who have adequate insurance coverage (Fig. 4.15), 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. 4.14
Percentage of
25
people who lack a
20
source of primary
care (1986)
15
10
5
0
All
People
Source: Robert Wood
Hispanics
Blacks
Low-income
w/o insurance
Johnson Foundation
50
4. Goals for the Nation
Private insurance
Fig. 4.15
77%
Health insurance
coverage for people
aged 64 and younger,
Other/unknown
by type of coverage
2%
(1986)
Medicaid
6%
Not covered
15%
Source: Based on Health,
United States, 1989 and
Prevention Profile
Note: Percent distribution approximate due to overlap among categories.
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 and Prevention Profile.
DHHS Pub. No. (PHS)90-1232. Hyattsville,
MD: U.S. Department of Health and Human
Services, 1990.
51
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 outlines
specific behavioral risks, disease conditions, and health outcomes that must be effectively
addressed in the coming years if 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.
53
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
54
5. Priorities for Health Promotion and Disease Prevention
Physical Activity and Fitness
Regular physical activity increases life expectancy, 74 can help older adults maintain func-
tional independence, and enhances quality of life at each stage of life. 33 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 cancer⁷⁷ and stroke⁸³ 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. 5,75 Activity that builds muscular strength, endurance, and flexi-
bility may protect against injury and disability. And any activity that expends energy is
important in weight control. Physical activity can also produce changes in blood pres-
sure, blood lipids, clotting factors, and glucose tolerance, that may help prevent and con-
trol high blood pressure, coronary heart disease and diabetes, 38
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 meas-
urable health benefits. 39,82
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. 78
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 sustained combined changes in diet and 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.
55
Healthy People 2000
Nutrition
In ways often interrelated with patterns of physical inactivity, dietary factors are associ-
ated with 5 of the 10 leading causes of death in the United States: coronary heart disease,
some types of cancer, stroke, noninsulin-dependent diabetes mellitus, and atherosclerosis.
The 1988 Surgeon General's Report on Nutrition and Health⁷⁹ 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, excesses and imbalan-
ces of some food components in the diet have replaced once-prevalent nutrient deficien-
cies 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. 79 To help promote health and prevent
chronic disease, the Dietary Guidelines for Americans,⁹¹ issued by the United States
Departments of Health and Human Services and Agriculture, recommend one should eat
a variety of foods; maintain healthy weight; choose a diet low in fat, saturated fat, and
cholesterol; choose a diet with plenty of vegetables, fruits, and grain products; use sugars
only in moderation; use 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. 79
Dietary fat contributes more than twice as many calories per unit of weight as carbo-
hydrate or protein, and currently constitutes 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. 79 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 to 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 and growth retardation in children; useful and informative nutrition
labeling for all food products; increasing availability of low-fat products; better
identification of low-fat, low-calorie food 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.
56
5. Priorities for Health Promotion and Disease Prevention
Tobacco
Tobacco use is the most important single preventable cause of death in the United States,
accounting for one of every six deaths, or some 390,000 deaths annually. 73 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. 73 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 than 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 prob-
lems. Between 20 and 30 percent of the incidence of low birth weight, 36 up to 14 percent
of preterm deliveries, and about 10 percent of all infant deaths are attributable to mater-
nal cigarette smoking. 73 Yet 25 percent of pregnant women smoke throughout their preg-
50
nancy.
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 per-
cent in 1965. Nearly half of all living adults who ever smoked have quit. Nevertheless,
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. 73
Smoking is a special problem for workers with exposure to hazardous substances that
may compound the risk.
Among youth, more than half of 8th graders and nearly two-thirds of 10th graders report
having tried cigarettes. 4 More than one-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 reducing lung cancer and chronic obstructive lung disease
deaths; 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.
57
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
alcohol use, and about 7 percent of drinkers experience moderate levels of dependence
symptoms. 65 Alcohol is a factor in approximately half of all homicides, suicides, and
motor vehicle fatalities 76 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. 65 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 used cocaine at least once, and 21 million also had used marijuana in the
last year. 63 Among high school seniors, almost 44 percent report having tried marijuana,
and 10 percent report ever using cocaine. 45 It has been estimated that one in four Ameri-
can adolescents is at very high risk of alcohol and other drug problems and their conse-
quences.
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 developmental
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 1990 to be $70 billion, and another $44 billion
for drug problems. 27,80 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. 64
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 devel-
oped ways to fight the pervasive dangers of alcohol and other drugs. A changing social
climate has been accompanied by legislative and policy actions, particularly concerning
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 (age adjusted)
(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.
58
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 that occur more
frequently as a result of family planning failures. Family planning is 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 deci-
sions accompanied by motivation to carry out those decisions. It requires the exercise
of personal responsibility. There are many effective means by which family planning
choices can be implemented. Childbearing, adoption, abstinence from sexual activity
outside of a monogamous relationship, use of contraception methods, natural family plan-
ning, and treatment of infertility are all means of reaching desired family planning goals.
Despite the fundamental importance of these decisions to each individual and to society
as a whole, problems attendant to poor family planning exert a tremendous toll on our
Nation. In 1988, nearly half of American women surveyed reported that their pregnan-
cies in the last 5 years had been mistimed or unwanted-56 percent if adjustment is made
for unreported abortions. 69
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 20.69,87 Each
year, one out of ten young women in this age group becomes pregnant. By age 20, ap-
proximately 40 percent of all women have been pregnant while 63 percent of black
women have been pregnant. 90 An estimated 84 percent of these pregnancies were unin-
tended, 32 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 aged 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.
59
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. 70 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 6,46 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 prob-
lems. Stress, whether stemming from life events, chronic strain, or environmental pres-
sures, is associated with biological changes linked to cognitive, emotional, and behav-
ioral dysfunctions. Healthful habits, such as good nutrition and adequate amounts of ex-
ercise, 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.
60
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 1987. 51 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. 25 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. 44
Intrafamilial violence is more prevalent than often recognized. In 1986 an estimated 1.6
million children nationwide experienced some form of abuse or neglect. 95 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
assistance for injuries caused by battering each year, and the vast majority of domestic
homicides are preceded by episodes of violence. 56
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.
61
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 shown that school health education is an effective means of help-
ing children improve their health knowledge and develop attitudes that facilitate healthier
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 employ-
ees, about two-thirds report offering at least one health promotion activity. 71 A much
smaller share offers a comprehensive package to employees, and even fewer include spe-
cial activities for family members or retirees.
To enhance educational and community-based programs, by the year 2000
8.4
Provide quality K-12 school health education in at least 75% of schools
8.6
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 preschool programs for disadvantaged children; strengthening the public
health system; increasing accessibility of health promotion programs for older people;
development of broad State-based strategies for health promotion; and stronger focus
on the health promotion needs of minorities.
62
5. Priorities for Health Promotion and Disease Prevention
Health Protection
Unintentional Injuries
Occupational Safety and Health
Environmental Health
Food and Drug Safety
Oral Health
63
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. 51 Nonfatal injuries are
responsible for one of every six hospital days and one of every 10 hospital discharges.⁸¹
Nearly two-thirds of all injury deaths and 84 percent of all injuries resulting in hospital-
ization involve unintentional injuries. Motor vehicle crashes account for approximately
one-half of the deaths from unintentional injuries. Deaths from falls rank second, fol-
lowed 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 inju-
ries 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. 51 American Indian and Alaska Natives have disproportionately higher in-
jury death rates. 30
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. 81
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. 60
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 fatal-
ities are related to motorcycle, pedestrian, and bicycle casualities, increasing helmet use
could also prove of substantial benefit. 61,62
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 through 19. 14 Of these, about 15 percent were unintentional and often due to im-
proper handling, accessibility to children, and lack of safety mechanisms. 14 Progress in
reducing unintentional injuries will require full participation of the fields of education,
transportation, 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.
64
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 work-related fatalities involved people 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 in-
juries (11 percent), blows other than by vehicles or equipment (8 percent), and electrocu-
tions (7 percent). 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 enter-
prises comprise about one-fifth of the total workforce, they report one-fourth of the inju-
ries.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.
65
Healthy People 2000
Environmental Health
Environmental measures have long been a mainstay of public health. State and local ef-
forts to assure safe supplies of food and water, to manage sewage and municipal wastes,
and to control or eliminate vector-borne illnesses have contributed substantially to public
health improvements in the United States. The most difficult challenges for environmen-
tal 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 percent 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. 68 Still, enough is known to target improvement 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 µg/dL and 1 out of 10 has levels above 25 µg/dL. For the
Nation 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. 72
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 71% 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.
66
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.
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.
67
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. 66 Currently 53 percent of children aged 6 to 8 and 78 percent of 15 year olds
have caries. 67 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. 53 Periodontal
diseases, especially gingivitis, also affect many adults. The total cost of dental care to the
Nation was more than $27 billion in 1988. 28
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. 53 The proportions of black and His-
panic adolescents with untreated decay are approximately 65 percent higher than for the
total population. 57,67 One out of every four American Indian and Alaska Native adults
aged 35 through 44, and nearly three out of four aged 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 affects oral health.
Oral cancer is also a serious problem, with 30,000 new cases and 8,600 deaths a year. 88
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, they are prevent-
able. 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 prevalence of dental caries to no more than 35% of children by
age 8
(a 34% decrease)
13.4 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.
68
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
69
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. 70 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 National 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 congenital anomalies,
sudden infant death syndrome (SIDS), respiratory distress syndrome, and disorders relat-
ing to short gestation. 49
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. 55 From 1970 to 1981 low birth weight declined about 1.3 percent per
year, but has since been stagnant. 70 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. 35 Smoking is estimated to be associated with from 20 to 30 percent of
all low-birth-weight births in this country. 36 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 receives no care in the first trimester of her pregnancy. 70 A disproportionate share
of these mothers has low income, less than a high school education, or is very young. 86
Between 1970 and 1980 there was a significant trend toward increasing early entry into
prenatal care, but that trend has since plateaued. 70 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 recommended primary care services.
70
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 are affected by coronary artery disease, and cardio-
vascular diseases still cause more deaths in the United States than all other diseases com-
bined. 51 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. 58 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). 58 Although surveys indicate that most adults with
high blood pressure are aware of their condition, only about one-quarter to a third have
their blood pressure under control. 57 This remains a problem despite the fact that many
can reduce their blood pressure to normal through programs of physical activity 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. 58 Yet the mean cholesterol level for Americans is 213 mg/dL, 54
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. 84 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. 40 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 appropriate management behaviors 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.
71
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. 47 More people are surviving cancer now than several decades ago.
Not everyone, however, 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 educa-
tional 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 roughly another 35 percent. 48 For example,
most cases of lung cancer, the leading cause of cancer mortality, can be prevented by not
smoking, and epidemiological research suggests that diets relatively low in fat and higher
in foods containing fiber may help prevent colon, rectal, breast, prostate, and other can-
cers. High levels of alcohol use have been linked to esophageal and oral cancers. Limit-
ing sun exposure, 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, fecal occult blood
tests, proctosigmoidoscopy, and oral, skin, and digital rectal examinations make it pos-
sible to treat cancers before they spread. For example, research suggests than breast can-
cer deaths could be reduced by 30 percent among women aged 50 and older through the
use of mammography and clinical breast examination. 85,89,93 Yet in 1987, only 25 per-
cent of such women had these tests within the preceding 2 years. A Pap test could reduce
cervical cancer deaths by an estimated 75 percent, but one out of every five women with
family incomes less than $10,000 has never had a Pap test. 53 Despite the fact that fecal
occult blood testing and sigmoidoscopy are important 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 to 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.
72
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, affecting people in all age groups, such as
diabetes, arthritis, deformities or orthopedic impairments, hearing and speech impair-
ments, 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 major activities one is able to
perform, affected more than 9 percent of Americans in 1988 50 About 33 million people
have functional limitations that interfere with their daily activities, and more than 9 mil-
lion have limitations that prevent them from working, attending school, or maintaining a
household. The underlying impairments most often responsible for these conditions are
arthritis, heart disease, back conditions (including spinal curvature), lower extremity im-
pairments, and intervertebral disk disorders.³⁷ For those under age 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. Approxi-
mately 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 additional
deaths. According to the American Diabetes Association, in addition to death, diabetes is
accountable for 30 percent of kidney failure cases, is the second leading cause of blind-
ness in people aged 45 through 74, causes half of all nontraumatic amputations, and
causes a threefold increase in risk for congenital malformations 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, sometimes in combination with oral hypo-
glycemic agents. Careful control of diabetes is critical 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.
73
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
multiple-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. 29 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. 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. 14,43
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; 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.
74
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. 94 Because only some
teenagers are sexually active, this amounts to an effective rate of at least 25 percent among
those who are. 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 papillomavirus, fetal and infant
death, birth defects, and mental retardation. The total societal cost of sexually trans-
mitted diseases exceeds $3.5 billion annually, with the cost of PID and PID-associated
ectopic pregnancy and infertility alone exceeding $2.6 billion. 94
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 through 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 per-
cent 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 dra-
matically, due in part to an increase in the exchange of sex for drugs, to an increased num-
ber of crack cocaine users, and to increased sexual activity among adolescents. Between
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 infections to no more than 225 per 100,000 people
(a 25% decrease)
19.3 Reduce syphilis infections 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.
75
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, including the virtual elimination of diphtheria and poliomyelitis in
the United States. Much of the progress made has been a result of improvements in basic
hygiene, food production and food handling, and water treatment. The development and
use of antimicrobial drugs have reduced the morbidity and mortality associated with 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. Influ-
enza and pneumonia, for example, shorten the lives of many older adults despite the avail-
ability of vaccines. Approximately 80 to 90 percent of all influenza-associated deaths in
the United States occur in people 65 years or older.⁹ The childhood vaccine-preventable
diseases, although they have declined dramatically, remain problems among certain high-
risk, under-immunized groups. Moreover, newly recognized diseases, such as Legion-
naire's disease, toxic shock syndrome, Lyme disease, and the wide spectrum of diseases
associated with human immunodeficiency virus infection, have emerged as threats to
public health.
The occurrence of measles in the United States is an example of an infectious disease
problem that should be readily controlled in that 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 immunization of
low-income preschool children, as well as of young people, the disease has demonstrated
a resurgence in susceptible populations, with over 16,000 cases reported in 1989, includ-
ing
41
deaths. 42 In response, the measles immunization protocol recommended by the
Immunization Practices Advisory Committee now calls for a two-dose schedule of meas-
les vaccine, but effective control will also require better outreach in low-income com-
munities, continued strong enforcement of school entry laws, and efficient identification
and intervention 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 indigenous cases of 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 child care
settings; eliminating financial barriers to immunizations; fully involving primary care
providers in meeting the immunization needs of their patients; and expanding
laboratory capabilities for rapid viral diagnosis of influenza.
76
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 Services⁹² 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. 41 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.⁹⁶ 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
ongoing primary care; increasing primary care providers' delivery of recommended
preventive services; 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; and increasing representation of minorities
among primary care providers.
77
Healthy People 2000
Surveillance and Data Systems
78
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 pre-
vention 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 systems 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. ,,31 The development and dissemination of comparable procedures for data col-
lection 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 na-
tional data. In addition, the development of a small set of common health indicators, ar-
rived at through a consensus process, would facilitate communication among public
health officials and with others involved in programs and activities that affect the
Nation's health (e.g., employers and school administrators). Though complete com-
parability across data systems is not possible given the differences in purposes and ap-
proaches (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.
79
Healthy People 2000
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83
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
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 example,
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
individuals 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 stand-
ards of good health. When families experience stresses that can result in self-destruction
through abuse, neglect, and addiction, the community's responsibility becomes increas-
ingly urgent. Single-parent homes, children in poverty, and an aging society are all fac-
tors that threaten the family's viability. As the burdens of a family increase, 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.
85
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 are
often more efficient 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 pro-
motion services for the people they serve-in addition to their historic roles of providing
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 one of our
strongest national traditions. Groups that have not traditionally been involved in reduc-
ing health risks should now begin to define their role in community health education.
For example, local organizations serving 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 enhance
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 themselves,
their dependents, and retirees. Many important disease prevention and health promotion
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 ecology 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 leader-
ship 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,
86
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 communities
where the health care system is weak and overburdened. In poor black communities, 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 institu-
tions are sponsoring health fairs and establishing blood pressure education, screening,
and control programs. They offer individual and family counseling and are often in-
volved in adolescent pregnancy prevention efforts. These are important contributions.
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 professionals in
order to integrate healthy practices into the daily lives of individuals, their families, and
communities. Professional associations can facilitate dissemination of the health promo-
tion and disease prevention knowledge base through their established information ex-
change and professional education networks. A special opportunity and responsibility
exists for the teachers of health professionals to design curricula and allocate educational
resources which will equip health-related professions with prevention expertise 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
directly to the target audience. New opportunities will also unfold through the evolving
integration of telecommunications media-telephone, television, computer-to make
customized health information more accessible than ever before.
87
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 Ameri-
cans are directly and indirectly shaped by such policy decisions. Local, State, and Fed-
eral governments can ensure that health promotion and disease prevention activities
receive adequate attention and support. The accomplishment of this task can be effec-
tively 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
surveillance systems on the occurrence of disease, exposure to risks, and delivery of
services. 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 envi-
ronments, 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, organi-
zation, or government has the resources to bring about the changes needed to implement
this broad program, and yet the program cannot succeed unless each of us contributes in-
dividually. In essence, Healthy People 2000 offers hope that through cooperative 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. It is what we do collectively and personally that will move us as
individuals and as a Nation towards a healthier future.
88
Appendices
Contents
A.
Summary List of
Objectives
B.
Contributors to Healthy
People 2000
C.
Priority Area Lead
Agencies
A. Summary List of Objectives
Duplicate objectives, which appear in two or more priority areas, are marked with an asterisk (*).
Except as otherwise noted, all rates in the following objectives are annual. Where the baseline rate is age adjusted, it is age
adjusted to the 1940 U.S. population, and the target is age adjusted also.
1.
Physical Activity And Fitness
Health Status Objectives
1.1*
Reduce coronary heart disease deaths to no more than 100 per 100,000 people. (Age-adjusted baseline: 135 per
100,000 in 1987)
Special Population Target
Coronary Deaths (per 100,000)
1987 Baseline
2000 Target
1.1a
Blacks
163
115
1.2*
Reduce overweight to a prevalence of no more than 20 percent among people aged 20 and older and no more than 15
percent among adolescents aged 12 through 19. (Baseline: 26 percent for people aged 20 through 74 in 1976-80,
24 percent for men and 27 percent for women; 15 percent for adolescents aged 12 through 19 in 1976-80)
Special Population Targets
Overweight Prevalence
1976-80 Baseline
2000 Target
1.2a
Low-income women aged 20 and older
37%
25%
1.2b
Black women aged 20 and older
44%
30%
1.2c
Hispanic women aged 20 and older
25%
Mexican-American women
39%
Cuban women
34%
Puerto Rican women
37%+
1.2d
American Indians/Alaska Natives
29-75%
30%
1.2e
People with disabilities
36%+
25%
1.2f
Women with high blood pressure
50%
41%
1.2g
Men with high blood pressure
39%
35%
+ Baseline for people aged 20-74 + 1982-84 baseline for Hispanics aged 20-74
§ 1984-88 estimates for different tribes +1985 baseline for people aged 20-74 who report any limitation in
activity due to chronic conditions
Note: For people aged 20 and older, overweight is defined as body mass index (BMI) equal to or greater than 27.8
for men and 27.3 for women. For adolescents, overweight is defined as BMI equal to or greater than 23.0 for
males aged 12 through 14, 24.3 for males aged 15 through 17, 25.8 for males aged 18 through 19, 23.4 for
females aged 12 through 14, 24.8 for females aged 15 through 17, and 25.7 for females aged 18 through 19. The
values for adolescents are the age- and gender-specific 85th percentile values of the 1976-80 National Health and
Nutrition Examination Survey (NHANES II), corrected for sample variation. BMI is calculated by dividing weight
in kilograms by the square of height in meters. The cut points used to define overweight approximate the 120 per-
cent of desirable body weight definition used in the 1990 objectives.
Risk Reduction Objectives
1.3*
Increase to at least 30 percent the proportion of people aged 6 and older who engage regularly, preferably daily, in
light to moderate physical activity for at least 30 minutes per day. (Baseline: 22 percent of people aged 18 and
older were active for at least 30 minutes 5 or more times per week and 12 percent were active 7 or more times per
week in 1985)
Note: Light to moderate physical activity requires sustained, rhythmic muscular movements, is at least equivalent
to sustained walking, and is performed at less than 60 percent of maximum heart rate for age. Maximum heart rate
equals roughly 220 beats per minute minus age. Examples may include walking, swimming, cycling, dancing, gar-
dening and yardwork, various domestic and occupational activities, and games and other childhood pursuits.
91
Healthy People 2000
1.4
Increase to at least 20 percent the proportion of people aged 18 and older and to at least 75 percent the proportion of
children and adolescents aged 6 through 17 who engage in vigorous physical activity that promotes the
development and maintenance of cardiorespiratory fitness 3 or more days per week for 20 or more minutes per
occasion. (Baseline: 12 percent for people aged 18 and older in 1985; 66 percent for youth aged 10 through 17 in
1984)
Special Population Target
Vigorous Physical Activity
1985 Baseline
2000 Target
1.4a
Lower-income people aged 18 and older (annual family
income <$20,000)
7%
12%
Note: Vigorous physical activities are rhythmic, repetitive physical activities that use large muscle groups at 60
percent or more of maximum heart rate for age. An exercise heart rate of 60 percent of maximum heart rate for age
is about 50 percent of maximal cardiorespiratory capacity and is sufficient for cardiorespiratory conditioning.
Maximum heart rate equals roughly 220 beats per minute minus age.
1.5
Reduce to no more than 15 percent the proportion of people aged 6 and older who engage in no leisure-time physical
activity. (Baseline: 24 percent for people aged 18 and older in 1985)
Special Population Targets
No Leisure-Time Physical Activity
1985 Baseline
2000 Target
1.5a
People aged 65 and older
43%
22%
1.5b
People with disabilities
35%¹
20%
1.5c
Lower-income people (annual family income <$20,000)
32%⁺
17%
Baseline for people aged 18 and older
Note: For this objective, people with disabilities are people who report any limitation in activity due to chronic con-
ditions.
1.6
Increase to at least 40 percent the proportion of people aged 6 and older who regularly perform physical activities that
enhance and maintain muscular strength, muscular endurance, and flexibility. (Baseline data available in 1991)
1.7*
Increase to at least 50 percent the proportion of overweight people aged 12 and older who have adopted sound dietary
practices combined with regular physical activity to attain an appropriate body weight. (Baseline: 30 percent of
overweight women and 25 percent of overweight men for people aged 18 and older in 1985)
Services and Protection Objectives
1.8
Increase to at least 50 percent the proportion of children and adolescents in 1st through 12th grade who participate in
daily school physical education. (Baseline: 36 percent in 1984-86)
1.9
Increase to at least 50 percent the proportion of school physical education class time that students spend being
physically active, preferably engaged in lifetime physical activities. (Baseline: Students spent an estimated 27
percent of class time being physically active in 1983)
Note: Lifetime activities are activities that may be readily carried into adulthood because they generally need only
one or two people. Examples include swimming, bicycling, jogging, and racquet sports. Also counted as lifetime
activities are vigorous social activities such as dancing. Competitive group sports and activities typically played
only by young children such as group games are excluded.
1.10
Increase the proportion of worksites offering employer-sponsored physical activity and fitness programs as follows:
Worksite Size
1985 Baseline
2000 Target
50-99 employees
14%
20%
100-249 employees
23%
35%
250-749 employees
32%
50%
≥750 employees
54%
80%
1.11
Increase community availability and accessibility of physical activity and fitness facilities as follows:
Facility
1986 Baseline
2000 Target
Hiking, biking, and fitness trail miles
1 per 71,000 people
1 per 10,000 people
Public swimming pools
1 per 53,000 people
1 per 25,000 people
Acres of park and recreation open space
1.8 per 1,000 people
4 per 1,000 people
(553 people per
(250 people per
managed acre)
managed acre)
1.12 Increase to at least 50 percent the proportion of primary care providers who routinely assess and counsel their patients
regarding the frequency, duration, type, and intensity of each patient's physical activity practices. (Baseline:
Physicians provided exercise counseling for about 30 percent of sedentary patients in 1988)
92
A. Summary List of Objectives
2.
Nutrition
Health Status Objectives
2.1*
Reduce coronary heart disease deaths to no more than 100 per 100,000 people. (Age-adjusted baseline: 135 per
100,000 in 1987)
Special Population Target
Coronary Deaths (per 100,000)
1987 Baseline
2000 Target
2.1a
Blacks
163
115
2.2*
Reverse the rise in cancer deaths to achieve a rate of no more than 130 per 100,000 people. (Age-adjusted baseline:
133 per 100,000 in 1987)
Note: In its publications, the National Cancer Institute age adjusts cancer death rates to the 1970 U.S. population.
Using the 1970 standard, the equivalent baseline and target values for this objective would be 171 and 175 per
100,000, respectively.
2.3*
Reduce overweight to a prevalence of no more than 20 percent among people aged 20 and older and no more than 15
percent among adolescents aged 12 through 19. (Baseline: 26 percent for people aged 20 through 74 in 1976-80,
24 percent for men and 27 percent for women; 15 percent for adolescents aged 12 through 19 in 1976-80)
Special Population Targets
Overweight Prevalence
1976-80 Baseline¹ 2000 Target
2.3a
Low-income women aged 20 and older
37%
25%
2.3b
Black women aged 20 and older
44%
30%
2.3c
Hispanic women aged 20 and older
25%
Mexican-American women
39%
Cuban women
34%
Puerto Rican women
37%
2.3d
American Indians/Alaska Natives
29-75%
30%
2.3e
People with disabilities
36%+
25%
2.3f
Women with high blood pressure
50%
41%
2.3g
Men with high blood pressure
39%
35%
Baseline for people aged 20-74 + 1982-84 baseline for Hispanics aged 20-74
§ 1984-88 estimates for different tribes 1985 baseline for people aged 20-74 who report any limitation in
activity due to chronic conditions
Note: For people aged 20 and older, overweight is defined as body mass index (BMI) equal to or greater than 27.8
for men and 27.3 for women. For adolescents, overweight is defined as BMI equal to or greater than 23.0 for
males aged 12 through 14, 24.3 for males aged 15 through 17, 25.8 for males aged 18 through 19, 23.4 for females
aged 12 through 14, 24.8 for females aged 15 through 17, and 25.7 for females aged 18 through 19. The values for
adolescents are the age- and gender-specific 85th percentile values of the 1976-80 National Health and Nutrition
Examination Survey (NHANES II), corrected for sample variation. BMI is calculated by dividing weight in
kilograms by the square of height in meters. The cut points used to define overweight approximate the 120 percent
of desirable body weight definition used in the 1990 objectives.
2.4
Reduce growth retardation among low-income children aged 5 and younger to less than 10 percent. (Baseline: Up to
16 percent among low-income children in 1988, depending on age and race/ethnicity)
Special Population Targets
Prevalence of Short Stature
1988 Baseline
2000 Target
2.4a
Low-income black children <age 1
15%
10%
2.4b
Low-inçome Hispanic children <age 1
13%
10%
2.4c
Low-income Hispanic children aged 1
16%
10%
2.4d
Low-income Asian/Pacific Islander children aged 1
14%
10%
2.4e
Low-income Asian/Pacific Islander children aged 2-4
16%
10%
Note: Growth retardation is defined as height-for-age below the fifth percentile of children in the National Center
for Health Statistics' reference population.
Risk Reduction Objectives
2.5*
Reduce dietary fat intake to an average of 30 percent of calories or less and average saturated fat intake to less than 10
percent of calories among people aged 2 and older. (Baseline: 36 percent of calories from total fat and 13 percent
from saturated fat for people aged 20 through 74 in 1976-80; 36 percent and 13 percent for women aged 19
through 50 in 1985)
2.6*
Increase complex carbohydrate and fiber-containing foods in the diets of adults to 5 or more daily servings for
vegetables (including legumes) and fruits, and to 6 or more daily servings for grain products. (Baseline: 2½
servings of vegetables and fruits and 3 servings of grain products for women aged 19 through 50 in 1985)
2.7*
Increase to at least 50 percent the proportion of overweight people aged 12 and older who have adopted sound dietary
practices combined with regular physical activity to attain an appropriate body weight. (Baseline: 30 percent of
overweight women and 25 percent of overweight men for people aged 18 and older in 1985)
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Healthy People 2000
2.8
Increase calcium intake so at least 50 percent of youth aged 12 through 24 and 50 percent of pregnant and lactating
women consume 3 or more servings daily of foods rich in calcium, and at least 50 percent of people aged 25 and
older consume 2 or more servings daily. (Baseline: 7 percent of women and 14 percent of men aged 19 though 24
and 24 percent of pregnant and lactating women consumed 3 or more servings, and 15 percent of women and 23
percent of men aged 25 through 50 consumed 2 or more servings in 1985-86)
Note: The number of servings of foods rich in calcium is based on milk and milk products. A serving is considered
to be 1 cup of skim milk or its equivalent in calcium (302 mg). The number of servings in this objective will general-
ly provide approximately three-fourths of the 1989 Recommended Dietary Allowance (RDA) of calcium. The RDA
is 1200 mg for people aged 12 through 24, 800 mg for people aged 25 and older, and 1200 mg for pregnant and lac-
tating women.
2.9
Decrease salt and sodium intake so at least 65 percent of home meal preparers prepare foods without adding salt, at
least 80 percent of people avoid using salt at the table, and at least 40 percent of adults regularly purchase foods
modified or lower in sodium. (Baseline: 54 percent of women aged 19 through 50 who served as the main meal
preparer did not use salt in food preparation, and 68 percent of women aged 19 through 50 did not use salt at the
table in 1985; 20 percent of all people aged 18 and older regularly purchased foods with reduced salt and sodium
content in 1988)
2.10 Reduce iron deficiency to less than 3 percent among children aged 1 through 4 and among women of childbearing
age. (Baseline: 9 percent for children aged 1 through 2, 4 percent for children aged 3 through 4, and 5 percent for
women aged 20 through 44 in 1976-80)
Special Population Targets
Iron Deficiency Prevalence
1976-80 Baseline
2000 Target
2.10a Low-income children aged 1-2
21%
10%
2.10b Low-income children aged 3-4
10%
5%
2.10c Low-income women of childbearing age
8%⁺
4%
Anemia Prevalence
1983-85 Baseline
2000 Target
2.10d Alaska Native children aged 1-5
22-28%
10%
2.10e Black, low-income pregnant women (third trimester)
41%
20%
Baseline for women aged 20-44 +1988 baseline for women aged 15-44
Note: Iron deficiency is defined as having abnormal results for 2 or more of the following tests: mean corpuscular
volume, erythrocyte protoporphyrin, and transferrin saturation. Anemia is used as an index of iron deficiency.
Anemia among Alaska Native children was defined as hemoglobin <11 gm/dL or hematocrit <34 percent. For preg-
nant women in the third trimester, anemia was defined according to CDC criteria. The above prevalences of iron
deficiency and anemia may be due to inadequate dietary iron intakes or to inflammatory conditions and infections.
For anemia, genetics may also be a factor.
2.11* Increase to at least 75 percent the proportion of mothers who breastfeed their babies in the early postpartum period
and to at least 50 percent the proportion who continue breastfeeding until their babies are 5 to 6 months old.
(Baseline: 54 percent at discharge from birth site and 21 percent at 5 to 6 months in 1988)
Special Population Targets
Mothers Breastfeeding Their Babies:
1988 Baseline
2000 Target
During Early Postpartum Period-
2.11a Low-income mothers
32%
75%
2.11b Black mothers
25%
75%
2.11c Hispanic mothers
51%
75%
2.11d American Indian/Alaska Native mothers
47%
75%
At Age 5-6 Months-
2.11a Low-income mothers
9%
50%
2.11b Black mothers
8%
50%
2.11c Hispanic mothers
16%
50%
2.11d American Indian/Alaska Native mothers
28%
50%
2.12* Increase to at least 75 percent the proportion of parents and caregivers who use feeding practices that prevent baby
bottle tooth decay. (Baseline data available in 1991)
Special Population Targets
Appropriate Feeding Practices
Baseline
2000 Target
2.12a Parents and caregivers with less than high school education
-
65%
2.12b American Indian/Alaska Native parents and caregivers
I
65%
2.13 Increase to at least 85 percent the proportion of people aged 18 and older who use food labels to make nutritious food
selections. (Baseline: 74 percent used labels to make food selections in 1988)
Services and Protection Objectives
2.14
Achieve useful and informative nutrition labeling for virtually all processed foods and at least 40 percent of fresh
meats, poultry, fish, fruits, vegetables, baked goods, and ready-to-eat carry-away foods. (Baseline: 60 percent of
sales of processed foods regulated by FDA had nutrition labeling in 1988; baseline data on fresh and carry-away
foods unavailable)
94
A. Summary List of Objectives
2.15
Increase to at least 5,000 brand items the availability of processed food products that are reduced in fat and saturated
fat. (Baseline: 2,500 items reduced in fat in 1986)
Note: A brand item is defined as a particular flavor and/or size of a specific brand and is typically the consumer
unit of purchase.
2.16 Increase to at least 90 percent the proportion of restaurants and institutional food service operations that offer
identifiable low-fat, low-calorie food choices, consistent with the Dietary Guidelines for Americans. (Baseline:
About 70 percent of fast food and family restaurant chains with 350 or more units had at least one low-fat,
low-calorie item on their menu in 1989)
2.17
Increase to at least 90 percent the proportion of school lunch and breakfast services and child care food services with
menus that are consistent with the nutrition principles in the Dietary Guidelines for Americans. (Baseline data
available in 1993)
2.18
Increase to at least 80 percent the receipt of home food services by people aged 65 and older who have difficulty in
preparing their own meals or are otherwise in need of home-delivered meals. (Baseline data available in 1991)
2.19 Increase to at least 75 percent the proportion of the Nation's schools that provide nutrition education from preschool
through 12th grade, preferably as part of quality school health education. (Baseline data available in 1991)
2.20
Increase to at least 50 percent the proportion of worksites with 50 or more employees that offer nutrition education
and/or weight management programs for employees. (Baseline: 17 percent offered nutrition education activities
and 15 percent offered weight control activities in 1985)
2.21
Increase to at least 75 percent the proportion of primary care providers who provide nutrition assessment and
counseling and/or referral to qualified nutritionists or dietitians. (Baseline: Physicians provided diet counseling
for an estimated 40 to 50 percent of patients in 1988)
3. Tobacco
Health Status Objectives
3.1*
Reduce coronary heart disease deaths to no more than 100 per 100,000 people. (Age-adjusted baseline: 135 per
100,000 in 1987)
Special Population Target
Coronary Deaths (per 100,000)
1987 Baseline
2000 Target
3.1a
Blacks
163
115
3.2*
Slow the rise in lung cancer deaths to achieve a rate of no more than 42 per 100,000 people. (Age-adjusted baseline:
37.9 per 100,000 in 1987)
Note: In its publications, the National Cancer Institute age adjusts cancer death rates to the 1970 U.S. population.
Using the 1970 standard, the equivalent baseline and target values for this objective would be 47.9 and 53 per
100,000, respectively.
3.3
Slow the rise in deaths from chronic obstructive pulmonary disease to achieve a rate of no more than 25 per 100,000
people. (Age-adjusted baseline: 18.7 per 100,000 in 1987)
Note: Deaths from chronic obstructive pulmonary disease include deaths due to chronic bronchitis, emphysema,
asthma, and other chronic obstructive pulmonary diseases and allied conditions.
Risk Reduction Objectives
3.4*
Reduce cigarette smoking to a prevalence of no more than 15 percent among people aged 20 and older. (Baseline: 29
percent in 1987, 32 percent for men and 27 percent for women)
Special Population Targets
Cigarette Smoking Prevalence
1987 Baseline
2000 Target
3.4a
People with a high school education or less aged 20 and older
34%
20%
3.4b
Blue-collar workers aged 20 and older
36%
20%
3.4c
Military personnel
42%⁺
20%
3.4d
Blacks aged 20 and older
34%
18%
3.4e
Hispanics aged 20 and older
33%⁺
18%
3.4f
American Indians/Alaska Natives
42-70%
20%
3.4g
Southeast Asian men
55%⁺
20%
3.4h
Women of reproductive age
29%⁺⁺
12%
3.4i
Pregnant women
25%
10%
3.4j
Women who use oral contraceptives
36% ⁸⁸
10%
1988 baseline 982-84 baseline for Hispanics aged 20-74 1979-87 estimates for different tribes
+1984-88 baseline ++ Baseline for women aged 18-44 1985 baseline §§ 1983 baseline
Note: A cigarette smoker is a person who has smoked at least 100 cigarettes and currently smokes cigarettes.
95
Healthy People 2000
3.5
Reduce the initiation of cigarette smoking by children and youth so that no more than 15 percent have become regular
cigarette smokers by age 20. (Baseline: 30 percent of youth had become regular cigarette smokers by ages 20
through 24 in 1987)
Special Population Target
Initiation of Smoking
1987 Baseline
2000 Target
3.5a
Lower socioeconomic status youth⁺
40%
18%
+ As measured by people aged 20-24 with a high school education or less
3.6
Increase to at least 50 percent the proportion of cigarette smokers aged 18 and older who stopped smoking cigarettes
for at least one day during the preceding year. (Baseline: In 1986, 34 percent of people who smoked in the
preceding year stopped for at least one day during that year)
3.7
Increase smoking cessation during pregnancy so that at least 60 percent of women who are cigarette smokers at the
time they become pregnant quit smoking early in pregnancy and maintain abstinence for the remainder of their
pregnancy. (Baseline: 39 percent of white women aged 20 through 44 quit at any time during pregnancy in 1985)
Special Population Target
Cessation and Abstinence During Pregnancy
1985 Baseline
2000 Target
3.7a
Women with less than a high school education
28%⁺
45%
+ Baseline for white women aged 20-44
3.8
Reduce to no more than 20 percent the proportion of children aged 6 and younger who are regularly exposed to tobacco
smoke at home. (Baseline: More than 39 percent in 1986, as 39 percent of households with one or more children
aged 6 or younger had a cigarette smoker in the household)
Note: Regular exposure to tobacco smoke at home is defined as the occurrence of tobacco smoking anywhere in the
home on more than 3 days each week.
3.9
Reduce smokeless tobacco use by males aged 12 through 24 to a prevalence of no more than 4 percent. (Baseline: 6.6
percent among males aged 12 through 17 in 1988; 8.9 percent among males aged 18 through 24 in 1987)
Special Population Target
Smokeless Tobacco Use
1986-87 Baseline
2000 Target
3.9a
American Indian/Alaska Native youth
18-64%
10%
Note: For males aged 12 through 17, a smokeless tobacco user is someone who has used snuff or chewing tobacco
in the preceding month. For males aged 18 through 24, a smokeless tobacco user is someone who has used either
snuff or chewing tobacco at least 20 times and who currently uses snuff or chewing tobacco.
Services and Protection Objectives
3.10
Establish tobacco-free environments and include tobacco use prevention in the curricula of all elementary, middle,
and secondary schools, preferably as part of quality school health education. (Baseline: 17 percent of school
districts totally banned smoking on school premises or at school functions in 1988; antismoking education was
provided by 78 percent of school districts at the high school level, 81 percent at the middle school level, and 75
percent at the elementary school level in 1988)
3.11
Increase to at least 75 percent the proportion of worksites with a formal smoking policy that prohibits or severely
restricts smoking at the workplace. (Baseline: 27 percent of worksites with 50 or more employees in 1985; 54
percent of medium and large companies in 1987)
3.12 Enact in 50 States comprehensive laws on clean indoor air that prohibit or strictly limit smoking in the workplace and
enclosed public places (including health care facilities, schools, and public transportation). (Baseline: 42 States
and the District of Columbia had laws restricting smoking in public places; 31 States restricted smoking in public
workplaces; but only 13 States had comprehensive laws regulating smoking in private as well as public worksites
and at least 4 public places, including restaurants, as of 1988)
3.13
Enact and enforce in 50 States laws prohibiting the sale and distribution of tobacco products to youth younger than
age 19. (Baseline: 44 States and the District of Columbia had, but rarely enforced, laws regulating the sale and/or
distribution of cigarettes or tobacco products to minors in 1990; only 3 set the age of majority at 19 and only 6
prohibited cigarette vending machines accessible to minors)
Note: Model legislation proposed by DHHS recommends licensure of tobacco vendors, civil money penalties and
license suspension or revocation for violations, and a ban on cigarette vending machines.
3.14
Increase to 50 the number of States with plans to reduce tobacco use, especially among youth. (Baseline: 12 States
in 1989)
3.15
Eliminate or severely restrict all forms of tobacco product advertising and promotion to which youth younger than age
18 are likely to be exposed. (Baseline: Radio and television advertising of tobacco products were prohibited, but
other restrictions on advertising and promotion to which youth may be exposed were minimal in 1990)
3.16
Increase to at least 75 percent the proportion of primary care and oral health care providers who routinely advise
cessation and provide assistance and followup for all of their tobacco-using patients. (Baseline: About 52 percent
of internists reported counseling more than 75 percent of their smoking patients about smoking cessation in 1986;
about 35 percent of dentists reported counseling at least 75 percent of their smoking patients about smoking in
1986)
96
A. Summary List of Objectives
4. Alcohol and Other Drugs
Health Status Objectives
4.1
Reduce deaths caused by alcohol-related motor vehicle crashes to no more than 8.5 per 100,000 people. (Age-adjusted
baseline: 9.8 per 100,000 in 1987)
Special Population Targets
Alcohol-Related Motor Vehicle Crash Deaths
(per 100,000)
1987 Baseline
2000 Target
4.1a
American Indian/Alaska Native men
52.2
44.8
4.1b
People aged 15-24
21.5
18
4.2
Reduce cirrhosis deaths to no more than 6 per 100,000 people. (Age-adjusted baseline: 9.1 per 100,000 in 1987)
Special Population Targets
Cirrhosis Deaths (per 100,000)
1987 Baseline
2000 Target
4.2a
Black men
22
12
4.2b
American Indians/Alaska Natives
25.9
13
4.3
Reduce drug-related deaths to no more than 3 per 100,000 people. (Age-adjusted baseline: 3.8 per 100,000 in 1987)
4.4
Reduce drug abuse-related hospital emergency department visits by at least 20 percent. (Baseline data available in
1991)
Risk Reduction Objectives
4.5
Increase by at least 1 year the average age of first use of cigarettes, alcohol, and marijuana by adolescents aged 12
through 17. (Baseline: Age 11.6 for cigarettes, age 13.1 for alcohol, and age 13.4 for marijuana in 1988)
4.6
Reduce the proportion of young people who have used alcohol, marijuana, and cocaine in the past month, as follows:
Substance/Age
1988 Baseline
2000 Target
Alcohol/aged 12-17
25.2%
12.6%
Alcohol/aged 18-20
57.9%
29%
Marijuana/aged 12-17
6.4%
3.2%
Marijuana/aged 18-25
15.5%
7.8%
Cocaine/aged 12-17
1.1%
0.6%
Cocaine/aged 18-25
4.5%
2.3%
Note: The targets of this objective are consistent with the goals established by the Office of National Drug Control
Policy, Executive Office of the President.
4.7
Reduce the proportion of high school seniors and college students engaging in recent occasions of heavy drinking of
alcoholic beverages to no more than 28 percent of high school seniors and 32 percent of college students.
(Baseline: 33 percent of high school seniors and 41.7 percent of college students in 1989)
Note: Recent heavy drinking is defined as having 5 or more drinks on one occasion in the previous 2-week period
as monitored by self-reports.
4.8
Reduce alcohol consumption by people aged 14 and older to an annual average of no more than 2 gallons of ethanol per
person. (Baseline: 2.54 gallons of ethanol in 1987)
4.9
Increase the proportion of high school seniors who perceive social disapproval associated with the heavy use of
alcohol, occasional use of marijuana, and experimentation with cocaine, as follows:
Behavior
1989 Baseline
2000 Target
Heavy use of alcohol
56.4%
70%
Occasional use of marijuana
71.1%
85%
Trying cocaine once or twice
88.9%
95%
Note: Heavy drinking is defined as having 5 or more drinks once or twice each weekend.
4.10
Increase the proportion of high school seniors who associate risk of physical or psychological harm with the heavy use
of alcohol, regular use of marijuana, and experimentation with cocaine, as follows:
Behavior
1989 Baseline
2000 Target
Heavy use of alcohol
44%
70%
Regular use of marijuana
77.5%
90%
Trying cocaine once or twice
54.9%
80%
Note: Heavy drinking is defined as having 5 or more drinks once or twice each weekend.
4.11
Reduce to no more than 3 percent the proportion of male high school seniors who use anabolic steroids. (Baseline:
4.7 percent in 1989)
Services and Protection Objectives
4.12
Establish and monitor in 50 States comprehensive plans to ensure access to alcohol and drug treatment programs for
traditionally underserved people. (Baseline data available in 1991)
97
Healthy People 2000
4.13
Provide to children in all school districts and private schools primary and secondary school educational programs on
alcohol and other drugs, preferably as part of quality school health education. (Baseline: 63 percent provided
some instruction, 39 percent provided counseling, and 23 percent referred students for clinical assessments in 1987)
4.14
Extend adoption of alcohol and drug policies for the work environment to at least 60 percent of worksites with 50 or
more employees. (Baseline data available in 1991)
4.15
Extend to 50 States administrative driver's license suspension/revocation laws or programs of equal effectiveness for
people determined to have been driving under the influence of intoxicants. (Baseline: 28 States and the District of
Columbia in 1990)
4.16
Increase to 50 the number of States that have enacted and enforce policies, beyond those in existence in 1989, to
reduce access to alcoholic beverages by minors.
Note: Policies to reduce access to alcoholic beverages by minors may include those that address restriction of the
sale of alcoholic beverages at recreational and entertainment events at which youth make up a majority of par-
ticipants/consumers, product pricing, penalties and license-revocation for sale of alcoholic beverages to minors,
and other approaches designed to discourage and restrict purchase of alcoholic beverages by minors.
4.17
Increase to at least 20 the number of States that have enacted statutes to restrict promotion of alcoholic beverages that
is focused principally on young audiences. (Baseline data available in 1992)
4.18
Extend to 50 States legal blood alcohol concentration tolerance levels of .04 percent for motor vehicle drivers aged 21
and older and .00 percent for those younger than age 21. (Baseline: 0 States in 1990)
4.19
Increase to at least 75 percent the proportion of primary care providers who screen for alcohol and other drug use
problems and provide counseling and referral as needed. (Baseline data available in 1992)
5. Family Planning
Health Status Objectives
5.1
Reduce pregnancies among girls aged 17 and younger to no more than 50 per 1,000 adolescents. (Baseline: 71.1
pregnancies per 1,000 girls aged 15 through 17 in 1985)
Special Population Targets
Pregnancies (per 1,000)
1985 Baseline
2000 Target
5.1a
Black adolescent girls aged 15-19
186⁺
120
5.1b
Hispanic adolescent girls aged 15-19
158
105
Non-white adolescents
Note: For black and Hispanic adolescent girls, baseline data are unavailable for those aged 15 through 17. The
targets for these two populations are based on data for women aged 15 through 19. If more complete data become
available, a 35-percent reduction from baseline figures should be used as the target.
5.2
Reduce to no more than 30 percent the proportion of all pregnancies that are unintended. (Baseline: 56 percent of
pregnancies in the previous 5 years were unintended, either unwanted or earlier than desired, in 1988)
Special Population Target
Unintended Pregnancies
1988 Baseline
2000 Target
5.2a
Black women
78%
40%
5.3
Reduce the prevalence of infertility to no more than 6.5 percent. (Baseline: 7.9 percent of married couples with wives
aged 15 through 44 in 1988)
Special Population Targets
Prevalence of Infertility
1988 Baseline
2000 Target
5.3a
Black couples
12.1%
9%
5.3b
Hispanic couples
12.4%
9%
Note: Infertility is the failure of couples to conceive after 12 months of intercourse without contraception.
Risk Reduction Objectives
5.4*
Reduce the proportion of adolescents who have engaged in sexual intercourse to no more than 15 percent by age 15
and no more than 40 percent by age 17. (Baseline: 27 percent of girls and 33 percent of boys by age 15; 50
percent of girls and 66 percent of boys by age 17; reported in 1988)
5.5
Increase to at least 40 percent the proportion of ever sexually active adolescents aged 17 and younger who have
abstained from sexual activity for the previous 3 months. (Baseline: 26 percent of sexually active girls aged 15
through 17 in 1988)
5.6
Increase to at least 90 percent the proportion of sexually active, unmarried people aged 19 and younger who use
contraception, especially combined method contraception that both effectively prevents pregnancy and provides
barrier protection against disease. (Baseline: 78 percent at most recent intercourse and 63 percent at first
intercourse; 2 percent used oral contraceptives and the condom at most recent intercourse; among young women
aged 15 through 19 reporting in 1988)
Note: Strategies to achieve this objective must be undertaken sensitively to avoid indirectly encouraging or condon-
ing sexual activity among teens who are not yet sexually active.
98
A. Summary List of Objectives
5.7
Increase the effectiveness with which family planning methods are used, as measured by a decrease to no more than 5
percent in the proportion of couples experiencing pregnancy despite use of a contraceptive method. (Baseline:
Approximately 10 percent of women using reversible contraceptive methods experienced an unintended pregnancy
in 1982)
Services and Protection Objectives
5.8
Increase to at least 85 percent the proportion of people aged 10 through 18 who have discussed human sexuality,
including values surrounding sexuality, with their parents and/or have received information through another
parentally endorsed source, such as youth, school, or religious programs. (Baseline: 66 percent of people aged 13
through 18 have discussed sexuality with their parents; reported in 1986)
Note: This objective, which supports family communication on a range of vital personal health issues, will be track-
ed using the National Health Interview Survey, a continuing, voluntary, national sample survey of adults who report
on household characteristics including such items as illnesses, injuries, use of health services, and demographic
characteristics.
5.9
Increase to at least 90 percent the proportion of pregnancy counselors who offer positive, accurate information about
adoption to their unmarried patients with unintended pregnancies. (Baseline: 60 percent of pregnancy counselors
in 1984)
Note: Pregnancy counselors are any providers of health or social services who discuss the management or out-
come of pregnancy with a woman after she has received a diagnosis of pregnancy.
5.10* Increase to at least 60 percent the proportion of primary care providers who provide age-appropriate preconception
care and counseling. (Baseline data available in 1992)
5.11* Increase to at least 50 percent the proportion of family planning clinics, maternal and child health clinics, sexually
transmitted disease clinics, tuberculosis clinics, drug treatment centers, and primary care clinics that screen,
diagnose, treat, counsel, and provide (or refer for) partner notification services for HIV infection and bacterial
sexually transmitted diseases (gonorrhea, syphilis, and chlamydia). (Baseline: 40 percent of family planning
clinics for bacterial sexually transmitted diseases in 1989)
6. Mental Health and Mental Disorders
Health Status Objectives
6.1*
Reduce suicides to no more than 10.5 per 100,000 people. (Age-adjusted baseline: 11.7 per 100,000 in 1987)
Special Population Targets
Suicides (per 100,000)
1987 Baseline
2000 Target
6.1a
Youth aged 15-19
10.3
8.2
6.1b
Men aged 20-34
25.2
21.4
6.1c
White men aged 65 and older
46.1
39.2
6.1d
American Indian/Alaska Native men in Reservation States 15
12.8
6.2*
Reduce by 15 percent the incidence of injurious suicide attempts among adolescents aged 14 through 17. (Baseline
data available in 1991)
6.3
Reduce to less than 10 percent the prevalence of mental disorders among children and adolescents. (Baseline: An
estimated 12 percent among youth younger than age 18 in 1989)
6.4
Reduce the prevalence of mental disorders (exclusive of substance abuse) among adults living in the community to less
than 10.7 percent. (Baseline: One-month point prevalence of 12.6 percent in 1984)
6.5
Reduce to less than 35 percent the proportion of people aged 18 and older who experienced adverse health effects from
stress within the past year. (Baseline: 42.6 percent in 1985)
Special Population Target
1985 Baseline
2000 Target
6.5a
People with disabilities
53.5%
40%
Note: For this objective, people with disabilities are people who report any limitation in activity due to chronic
conditions.
Risk Reduction Objectives
6.6
Increase to at least 30 percent the proportion of people aged 18 and older with severe, persistent mental disorders who
use community support programs. (Baseline: 15 percent in 1986)
6.7
Increase to at least 45 percent the proportion of people with major depressive disorders who obtain treatment.
(Baseline: 31 percent in 1982)
99
Healthy People 2000
6.8
Increase to at least 20 percent the proportion of people aged 18 and older who seek help in coping with personal and
emotional problems. (Baseline: 11.1 percent in 1985)
Special Population Target
1985 Baseline
2000 Target
6.8a
People with disabilities
14.7%
30%
6.9
Decrease to no more than 5 percent the proportion of people aged 18 and older who report experiencing significant
levels of stress who do not take steps to reduce or control their stress. (Baseline: 21 percent in 1985)
Services and Protection Objectives
6.10*
Increase to 50 the number of States with officially established protocols that engage mental health, alcohol and drug,
and public health authorities with corrections authorities to facilitate identification and appropriate intervention to
prevent suicide by jail inmates. (Baseline data available in 1992)
6.11
Increase to at least 40 percent the proportion of worksites employing 50 or more people that provide programs to
reduce employee stress. (Baseline: 26.6 percent in 1985)
6.12
Establish mutual help clearinghouses in at least 25 States. (Baseline: 9 States in 1989)
6.13
Increase to at least 50 percent the proportion of primary care providers who routinely review with patients their
patients' cognitive, emotional, and behavioral functioning and the resources available to deal with any problems
that are identified. (Baseline data available in 1992)
6.14
Increase to at least 75 percent the proportion of providers of primary care for children who include assessment of
cognitive, emotional, and parent-child functioning, with appropriate counseling, referral, and followup, in their
clinical practices. (Baseline data available in 1992)
7. Violent and Abusive Behavior
Health Status Objectives
7.1
Reduce homicides to no more than 7.2 per 100,000 people. (Age-adjusted baseline: 8.5 per 100,000 in 1987)
Special Population Targets
Homicide Rate (per 100,000)
1987 Baseline
2000 Target
7.1a
Children aged 3 and younger
3.9
3.1
7.1b
Spouses aged 15-34
1.7
1.4
7.1c
Black men aged 15-34
90.5
72.4
7.1d
Hispanic men aged 15-34
53.1
42.5
7.1e
Black women aged 15-34
20.0
16.0
7.1f
American Indians/Alaska Natives in Reservation States
14.1
11.3
7.2*
Reduce suicides to no more than 10.5 per 100,000 people. (Age-adjusted baseline: 11.7 per 100,000 in 1987)
Special Population Targets
Suicides (per 100,000)
1987 Baseline
2000 Target
7.2a
Youth aged 15-19
10.3
8.2
7.2b
Men aged 20-34
25.2
21.4
7.2c
White men aged 65 and older
46.1
39.2
7.2d
American Indian/Alaska Native men in Reservation States 15
12.8
7.3
Reduce weapon-related violent deaths to no more than 12.6 per 100,000 people from major causes. (Age-adjusted
baseline: 12.9 per 100,000 by firearms, 1.9 per 100,000 by knives, in 1987)
7.4
Reverse to less than 25.2 per 1,000 children the rising incidence of maltreatment of children younger than age 18.
(Baseline: 25.2 per 1,000 in 1986)
Type-Specific Targets
Incidence of Types of Maltreatment (per 1,000)
1986 Baseline
2000 Target
7.4a
Physical abuse
5.7
<5.7
7.4b
Sexual abuse
2.5
<2.5
7.4c
Emotional abuse
3.4
<3.4
7.4d
Neglect
15.9
<15.9
7.5
Reduce physical abuse directed at women by male partners to no more than 27 per 1,000 couples. (Baseline: 30 per
1,000 in 1985)
7.6
Reduce assault injuries among people aged 12 and older to no more than 10 per 1,000 people. (Baseline: 11.1 per
1,000 in 1986)
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A. Summary List of Objectives
7.7
Reduce rape and attempted rape of women aged 12 and older to no more than 108 per 100,000 women. (Baseline:
120 per 100,000 in 1986)
Special Population Target
Incidence of Rape and Attempted Rape (per 100,000) 1986 Baseline
2000 Target
7.7a
Women aged 12-34
250
225
7.8*
Reduce by 15 percent the incidence of injurious suicide attempts among adolescents aged 14 through 17. (Baseline
data available in 1991)
Risk Reduction Objectives
7.9
Reduce by 20 percent the incidence of physical fighting among adolescents aged 14 through 17. (Baseline data
available in 1991)
7.10
Reduce by 20 percent the incidence of weapon-carrying by adolescents aged 14 through 17. (Baseline data available
in 1991)
7.11
Reduce by 20 percent the proportion of people who possess weapons that are inappropriately stored and therefore
dangerously available. (Baseline data available in 1992)
Services and Protection Objectives
7.12
Extend protocols for routinely identifying, treating, and properly referring suicide attempters, victims of sexual
assault, and victims of spouse, elder, and child abuse to at least 90 percent of hospital emergency departments.
(Baseline data available in 1992)
7.13
Extend to at least 45 States implementation of unexplained child death review systems. (Baseline data available in
1991)
7.14 Increase to at least 30 the number of States in which at least 50 percent of children identified as neglected or
physically or sexually abused receive physical and mental evaluation with appropriate followup as a means of
breaking the intergenerational cycle of abuse. (Baseline data available in 1993)
7.15 Reduce to less than 10 percent the proportion of battered women and their children turned away from emergency
housing due to lack of space. (Baseline: 40 percent in 1987)
7.16
Increase to at least 50 percent the proportion of elementary and secondary schools that teach nonviolent conflict
resolution skills, preferably as a part of quality school health education. (Baseline data available in 1991)
7.17
Extend coordinated, comprehensive violence prevention programs to at least 80 percent of local jurisdictions with
populations over 100,000. (Baseline data available in 1993)
7.18* Increase to 50 the number of States with officially established protocols that engage mental health, alcohol and drug,
and public health authorities with corrections authorities to facilitate identification and appropriate intervention to
prevent suicide by jail inmates. (Baseline data available in 1992)
8. Educational and Community-Based Programs
Health Status Objective
8.1*
Increase years of healthy life to at least 65 years. (Baseline: An estimated 62 years in 1980)
Special Population Targets
Years of Healthy Life
1980 Baseline
2000 Target
8.1a
Blacks
56
60
8.1b
Hispanics
62
65
8.1c
People aged 65 and older
12⁺
14⁺
Years of healthy life remaining at age 65
Note: Years of healthy life (also referred to as quality-adjusted life years) is a summary measure of health that com-
bines mortality (quantity of life) and morbidity and disability (quality of life) into a single measure. For people
aged 65 and older, active life-expectancy, a related summary measure, also will be tracked.
Risk Reduction Objective
8.2
Increase the high school graduation rate to at least 90 percent, thereby reducing risks for multiple problem behaviors
and poor mental and physical health. (Baseline: 79 percent of people aged 20 through 21 had graduated from high
school with a regular diploma in 1989)
Note: This objective and its target are consistent with the National Education Goal to increase high school gradua-
tion rates. The baseline estimate is a proxy. When a measure is chosen to monitor the National Education Goal,
the same measure and data source will be used to track this objective.
101
Healthy People 2000
Services and Protection Objectives
8.3
Achieve for all disadvantaged children and children with disabilities access to high quality and developmentally
appropriate preschool programs that help prepare children for school, thereby improving their prospects with
regard to school performance, problem behaviors, and mental and physical health. (Baseline: 47 percent of
eligible children aged 4 were afforded the opportunity to enroll in Head Start in 1990)
Note: This objective and its target are consistent with the National Education Goal to increase school readiness
and its objective to increase access to preschool programs for disadvantaged and disabled children. The baseline
estimate is an available, but partial, proxy. When a measure is chosen to monitor this National Education Objec-
tive, the same measure and data source will be used to track this objective.
8.4
Increase to at least 75 percent the proportion of the Nation's elementary and secondary schools that provide planned
and sequential kindergarten through 12th grade quality school health education. (Baseline data available in 1991)
8.5
Increase to at least 50 percent the proportion of postsecondary institutions with institutionwide health promotion
programs for students, faculty, and staff. (Baseline: At least 20 percent of higher education institutions offered
health promotion activities for students in 1989-90)
8.6
Increase to at least 85 percent the proportion of workplaces with 50 or more employees that offer health promotion
activities for their employees, preferably as part of a comprehensive employee health promotion program.
(Baseline: 65 percent of worksites with 50 or more employees offered at least one health promotion activity in
1985; 63 percent of medium and large companies had a wellness program in 1987)
8.7
Increase to at least 20 percent the proportion of hourly workers who participate regularly in employer-sponsored health
promotion activities. (Baseline data available in 1992)
8.8
Increase to at least 90 percent the proportion of people aged 65 and older who had the opportunity to participate during
the preceding year in at least one organized health promotion program through a senior center, lifecare facility, or
other community-based setting that serves older adults. (Baseline data available in 1992)
8.9
Increase to at least 75 percent the proportion of people aged 10 and older who have discussed issues related to nutrition,
physical activity, sexual behavior, tobacco, alcohol, other drugs, or safety with family members on at least one
occasion during the preceding month. (Baseline data available in 1991)
Note: This objective, which supports family communication on a range of vital personal health issues, will be track-
ed using the National Health Interview Survey, a continuing, voluntary, national sample survey of adults who report
on household characteristics including such items as illnesses, injuries, use of health services, and demographic
characteristics.
8.10
Establish community health promotion programs that separately or together address at least three of the Healthy
People 2000 priorities and reach at least 40 percent of each State's population. (Baseline data available in 1992)
8.11
Increase to at least 50 percent the proportion of counties that have established culturally and linguistically appropriate
community health promotion programs for racial and ethnic minority populations. (Baseline data available in
1992)
Note: This objective will be tracked in counties in which a racial or ethnic group constitutes more than 10 percent
of the population.
8.12
Increase to at least 90 percent the proportion of hospitals, health maintenance organizations, and large group practices
that provide patient education programs, and to at least 90 percent the proportion of community hospitals that offer
community health promotion programs addressing the priority health needs of their communities. (Baseline: 66
percent of 6,821 registered hospitals provided patient education services in 1987; 60 percent of 5,677 community
hospitals offered community health promotion programs in 1987)
8.13
Increase to at least 75 percent the proportion of local television network affiliates in the top 20 television markets that
have become partners with one or more community organizations around one of the health problems addressed by
the Healthy People 2000 objectives. (Baseline data available in 1991)
8.14
Increase to at least 90 percent the proportion of people who are served by a local health department that is effectively
carrying out the core functions of public health. (Baseline data available in 1992)
Note: The core functions of public health have been defined as assessment, policy development, and assurance.
Local health department refers to any local component of the public health system, defined as an administrative and
service unit of local or State government concerned with health and carrying some responsibility for the health of a
jurisdiction smaller than a State.
102
A. Summary List of Objectives
9. Unintentional Injuries
Health Status Objectives
9.1
Reduce deaths caused by unintentional injuries to no more than 29.3 per 100,000 people. (Age-adjusted baseline: 34.5
per 100,000 in 1987)
Special Population Targets
Deaths Caused By Unintential Injuries (per 100,000)
1987 Baseline
2000 Target
9.1a
American Indians/Alaska Natives
82.6
66.1
9.1b
Black males
64.9
51.9
9.1c
White males
53.6
42.9
9.2
Reduce nonfatal unintentional injuries so that hospitalizations for this condition are no more than 754 per 100,000
people. (Baseline: 887 per 100,000 in 1988)
9.3
Reduce deaths caused by motor vehicle crashes to no more than 1.9 per 100 million vehicle miles traveled and 16.8 per
100,000 people. (Baseline: 2.4 per 100 million vehicle miles traveled (VMT) and 18.8 per 100,000 people (age
adjusted) in 1987)
Special Population Targets
Deaths Caused By Motor Vehicle Crashes (per 100,000)
1987 Baseline
2000 Target
9.3a
Children aged 14 and younger
6.2
5.5
9.3b
Youth aged 15-24
36.9
33
9.3c
People aged 70 and older
22.6
20
9.3d
American Indians/Alaska Natives
46.8
39.2
Type-Specific Targets
Deaths Caused By Motor Vehicle Crashes
1987 Baseline
2000 Target
9.3e
Motorcyclists
40.9/100 million VMT &
33/100 million VMT &
1.7/100,000
1.5/100,000
9.3f
Pedestrians
3.1/100,000
2.7/100,000
9.4
Reduce deaths from falls and fall-related injuries to no more than 2.3 per 100,000 people. (Age-adjusted baseline:
2.7 per 100,000 in 1987)
Special Population Targets
Deaths From Falls and Fall-Related Injuries (per 100,000)
1987 Baseline
2000 Target
9.4a
People aged 65-84
18
14.4
9.4b
People aged 85 and older
131.2
105.0
9.4c
Black men aged 30-69
8
5.6
9.5
Reduce drowning deaths to no more than 1.3 per 100,000 people. (Age-adjusted baseline: 2.1 per 100,000 in 1987)
Special Population Targets
Drowning Deaths (per 100,000)
1987 Baseline
2000 Target
9.5a
Children aged 4 and younger
4.2
2.3
9.5b
Men aged 15-34
4.5
2.5
9.5c
Black males
6.6
3.6
9.6
Reduce residential fire deaths to no more than 1.2 per 100,000 people. (Age-adjusted baseline: 1.5 per 100,000 in
1987)
Special Population Targets
Residential Fire Deaths (per 100,000)
1987 Baseline
2000 Target
9.6a
Children aged 4 and younger
4.4
3.3
9.6b
People aged 65 and older
4.4
3.3
9.6c
Black males
5.7
4.3
9.6d
Black females
3.4
2.6
Type-Specific Target
1983 Baseline
2000 Target
9.6e
Residential fire deaths caused by smoking
17%
5%
9.7
Reduce hip fractures among people aged 65 and older so that hospitalizations for this condition are no more than 607
per 100,000. (Baseline: 714 per 100,000 in 1988)
Special Population Target
Hip Fractures (per 100,000)
1988 Baseline
2000 Target
9.7a
White women aged 85 and older
2,721
2,177
103
Healthy People 2000
9.8
Reduce nonfatal poisoning to no more than 88 emergency department treatments per 100,000 people. (Baseline: 103
per 100,000 in 1986)
Special Population Target
Nonfatal Poisoning (per 100,000)
1986 Baseline
2000 Target
9.8a
Among children aged 4 and younger
650
520
9.9
Reduce nonfatal head injuries so that hospitalizations for this condition are no more than 106 per 100,000 people.
(Baseline: 125 per 100,000 in 1988)
9.10
Reduce nonfatal spinal cord injuries so that hospitalizations for this condition are no more than 5 per 100,000 people.
(Baseline: 5.9 per 100,000 in 1988)
Special Population Target
Nonfatal Spinal Cord Injuries (per 100,000)
1988 Baseline
2000 Target
9.10a Males
8.9
7.1
9.11
Reduce the incidence of secondary disabilities associated with injuries of the head and spinal cord to no more than 16
and 2.6 per 100,000 people, respectively. (Baseline: 20 per 100,000 for serious head injuries and 3.2 per 100,000
for spinal cord injuries in 1986)
Note: Secondary disabilities are defined as those medical conditions secondary to traumatic head or spinal cord in-
jury that impair independent and productive lifestyles.
Risk Reduction Objectives
9.12
Increase use of occupant protection systems, such as safety belts, inflatable safety restraints, and child safety seats, to
at least 85 percent of motor vehicle occupants. (Baseline: 42 percent in 1988)
Special Population Target
Use of Occupant Protection Systems
1988 Baseline
2000 Target
9.12a Children aged 4 and younger
84%
95%
9.13
Increase use of helmets to at least 80 percent of motorcyclists and at least 50 percent of bicyclists. (Baseline: 60
percent of motorcyclists in 1988 and an estimated 8 percent of bicyclists in 1984)
Services and Protection Objectives
9.14
Extend to 50 States laws requiring safety belt and motorcycle helmet use for all ages. (Baseline: 33 States and the
District of Columbia in 1989 for automobiles; 22 States, the District of Columbia, and Puerto Rico for motorcycles)
9.15
Enact in 50 States laws requiring that new handguns be designed to minimize the likelihood of discharge by children.
(Baseline: 0 States in 1989)
9.16
Extend to 2,000 local jurisdictions the number whose codes address the installation of fire suppression sprinkler
systems in those residences at highest risk for fires. (Baseline data available in 1991)
9.17 Increase the presence of functional smoke detectors to at least one on each habitable floor of all inhabited residential
dwellings. (Baseline: 81 percent of residential dwellings in 1989)
9.18
Provide academic instruction on injury prevention and control, preferably as part of quality school health education, in
at least 50 percent of public school systems (grades K through 12). (Baseline data available in 1991)
9.19* Extend requirement of the use of effective head, face, eye, and mouth protection to all organizations, agencies, and
institutions sponsoring sporting and recreation events that pose risks of injury. (Baseline: Only National
Collegiate Athletic Association football, hockey, and lacrosse; high school football; amateur boxing; and amateur
ice hockey in 1988)
9.20 Increase to at least 30 the number of States that have design standards for signs, signals, markings, lighting, and other
characteristics of the roadway environment to improve the visual stimuli and protect the safety of older drivers and
pedestrians. (Baseline data available in 1992)
9.21
Increase to at least 50 percent the proportion of primary care providers who routinely provide age-appropriate
counseling on safety precautions to prevent unintentional injury. (Baseline data available in 1992)
9.22 Extend to 50 States emergency medical services and trauma systems linking prehospital, hospital, and rehabilitation
services in order to prevent trauma deaths and long-term disability. (Baseline: 2 States in 1987)
10. Occupational Safety and Health
Health Status Objectives
10.1 Reduce deaths from work-related injuries to no more than 4 per 100,000 full-time workers. (Baseline: Average of 6
per 100,000 during 1983-87)
Special Population Targets
Work-Related Deaths (per 100,000)
1983-87 Average
2000 Target
10.1a Mine workers
30.3
21
10.1b Construction workers
25.0
17
10.1c Transportation workers
15.2
10
10.1d Farm workers
14.0
9.5
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A. Summary List of Objectives
10.2 Reduce work-related injuries resulting in medical treatment, lost time from work, or restricted work activity to no
more than 6 cases per 100 full-time workers. (Baseline: 7.7 per 100 in 1987)
Special Population Targets
Work-Related Injuries (per 100)
1983-87 Average
2000 Target
10.2a Construction workers
14.9
10
10.2b Nursing and personal care workers
12.7
9
10.2c
Farm workers
12.4
8
10.2d Transportation workers
8.3
6
10.2e Mine workers
8.3
6
10.3 Reduce cumulative trauma disorders to an incidence of no more than 60 cases per 100,000 full-time workers.
(Baseline: 100 per 100,000 in 1987)
Special Population Targets
Cumulative Trauma Disorders (per 100,000)
1987 Baseline
2000 Target
10.3a Manufacturing industry workers
355
150
10.3b Meat product workers
3,920
2,000
10.4 Reduce occupational skin disorders or diseases to an incidence of no more than 55 per 100,000 full-time workers.
(Baseline: Average of 64 per 100,000 during 1983-87)
10.5* Reduce hepatitis B infections among occupationally exposed workers to an incidence of no more than 1,250 cases.
(Baseline: An estimated 6,200 cases in 1987)
Risk Reduction Objectives
10.6
Increase to at least 75 percent the proportion of worksites with 50 or more employees that mandate employee use of
occupant protection systems, such as seatbelts, during all work-related motor vehicle travel. (Baseline data
available in 1991)
10.7
Reduce to no more than 15 percent the proportion of workers exposed to average daily noise levels that exceed 85
dBA. (Baseline data available in 1992)
10.8
Eliminate exposures which result in workers having blood lead concentrations greater than 25 µg/dL of whole blood.
(Baseline: 4,804 workers with blood lead levels above 25 µg/dL in 7 States in 1988)
10.9* Increase hepatitis B immunization levels to 90 percent among occupationally exposed workers. (Baseline data
available in 1991)
Services and Protection Objectives
10.10 Implement occupational safety and health plans in 50 States for the identification, management, and prevention of
leading work-related diseases and injuries within the State. (Baseline: 10 States in 1989)
10.11 Establish in 50 States exposure standards adequate to prevent the major occupational lung diseases to which their
worker populations are exposed (byssinosis, asbestosis, coal workers' pneumoconiosis, and silicosis). (Baseline
data available in 1991)
10.12 Increase to at least 70 percent the proportion of worksites with 50 or more employees that have implemented
programs on worker health and safety. (Baseline data available in 1991)
10.13 Increase to at least 50 percent the proportion of worksites with 50 or more employees that offer back injury
prevention and rehabilitation programs. (Baseline: 28.6 percent offered back care activities in 1985)
10.14 Establish in 50 States either public health or labor department programs that provide consultation and assistance to
small businesses to implement safety and health programs for their employees. (Baseline data available in 1991)
10.15 Increase to at least 75 percent the proportion of primary care providers who routinely elicit occupational health
exposures as a part of patient history and provide relevant counseling. (Baseline data available in 1992)
11. Environmental Health
Health Status Objectives
11.1
Reduce asthma morbidity, as measured by a reduction in asthma hospitalizations to no more than 160 per 100,000
people. (Baseline: 188 per 100,000 in 1987)
Special Population Targets
Asthma Hospitalizations (per 100,000)
1987 Baseline
2000 Target
11.1a Blacks and other nonwhites
334
265
11.1b Children
284⁺
225
Children aged 14 and younger
11.2* Reduce the prevalence of serious mental retardation among school-aged children to no more than 2 per 1,000
children. (Baseline: 2.7 per 1,000 children aged 10 in 1985-88)
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Healthy People 2000
11.3 Reduce outbreaks of waterborne disease from infectious agents and chemical poisoning to no more than 11 per year.
(Baseline: Average of 31 outbreaks per year during 1981-88)
Type-Specific Target
Average Annual Number of Waterborne Disease Outbreaks
1981-88 Baseline 2000 Target
11.3a People served by community water systems
13
6
Note: Community water systems are public or investor-owned water systems that serve large or small communities,
subdivisions, or trailer parks with at least 15 service connections or 25 year-round residents.
11.4 Reduce the prevalence of blood lead levels exceeding 15 µg/dL and 25 µg/dL among children aged 6 months through
5 years to no more than 500,000 and zero, respectively. (Baseline: An estimated 3 million children had levels
exceeding 15 µg/dL, and 234,000 had levels exceeding 25 µg/dL, in 1984)
Special Population Target
Prevalence of Blood Lead Levels Exceeding 15 µg/dL & 25 µg/dL 1984 Baseline
2000 Target
11.4a Inner-city low-income black children (annual family income
234,900
75,000
<$6,000 in 1984 dollars)
& 36,700
& 0
Risk Reduction Objectives
11.5 Reduce human exposure to criteria air pollutants, as measured by an increase to at least 85 percent in the proportion of
people who live in counties that have not exceeded any Environmental Protection Agency standard for air quality
in the previous 12 months. (Baseline: 49.7 percent in 1988)
Proportion Living in Counties That Have Not Exceeded Criteria Air Pollutant Standards in 1988 for:
Ozone
53.6%
Carbon monoxide
87.8%
Nitrogen dioxide
96.6%
Sulfur dioxide
99.3%
Particulates
89.4%
Lead
99.3%
Total (any of above pollutants)
49.7%
Note: An individual living in a county that exceeds an air quality standard may not actually be exposed to unheal-
thy air. Of all criteria air pollutants, ozone is the most likely to have fairly uniform concentrations throughout an
area. Exposure is to criteria air pollutants in ambient air. Due to weather fluctuations, multi-year averages may
be the most appropriate way to monitor progress toward this objective.
11.6 Increase to at least 40 percent the proportion of homes in which homeowners/occupants have tested for radon
concentrations and that have either been found to pose minimal risk or have been modified to reduce risk to health.
(Baseline: Less than 5 percent of homes had been tested in 1989)
Special Population Targets
Testing and Modification As Necessary
Baseline
2000 Target
11.6a Homes with smokers and former smokers
-
50%
11.6b Homes with children
-
50%
11.7 Reduce human exposure to toxic agents by confining total pounds of toxic agents released into the air, water, and soil
each year to no more than:
0.24 billion pounds of those toxic agents included on the Department of Health and Human Services list of
carcinogens. (Baseline: 0.32 billion pounds in 1988)
2.6 billion pounds of those toxic agents included on the Agency for Toxic Substances and Disease Registry list of
the most toxic chemicals. (Baseline: 2.62 billion pounds in 1988)
11.8 Reduce human exposure to solid waste-related water, air, and soil contamination, as measured by a reduction in
average pounds of municipal solid waste produced per person each day to no more than 3.6 pounds. (Baseline: 4.0
pounds per person each day in 1988)
11.9 Increase to at least 85 percent the proportion of people who receive a supply of drinking water that meets the safe
drinking water standards established by the Environmental Protection Agency. (Baseline: 74 percent of 58,099
community water systems serving approximately 80 percent of the population in 1988)
Note: Safe drinking water standards are measured using Maximum Contaminant Level (MCL) standards set by the
Environmental Protection Agency which define acceptable levels of contaminants. See Objective 11.3 for defini-
tion of community water systems.
11.10 Reduce potential risks to human health from surface water, as measured by a decrease to no more than 15 percent in
the proportion of assessed rivers, lakes, and estuaries that do not support beneficial uses, such as fishing and
swimming. (Baseline: An estimated 25 percent of assessed rivers, lakes, and estuaries did not support designated
beneficial uses in 1988)
Note: Designated beneficial uses, such as aquatic life support, contact recreation (swimming), and water supply,
are designated by each State and approved by the Environmental Protection Agency. Support of beneficial use is a
proxy measure of risk to human health, as many pollutants causing impaired water uses do not have human health
effects (e.g., siltation, impaired fish habitat).
106
A. Summary List of Objectives
Services and Protection Objectives
11.11 Perform testing for lead-based paint in at least 50 percent of homes built before 1950. (Baseline data available in
1991)
11.12 Expand to at least 35 the number of States in which at least 75 percent of local jurisdictions have adopted
construction standards and techniques that minimize elevated indoor radon levels in those new building areas
locally determined to have elevated radon levels. (Baseline: 1 State in 1989)
Note: Since construction codes are frequently adopted by local jurisdictions rather than States, progress toward
this objective also may be tracked using the proportion of cities and counties that have adopted such construction
standards.
11.13 Increase to at least 30 the number of States requiring that prospective buyers be informed of the presence of
lead-based paint and radon concentrations in all buildings offered for sale. (Baseline: 2 States required disclosure
of lead-based paint in 1989; 1 State required disclosure of radon concentrations in 1989; 2 additional States
required disclosure that radon has been found in the State and that testing is desirable in 1989)
11.14 Eliminate significant health risks from National Priority List hazardous waste sites, as measured by performance of
clean-up at these sites sufficient to eliminate immediate and significant health threats as specified in health
assessments completed at all sites. (Baseline: 1,082 sites were on the list in March of 1990; of these, health
assessments have been conducted for approximately 1,000)
Note: The Comprehensive Environmental Response, Compensation, and Liability Act of 1980 required the Environ-
mental Protection Agency to develop criteria for determining priorities among hazardous waste sites and to develop
and maintain a list of these priority sites. The resulting list is called the National Priorities List (NPL).
11.15 Establish programs for recyclable materials and household hazardous waste in at least 75 percent of counties.
(Baseline: Approximately 850 programs in 41 States collected household toxic waste in 1987; extent of recycling
collections unknown)
11.16 Establish and monitor in at least 35 States plans to define and track sentinel environmental diseases. (Baseline: 0
States in 1990)
Note: Sentinel environmental diseases include lead poisoning, other heavy metal poisoning (e.g., cadmium, ar-
senic, and mercury), pesticide poisoning, carbon monoxide poisoning, heatstroke, hypothermia, acute chemical
poisoning, methemoglobinemia, and respiratory diseases triggered by environmental factors (e.g., asthma).
12. Food and Drug Safety
Health Status Objectives
12.1
Reduce infections caused by key foodborne pathogens to incidences of no more than:
Disease (per 100,000)
1987 Baseline
2000 Target
Salmonella species
18
16
Campylobacter jejuni
50
25
Escherichia coli 0157:H7
8
4
Listeria monocytogenes
0.7
0.5
12.2
Reduce outbreaks of infections due to Salmonella enteritidis to fewer than 25 outbreaks yearly. (Baseline: 77
outbreaks in 1989)
Risk Reduction Objective
12.3
Increase to at least 75 percent the proportion of households in which principal food preparers routinely refrain from
leaving perishable food out of the refrigerator for over 2 hours and wash cutting boards and utensils with soap after
contact with raw meat and poultry. (Baseline: For refrigeration of perishable foods, 70 percent; for washing
cutting boards with soap, 66 percent; and for washing utensils with soap, 55 percent, in 1988)
Services and Protection Objectives
12.4
Extend to at least 70 percent the proportion of States and territories that have implemented model food codes for
institutional food operations and to at least 70 percent the proportion that have adopted the new uniform food
protection code ("Unicode") that sets recommended standards for regulation of all food operations. (Baseline: For
institutional food operations currently using FDA's recommended model codes, 20 percent; for the new Unicode to
be released in 1991, 0 percent, in 1990)
12.5
Increase to at least 75 percent the proportion of pharmacies and other dispensers of prescription medications that use
linked systems to provide alerts to potential adverse drug reactions among medications dispensed by different
sources to individual patients. (Baseline data available in 1993)
12.6
Increase to at least 75 percent the proportion of primary care providers who routinely review with their patients aged
65 and older all prescribed and over-the-counter medicines taken by their patients each time a new medication is
prescribed. (Baseline data available in 1992)
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Healthy People 2000
13. Oral Health
Health Status Objectives
13.1
Reduce dental caries (cavities) so that the proportion of children with one or more caries (in permanent or primary
teeth) is no more than 35 percent among children aged 6 through 8 and no more than 60 percent among adolescents
aged 15. (Baseline: 53 percent of children aged 6 through 8 in 1986-87; 78 percent of adolescents aged 15 in
1986-87)
Special Population Targets
Dental Caries Prevalence
1986-87 Baseline
2000 Target
13.1a Children aged 6-8 whose parents have less than high school education
70%
45%
13.1b American Indian/Alaska Native children aged 6-8
92%⁺
45%
52%+
13.1c Black children aged 6-8
61%
40%
13.1d American Indian/Alaska Native adolescents aged 15
93%+
70%
In primary teeth in 1983-84 *In permanent teeth in 1983-84
13.2
Reduce untreated dental caries so that the proportion of children with untreated caries (in permanent or primary teeth)
is no more than 20 percent among children aged 6 through 8 and no more than 15 percent among adolescents aged
15. (Baseline: 27 percent of children aged 6 through 8 in 1986; 23 percent of adolescents aged 15 in 1986-87)
Special Population Targets
Untreated Dental Caries:
1986-87 Baseline 2000 Target
Among Children-
13.2a Children aged 6-8 whose parents have less than high school education
43%
30%
13.2b American Indian/Alaska Native children aged 6-8
64%⁺
35%
13.2c Black children aged 6-8
38%
25%
13.2d Hispanic children aged 6-8
36%+
25%
Among Adolescents-
13.2a Adolescents aged 15 whose parents have less than a high school education
41%
25%
13.2b American Indian/Alaska Native adolescents aged 15
84%⁺
40%
13.2c Black adolescents aged 15
38%
20%
13.2d Hispanic adolescents aged 15
31-47%
25%
1983-84 baseline
+ 1982-84 baseline
13.3
Increase to at least 45 percent the proportion of people aged 35 through 44 who have never lost a permanent tooth due
to dental caries or periodontal diseases. (Baseline: 31 percent of employed adults had never lost a permanent tooth
for any reason in 1985-86)
Note: Never lost a permanent tooth is having 28 natural teeth exclusive of third molars.
13.4 Reduce to no more than 20 percent the proportion of people aged 65 and older who have lost all of their natural teeth.
(Baseline: 36 percent in 1986)
Special Population Target
Complete Tooth Loss Prevalence
1986 Baseline
2000 Target
13.4a Low-income people (annual family income <$15,000)
46%
25%
13.5
Reduce the prevalence of gingivitis among people aged 35 through 44 to no more than 30 percent. (Baseline: 42
percent in 1985-86)
Special Population Targets
Gingivitis Prevalence
1985 Baseline
2000 Target
13.5a Low-income people (annual family income <$12,500)
50%
35%
13.5b American Indians/Alaska Natives
95%⁺
50%
13.5c Hispanics
50%
Mexican Americans
74%⁺
Cubans
79%
Puerto Ricans
82%
+
1983-84 baseline
+ 1982-84 baseline
13.6
Reduce destructive periodontal diseases to a prevalence of no more than 15 percent among people aged 35 through 44.
(Baseline: 24 percent in 1985-86)
Note: Destructive periodontal disease is one or more sites with 4 millimeters or greater loss of tooth attachment.
13.7
Reduce deaths due to cancer of the oral cavity and pharynx to no more than 10.5 per 100,000 men aged 45 through 74
and 4.1 per 100,000 women aged 45 through 74. (Baseline: 12.1 per 100,000 men and 4.1 per 100,000 women in
1987)
108
A. Summary List of Objectives
Risk Reduction Objectives
13.8
Increase to at least 50 percent the proportion of children who have received protective sealants on the occlusal
(chewing) surfaces of permanent molar teeth. (Baseline: 11 percent of children aged 8 and 8 percent of
adolescents aged 14 in 1986-87)
Note: Progress toward this objective will be monitored based on prevalence of sealants in children at age 8 and at
age 14, when the majority of first and second molars, respectively, are erupted.
13.9
Increase to at least 75 percent the proportion of people served by community water systems providing optimal levels
of fluoride. (Baseline: 62 percent in 1989)
Note: Optimal levels of fluoride are determined by the mean maximum daily air temperature over a 5-year period
and range between 0.7 and 1.2 parts of fluoride per one million parts of water (ppm).
13.10 Increase use of professionally or self-administered topical or systemic (dietary) fluorides to at least 85 percent of
people not receiving optimally fluoridated public water. (Baseline: An estimated 50 percent in 1989)
13.11* Increase to at least 75 percent the proportion of parents and caregivers who use feeding practices that prevent baby
bottle tooth decay. (Baseline data available in 1991)
Special Population Targets
Appropriate Feeding Practices
Baseline
2000 Target
13.11a Parents and caregivers with less than high school education
-
65%
13.11b American Indian/Alaska Native parents and caregivers
-
65%
Services and Protection Objectives
13.12 Increase to at least 90 percent the proportion of all children entering school programs for the first time who have
received an oral health screening, referral, and followup for necessary diagnostic, preventive, and treatment
services. (Baseline: 66 percent of children aged 5 visited a dentist during the previous year in 1986)
Note: School programs include Head Start, prekindergarten, kindergarten, and 1st grade.
13.13 Extend to all long-term institutional facilities the requirement that oral examinations and services be provided no
later than 90 days after entry into these facilities. (Baseline: Nursing facilities receiving Medicaid or Medicare
reimbursement will be required to provide for oral examinations within 90 days of patient entry beginning in 1990;
baseline data unavailable for other institutions)
Note: Long-term institutional facilities include nursing homes, prisons, juvenile homes, and detention facilities.
13.14 Increase to at least 70 percent the proportion of people aged 35 and older using the oral health care system during
each year. (Baseline: 54 percent in 1986)
Special Population Targets
Proportion Using Oral Health Care System During Each Year
1986 Baseline
2000 Target
13.14a Edentulous people
11%
50%
13.14b People aged 65 and older
42%
60%
13.15 Increase to at least 40 the number of States that have an effective system for recording and referring infants with cleft
lips and/or palates to craniofacial anomaly teams. (Baseline: In 1988, approximately 25 States had a central
recording mechanism for cleft lip and/or palate and approximately 25 States had an organized referral system to
craniofacial anomaly teams)
13.16* Extend requirement of the use of effective head, face, eye, and mouth protection to all organizations, agencies, and
institutions sponsoring sporting and recreation events that pose risks of injury. (Baseline: Only National
Collegiate Athletic Association football, hockey, and lacrosse; high school football; amateur boxing; and amateur
ice hockey in 1988)
109
Healthy People 2000
14. Maternal and Infant Health
Health Status Objectives
14.1
Reduce the infant mortality rate to no more than 7 per 1,000 live births. (Baseline: 10.1 per 1,000 live births in 1987)
Special Population Targets
Infant Mortality (per 1,000 live births)
1987 Baseline
2000 Target
14.1a Blacks
17.9
11
14.1b American Indians/Alaska Natives
12.5⁺
8.5
14.1c Puerto Ricans
12.9⁺
8
Type-Specific Targets
Neonatal and Postneonatal Mortality (per 1,000 live births)
1987 Baseline
2000 Target
14.1d Neonatal mortality
6.5
4.5
14.1e Neonatal mortality among blacks
11.7
7
14.1f Neonatal mortality among Puerto Ricans
8.6⁺
5.2
14.1g Postneonatal mortality
3.6
2.5
14.1h Postneonatal mortality among blacks
6.1
4
14.1i Postneonatal mortality among American Indians/Alaska Natives
6.5⁺
4
14.1j Postneonatal mortality among Puerto Ricans
4.3⁺
2.8
1984 baseline
Note: Infant mortality is deaths of infants under 1 year; neonatal mortality is deaths of infants under 28 days; and
postneonatal mortality is deaths of infants aged 28 days up to 1 year.
14.2 Reduce the fetal death rate (20 or more weeks of gestation) to no more than 5 per 1,000 live births plus fetal deaths.
(Baseline: 7.6 per 1,000 live births plus fetal deaths in 1987)
Special Population Target
Fetal Deaths
1987 Baseline
2000 Target
14.2a
Blacks
12.8⁺
7.5⁺
+
Per 1,000 live births plus fetal deaths
14.3
Reduce the maternal mortality rate to no more than 3.3 per 100,000 live births. (Baseline: 6.6 per 100,000 in 1987)
Special Population Target
Maternal Mortality
1987 Baseline
2000 Target
14.3a Blacks
14.2⁺
5⁺
+
Per 100,000 live births
Note: The objective uses the maternal mortality rate as defined by the National Center for Health Statistics. How-
ever, if other sources of maternal mortality data are used, a 50-percent reduction in maternal mortality is the in-
tended target.
14.4 Reduce the incidence of fetal alcohol syndrome to no more than 0.12 per 1,000 live births. (Baseline: 0.22 per 1,000
live births in 1987)
Special Population Targets
Fetal Alcohol Syndrome (per 1,000 live births)
1987 Baseline
2000 Target
14.4a American Indians/Alaska Natives
4
2
14.4b Blacks
0.8
0.4
Risk Reduction Objectives
14.5
Reduce low birth weight to an incidence of no more than 5 percent of live births and very low birth weight to no more
than 1 percent of live births. (Baseline: 6.9 and 1.2 percent, respectively, in 1987)
Special Population Target
1987 Baseline
2000 Target
Low Birth Weight
14.5a Blacks
12.7%
9%
Very Low Birth Weight
Blacks
2.7%
2%
Note: Low birth weight is weight at birth of less than 2,500 grams; very low birth weight is weight at birth of less
than 1,500 grams.
14.6 Increase to at least 85 percent the proportion of mothers who achieve the minimum recommended weight gain during
their pregnancies. (Baseline: 67 percent of married women in 1980)
Note: Recommended weight gain is pregnancy weight gain recommended in the 1990 National Academy of
Science's report, Nutrition During Pregnancy.
110
A. Summary List of Objectives
14.7
Reduce severe complications of pregnancy to no more than 15 per 100 deliveries. (Baseline: 22 hospitalizations
(prior to delivery) per 100 deliveries in 1987)
Note: Severe complications of pregnancy will be measured using hospitalizations due to pregnancy-related com-
plications.
14.8 Reduce the cesarean delivery rate to no more than 15 per 100 deliveries. (Baseline: 24.4 per 100 deliveries in 1987)
Type-Specific Targets
Cesarean Delivery (per 100 deliveries)
1987 Baseline
2000 Target
14.8a Primary (first time) cesarean delivery
17.4
12
14.8b Repeat cesarean deliveries
91.2⁺
65⁺
Among women who had a previous cesarean delivery
14.9* Increase to at least 75 percent the proportion of mothers who breastfeed their babies in the early postpartum period
and to at least 50 percent the proportion who continue breastfeeding until their babies are 5 to 6 months old.
(Baseline: 54 percent at discharge from birth site and 21 percent at 5 to 6 months in 1988)
Special Population Targets
Mothers Breastfeeding Their Babies:
1988 Baseline
2000 Target
During Early Postpartum Period-
14.9a Low-income mothers
32%
75%
14.9b Black mothers
25%
75%
14.9c
Hispanic mothers
51%
75%
14.9d American Indian/Alaska Native mothers
47%
75%
At Age 5-6 Months -
14.9a Low-income mothers
9%
50%
14.9b
Black mothers
8%
50%
14.9c Hispanic mothers
16%
50%
14.9d American Indian/Alaska Native mothers
28%
50%
14.10 Increase abstinence from tobacco use by pregnant women to at least 90 percent and increase abstinence from alcohol,
cocaine, and marijuana by pregnant women by at least 20 percent. (Baseline: 75 percent of pregnant women
abstained from tobacco use in 1985)
Note: Data for alcohol, cocaine, and marijuana use by pregnant women will be available from the National Mater-
nal and Infant Health Survey, CDC, in 1991.
Services and Protection Objectives
14.11 Increase to at least 90 percent the proportion of all pregnant women who receive prenatal care in the first trimester of
pregnancy. (Baseline: 76 percent of live births in 1987)
Special Population Targets
Proportion of Pregnant Women Receiving
Early Prenatal Care
1987 Baseline
2000 Target
14.11a Black women
61.1⁺
90⁺
14.11b American Indian/Alaska Native women
60.2⁺
90⁺
14.11c Hispanic women
61.0⁺
90+
+
Percent of live births
14.12* Increase to at least 60 percent the proportion of primary care providers who provide age-appropriate preconception
care and counseling. (Baseline data available in 1992)
14.13 Increase to at least 90 percent the proportion of women enrolled in prenatal care who are offered screening and
counseling on prenatal detection of fetal abnormalities. (Baseline data available in 1991)
Note: This objective will be measured by tracking use of maternal serum alpha-fetoprotein screening tests.
14.14 Increase to at least 90 percent the proportion of pregnant women and infants who receive risk-appropriate care.
(Baseline data available in 1991)
Note: This objective will be measured by tracking the proportion of very low birth weight infants (less than 1,500
grams) born in facilities covered by a neonatologist 24 hours a day.
14.15 Increase to at least 95 percent the proportion of newborns screened by State-sponsored programs for genetic
disorders and other disabling conditions and to 90 percent the proportion of newborns testing positive for disease
who receive appropriate treatment. (Baseline: For sickle cell anemia, with 20 States reporting, approximately 33
percent of live births screened (57 percent of black infants); for galactosemia, with 38 States reporting,
approximately 70 percent of live births screened)
Note: As measured by the proportion of infants served by programs for sickle cell anemia and galactosemia.
Screening programs should be appropriate for State demographic characteristics.
14.16 Increase to at least 90 percent the proportion of babies aged 18 months and younger who receive recommended
primary care services at the appropriate intervals. (Baseline data available in 1992)
111
Healthy People 2000
15. Heart Disease and Stroke
Health Status Objectives
15.1* Reduce coronary heart disease deaths to no more than 100 per 100,000 people. (Age-adjusted baseline: 135 per
100,000 in 1987)
Special Population Target
Coronary Deaths (per 100,000)
1987 Baseline
2000 Target
15.1a Blacks
163
115
15.2
Reduce stroke deaths to no more than 20 per 100,000 people. (Age-adjusted baseline: 30.3 per 100,000 in 1987)
Special Population Target
Stroke Deaths (per 100,000)
1987 Baseline
2000 Target
15.2a
Blacks
51.2
27
15.3
Reverse the increase in end-stage renal disease (requiring maintenance dialysis or transplantation) to attain an
incidence of no more than 13 per 100,000. (Baseline: 13.9 per 100,000 in 1987)
Special Population Target
ESRD Incidence (per 100,000)
1987 Baseline
2000 Target
15.3a
Blacks
32.4
30
Risk Reduction Objectives
15.4
Increase to at least 50 percent the proportion of people with high blood pressure whose blood pressure is under
control. (Baseline: 11 percent controlled among people aged 18 through 74 in 1976-80; an estimated 24 percent
for people aged 18 and older in 1982-84)
Special Population Target
High Blood Pressure Control
1976-80 Baseline 1982-84 Baseline 2000 Target
15.4a Men with high blood pressure
6%
16%
40%
Note: People with high blood pressure have blood pressure equal to or greater than 140 mm Hg systolic and/or 90
mm Hg diastolic and/or take antihypertensive medication. Blood pressure control is defined as maintaining a blood
pressure less than 140 mm Hg systolic and 90 mm Hg diastolic. In NHANES II and the Seven States Study, control
of hypertension did not include nonpharmacologic treatment. In NHANES III, those controlling their high blood
pressure without medication (e.g., through weight loss, low sodium diets, or restriction of alcohol) will be included.
15.5
Increase to at least 90 percent the proportion of people with high blood pressure who are taking action to help control
their blood pressure. (Baseline: 79 percent of aware hypertensives aged 18 and older were taking action to control
their blood pressure in 1985)
Special Population Targets
Taking Action to Control Blood Pressure
1985 Baseline
2000 Target
15.5a White hypertensive men aged 18-34
51%⁺
80%
15.5b Black hypertensive men aged 18-34
63%⁺
80%
Baseline for aware hypertensive men
Note: High blood pressure is defined as blood pressure equal to or greater than 140 mm Hg systolic and/or 90 mm
Hg diastolic and/or taking antihypertensive medication. Actions to control blood pressure include taking medica-
tion, dieting to lose weight, cutting down on salt, and exercising.
15.6
Reduce the mean serum cholesterol level among adults to no more than 200 mg/dL. (Baseline: 213 mg/dL among
people aged 20 through 74 in 1976-80, 211 mg/dL for men and 215 mg/dL for women)
15.7
Reduce the prevalence of blood cholesterol levels of 240 mg/dL or greater to no more than 20 percent among adults.
(Baseline: 27 percent for people aged 20 through 74 in 1976-80, 29 percent for women and 25 percent for men)
15.8
Increase to at least 60 percent the proportion of adults with high blood cholesterol who are aware of their condition
and are taking action to reduce their blood cholesterol to recommended levels. (Baseline: 11 percent of all people
aged 18 and older, and thus an estimated 30 percent of people with high blood cholesterol, were aware that their
blood cholesterol level was high in 1988)
Note: "High blood cholesterol" means a level that requires diet and, if necessary, drug treatment. Actions to con-
trol high blood cholesterol include keeping medical appointments, making recommended dietary changes (e.g.,
reducing saturated fat, total fat, and dietary cholesterol), and, if necessary, taking prescribed medication.
15.9* Reduce dietary fat intake to an average of 30 percent of calories or less and average saturated fat intake to less than
10 percent of calories among people aged 2 and older. (Baseline: 36 percent of calories from total fat and 13
percent from saturated fat for people aged 20 through 74 in 1976-80; 36 percent and 13 percent for women aged 19
through 50 in 1985)
112
A. Summary List of Objectives
15.10* Reduce overweight to a prevalence of no more than 20 percent among people aged 20 and older and no more than
15 percent among adolescents aged 12 through 19. (Baseline: 26 percent for people aged 20 through 74 in
1976-80, 24 percent for men and 27 percent for women; 15 percent for adolescents aged 12 through 19 in 1976-80)
Special Population Targets
Overweight Prevalence
1976-80 Baseline¹
2000 Target
15.10a Low-income women aged 20 and older
37%
25%
15.10b Black women aged 20 and older
44%
30%
15.10c Hispanic women aged 20 and older
25%
Mexican-American women
39%+
Cuban women
34%+
Puerto Rican women
37%+
15.10d American Indians/Alaska Natives
29-75%
30%
15.10e People with disabilities
36%+
25%
15.10f Women with high blood pressure
50%
41%
15.10g Men with high blood pressure
39%
35%
Baseline for people aged 20-74 1982-84 baseline for Hispanics aged 20-74
§ 1984-88 estimates for different tribes
1985 baseline for people aged 20-74 who report any limitation in activity due to chronic conditions
Note: For people aged 20 and older, overweight is defined as body mass index (BMI) equal to or greater than 27.8
for men and 27.3 for women. For adolescents, overweight is defined as BMI equal to or greater than 23.0 for
males aged 12 through 14, 24.3 for males aged 15 through 17, 25.8 for males aged 18 through 19, 23.4 for females
aged 12 through 14, 24.8 for females aged 15 through 17, and 25.7 for females aged 18 through 19. The values for
adolescents are the age- and gender-specific 85th percentile values of the 1976-80 National Health and Nutrition
Examination Survey (NHANES II), corrected for sample variation. BMI is calculated by dividing weight in
kilograms by the square of height in meters. The cut points used to define overweight approximate the 120 percent
of desirable body weight definition used in the 1990 objectives.
15.11* Increase to at least 30 percent the proportion of people aged 6 and older who engage regularly, preferably daily, in
light to moderate physical activity for at least 30 minutes per day. (Baseline: 22 percent of people aged 18 and
older were active for at least 30 minutes 5 or more times per week and 12 percent were active 7 or more times per
week in 1985)
Note: Light to moderate physical activity requires sustained, rhythmic muscular movements, is at least equivalent
to sustained walking, and is performed at less than 60 percent of maximum heart rate for age. Maximum heart rate
equals roughly 220 beats per minute minus age. Examples may include walking, swimming, cycling, dancing, gar-
dening and yardwork, various domestic and occupational activities, and games and other childhood pursuits.
15.12* Reduce cigarette smoking to a prevalence of no more than 15 percent among people aged 20 and older. (Baseline:
29 percent in 1987, 32 percent for men and 27 percent for women)
Special Population Targets
Cigarette Smoking Prevalence
1987 Baseline
2000 Target
15.12a People with a high school education or less aged 20 and older
34%
20%
15.12b Blue-collar workers aged 20 and older
36%
20%
15.12c Military personnel
42%⁺
20%
15.12d Blacks aged 20 and older
34%
18%
15.12e Hispanics aged 20 and older
33%⁺
18%
15.12f American Indians/Alaska Natives
42-70%
20%
15.12g Southeast Asian men
55%+
20%
15.12h Women of reproductive age
29%
12%
15.12i Pregnant women
25%*
10%
15.12j Women who use oral contraceptives
36%
10%
1988 baseline 1982-84 baseline for Hispanics aged 20-74 1979-87 estimates for different tribes
*1984-88 baseline ++ Baseline for women aged 18-44 # 1985 baseline §§ 1983 baseline
Note: A cigarette smoker is a person who has smoked at least 100 cigarettes and currently smokes cigarettes.
Services and Protection Objectives
15.13 Increase to at least 90 percent the proportion of adults who have had their blood pressure measured within the
preceding 2 years and can state whether their blood pressure was normal or high. (Baseline: 61 percent of people
aged 18 and older had their blood pressure measured within the preceding 2 years and were given the systolic and
diastolic values in 1985)
Note: A blood pressure measurement within the preceding 2 years refers to a measurement by a health professional
or other trained observer.
15.14 Increase to at least 75 percent the proportion of adults who have had their blood cholesterol checked within the
preceding 5 years. (Baseline: 59 percent of people aged 18 and older had "ever" had their cholesterol checked in
1988; 52 percent were checked "within the preceding 2 years" in 1988)
113
Healthy People 2000
15.15 Increase to at least 75 percent the proportion of primary care providers who initiate diet and, if necessary, drug
therapy at levels of blood cholesterol consistent with current management guidelines for patients with high blood
cholesterol. (Baseline data available in 1991)
Note: Current treatment recommendations are outlined in detail in the Report of the Expert Panel on the Detection,
Evaluation, and Treatment of High Blood Cholesterol in Adults, released by the National Cholesterol Education
Program in 1987. Guidelines appropriate for children are currently being established. Treatment recommenda-
tions are likely to be refined over time. Thus, for the year 2000, "current" means whatever recommendations are
then in effect.
15.16 Increase to at least 50 percent the proportion of worksites with 50 or more employees that offer high blood pressure
and/or cholesterol education and control activities to their employees. (Baseline: 16.5 percent offered high blood
pressure activities and 16.8 percent offered nutrition education activities in 1985)
15.17 Increase to at least 90 percent the proportion of clinical laboratories that meet the recommended accuracy standard
for cholesterol measurement. (Baseline: 53 percent in 1985)
16. Cancer
Health Status Objectives
16.1* Reverse the rise in cancer deaths to achieve a rate of no more than 130 per 100,000 people. (Age-adjusted baseline:
133 per 100,000 in 1987)
Note: In its publications, the National Cancer Institute age adjusts cancer death rates to the 1970 U.S. population.
Using the 1970 standard, the equivalent baseline and target values for this objective would be 171 and 175 per
100,000, respectively.
16.2* Slow the rise in lung cancer deaths to achieve a rate of no more than 42 per 100,000 people. (Age-adjusted baseline:
37.9 per 100,000 in 1987)
Note: In its publications, the National Cancer Institute age adjusts cancer death rates to the 1970 U.S. population.
Using the 1970 standard, the equivalent baseline and target values for this objective would be 47.9 and 53 per
100,000, respectively.
16.3 Reduce breast cancer deaths to no more than 20.6 per 100,000 women. (Age-adjusted baseline: 22.9 per 100,000 in
1987)
Note: In its publications, the National Cancer Institute age adjusts cancer death rates to the 1970 U.S. population.
Using the 1970 standard, the equivalent baseline and target values for this objective would be 27.2 and 25.2 per
100,000, respectively.
16.4 Reduce deaths from cancer of the uterine cervix to no more than 1.3 per 100,000 women. (Age-adjusted baseline: 2.8
per 100,000 in 1987)
Note: In its publications, the National Cancer Institute age adjusts cancer death rates to the 1970 U.S. population.
Using the 1970 standard, the equivalent baseline and target values for this objective would be 3.2 and 1.5 per
100,000, respectively.
16.5 Reduce colorectal cancer deaths to no more than 13.2 per 100,000 people. (Age-adjusted baseline: 14.4 per 100,000
in 1987)
Note: In its publications, the National Cancer Institute age adjusts cancer death rates to the 1970 U.S. population.
Using the 1970 standard, the equivalent baseline and target values for this objective would be 20.1 and 18.7 per
100,000, respectively.
Risk Reduction Objectives
16.6* Reduce cigarette smoking to a prevalence of no more than 15 percent among people aged 20 and older. (Baseline:
29 percent in 1987, 32 percent for men and 27 percent for women)
Special Population Targets
Cigarette Smoking Prevalence
1987 Baseline
2000 Target
16.6a People with a high school education or less aged 20 and older
34%
20%
16.6b Blue-collar workers aged 20 and older
36%
20%
16.6c Military personnel
42%⁺
20%
16.6d Blacks aged 20 and older
34%
18%
16.6e Hispanics aged 20 and older
33%*
18%
16.6f American Indians/Alaska Natives
42-70%
20%
16.6g Southeast Asian men
55%+
20%
16.6h Women of reproductive age
29%⁺
12%
16.6i Pregnant women
25%⁺⁺
10%
16.6j Women who use oral contraceptives
36%
10%
1988 baseline 1982-84 baseline for Hispanics aged 20-74 1979-87 estimates for different tribes
*1984-88 baseline ++ Baseline for women aged 18-44 # 1985 baseline §§ 1983 baseline
Note: A cigarette smoker is a person who has smoked at least 100 cigarettes and currently smokes cigarettes.
114
A. Summary List of Objectives
16.7* Reduce dietary fat intake to an average of 30 percent of calories or less and average saturated fat intake to less than
10 percent of calories among people aged 2 and older. (Baseline: 36 percent of calories from total fat and 13
percent from saturated fat for people aged 20 through 74 in 1976-80; 36 percent and 13 percent for women aged 19
through 50 in 1985)
Note: The inclusion of a saturated fat target in this objective should not be interpreted as evidence that reducing
only saturated fat will reduce cancer risk. Epidemiologic and experimental animal studies suggest that the amount
of fat consumed rather than the specific type of fat can influence the risk of some cancers.
16.8* Increase complex carbohydrate and fiber-containing foods in the diets of adults to 5 or more daily servings for
vegetables (including legumes) and fruits, and to 6 or more daily servings for grain products. (Baseline: 2½
servings of fruits and vegetables and 3 servings of grain products for women aged 19 through 50 in 1985)
16.9
Increase to at least 60 percent the proportion of people of all ages who limit sun exposure, use sunscreens and
protective clothing when exposed to sunlight, and avoid artificial sources of ultraviolet light (e.g., sun lamps,
tanning booths). (Baseline data available in 1992)
Services and Protection Objectives
16.10 Increase to at least 75 percent the proportion of primary care providers who routinely counsel patients about tobacco
use cessation, diet modification, and cancer screening recommendations. (Baseline: About 52 percent of internists
reported counseling more than 75 percent of their smoking patients about smoking cessation in 1986)
16.11 Increase to at least 80 percent the proportion of women aged 40 and older who have ever received a clinical breast
examination and a mammogram, and to at least 60 percent those aged 50 and older who have received them within
the preceding 1 to 2 years. (Baseline: 36 percent of women aged 40 and older "ever" in 1987; 25 percent of
women aged 50 and older "within the preceding 2 years" in 1987)
Special Population Targets
Clinical Breast Exam & Mammogram:
1987 Baseline
2000 Target
Ever Received-
16.11a Hispanic women aged 40 and older
20%
80%
16.11b Low-income women aged 40 and older (annual family income <$10,000)
22%
80%
16.11c Women aged 40 and older with less than high school education
23%
80%
16.11d Women aged 70 and older
25%
80%
16.11e Black women aged 40 and older
28%
80%
Received Within Preceding 2 Years—
16.11a Hispanic women aged 50 and older
18%
60%
16.11b Low-income women aged 50 and older (annual family income <$10,000)
15%
60%
16.11c Women aged 50 and older with less than high school education
16%
60%
16.11d Women aged 70 and older
18%
60%
16.11e Black women aged 50 and older
19%
60%
16.12 Increase to at least 95 percent the proportion of women aged 18 and older with uterine cervix who have ever received
a Pap test, and to at least 85 percent those who received a Pap test within the preceding 1 to 3 years. (Baseline: 88
percent "ever" and 75 percent "within the preceding 3 years" in 1987)
Special Population Targets
Pap Test:
1987 Baseline
2000 Target
Ever Received-
16.12a Hispanic women aged 18 and older
75%
95%
16.12b Women aged 70 and older
76%
95%
16.12c Women aged 18 and older with less than high school education
79%
95%
16.12d Low-income women aged 18 and older (annual family income <$10,000)
80%
95%
Received Within Preceding 3 Years—
16.12a Hispanic women aged 18 and older
66%
80%
16.12b Women aged 70 and older
44%
70%
16.12c Women aged 18 and older with less than high school education
58%
75%
16.12d Low-income women aged 18 and older (annual family income <$10,000)
64%
80%
16.13 Increase to at least 50 percent the proportion of people aged 50 and older who have received fecal occult blood
testing within the preceding 1 to 2 years, and to at least 40 percent those who have ever received
proctosigmoidoscopy. (Baseline: 27 percent received fecal occult blood testing during the preceding 2 years in
1987; 25 percent had ever received proctosigmoidoscopy in 1987)
16.14 Increase to at least 40 percent the proportion of people aged 50 and older visiting a primary care provider in the
preceding year who have received oral, skin, and digital rectal examinations during one such visit. (Baseline: An
estimated 27 percent received a digital rectal exam during a physician visit within the preceding year in 1987)
16.15 Ensure that Pap tests meet quality standards by monitoring and certifying all cytology laboratories. (Baseline data
available in 1991)
16.16 Ensure that mammograms meet quality standards by monitoring and certifying at least 80 percent of mammography
facilities. (Baseline: An estimated 18 to 21 percent certified by the American College of Radiology as of June
1990)
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Healthy People 2000
17. Diabetes and Chronic Disabling Conditions
Health Status Objectives
Chronic Disabling Conditions
17.1* Increase years of healthy life to at least 65 years. (Baseline: An estimated 62 years in 1980)
Special Population Targets
Years of Healthy Life
1980 Baseline
2000 Target
17.1a Blacks
56
60
17.1b Hispanics
62
65
17.1c People aged 65 and older
12⁺
14⁺
Years of healthy life remaining at age 65
Note: Years of healthy life (also referred to as quality-adjusted life years) is a summary measure of health that com-
bines mortality (quantity of life) and morbidity and disability (quality of life) into a single measure. For people
aged 65 and older, active life-expectancy, a related summary measure, also will be tracked.
17.2 Reduce to no more than 8 percent the proportion of people who experience a limitation in major activity due to
chronic conditions. (Baseline: 9.4 percent in 1988)
Special Population Targets
Prevalence of Disability
1988 Baseline
2000 Target
17.2a Low-income people (annual family income <$10,000 in 1988)
18.9%
15%
17.2b American Indians/Alaska Natives
13.4%
11%
17.2c Blacks
11.2%
9%
1983-85 baseline
Note: Major activity refers to the usual activity for one's age-gender group whether it is working, keeping house,
going to school, or living independently. Chronic conditions are defined as conditions that either (1) were first
noticed 3 or more months ago, or (2) belong to a group of conditions such as heart disease and diabetes, which are
considered chronic regardless of when they began.
17.3 Reduce to no more than 90 per 1,000 people the proportion of all people aged 65 and older who have difficulty in
performing two or more personal care activities, thereby preserving independence. (Baseline: 111 per 1,000 in
1984-85)
Special Population Target
Difficulty Performing Self-Care Activities (per 1,000)
1984-85 Baseline
2000 Target
17.3a People aged 85 and older
371
325
Note: Personal care activities are bathing, dressing, using the toilet, getting in and out of bed or chair, and eating.
17.4 Reduce to no more than 10 percent the proportion of people with asthma who experience activity limitation.
(Baseline: Average of 19.4 percent during 1986-88)
Note: Activity limitation refers to any self-reported limitation in activity attributed to asthma.
17.5 Reduce activity limitation due to chronic back conditions to a prevalence of no more than 19 per 1,000 people.
(Baseline: Average of 21.9 per 1,000 during 1986-88)
Note: Chronic back conditions include intervertebral disk disorders, curvature of the back or spine, and other self-
reported chronic back impairments such as permanent stiffness or deformity of the back or repeated trouble with
the back. Activity limitation refers to any self-reported limitation in activity attributed to a chronic back condition.
17.6 Reduce significant hearing impairment to a prevalence of no more than 82 per 1,000 people. (Baseline: Average of
88.9 per 1,000 during 1986-88)
Special Population Target
Hearing Impairment (per 1,000)
1986-88 Baseline
2000 Target
17.6a People aged 45 and older
203
180
Note: Hearing impairment covers the range of hearing deficits from mild loss in one ear to profound loss in both
ears. Generally, inability to hear sounds at levels softer (less intense) than 20 decibels (dB) constitutes abnormal
hearing. Significant hearing impairment is defined as having hearing thresholds for speech poorer than 25 dB.
However, for this objective, self-reported hearing impairment (i.e., deafness in one or both ears or any trouble hear-
ing in one or both ears) will be used as a proxy measure for significant hearing impairment.
17.7 Reduce significant visual impairment to a prevalence of no more than 30 per 1,000 people. (Baseline: Average of
34.5 per 1,000 during 1986-88)
Special Population Target
Visual Impairment (per 1,000)
1986-88 Baseline
2000 Target
17.7a People aged 65 and older
87.7
70
Note: Significant visual impairment is generally defined as a permanent reduction in visual acuity and/or field of
vision which is not correctable with eyeglasses or contact lenses. Severe visual impairment is defined as inability to
read ordinary newsprint even with corrective lenses. For this objective, self-reported blindness in one or both eyes
and other self-reported visual impairments (i.e., any trouble seeing with one or both eyes even when wearing glas-
ses or colorblindness) will be used as a proxy measure for significant visual impairment.
116
A. Summary List of Objectives
17.8* Reduce the prevalence of serious mental retardation in school-aged children to no more than 2 per 1,000 children.
(Baseline: 2.7 per 1,000 children aged 10 in 1985-88)
Note: Serious mental retardation is defined as an Intelligence Quotient (I.Q.) less than 50. This includes in-
dividuals defined by the American Association of Mental Retardation as profoundly retarded (1.Q. of 20 or less),
severely retarded (I.Q. of 21-35), and moderately retarded (I.Q. of 36-50).
Diabetes
17.9
Reduce diabetes-related deaths to no more than 34 per 100,000 people. (Age-adjusted baseline: 38 per 100,000 in
1986)
Special Population Targets
Diabetes-Related Deaths (per 100,000)
1986 Baseline
2000 Target
17.9a Blacks
65
58
17.9b American Indians/Alaska Natives
54
48
Note: Diabetes-related deaths refer to deaths from diabetes as an underlying or contributing cause.
17.10 Reduce the most severe complications of diabetes as follows:
Complications Among People With Diabetes
1988 Baseline
2000 Target
End-stage renal disease
1.5/1,000⁺
1.4/1,000
Blindness
2.2/1,000
1.4/1,000
Lower extremity amputation
8.2/1,000⁺
4.9/1,000
Perinatal mortality
5%
2%
Major congenital malformations
8%
4%
+ 1987 baseline *Among infants of women with established diabetes
Special Population Targets for ESRD
ESRD Due to Diabetes (per 1,000)
1983-86 Baseline
2000 Target
17.10a Blacks with diabetes
2.2
2
17.10b American Indians/Alaska Natives with diabetes
2.1
1.9
Special Population Target for Amputations
Lower Extremity Amputations Due to
Diabetes (per 1,000)
1984-87 Baseline 2000 Target
17.10c Blacks with diabetes
10.2
6.1
Note: End-stage renal disease (ESRD) is defined as requiring maintenance dialysis or transplantation and is
limited to ESRD due to diabetes. Blindness refers to blindness due to diabetic eye disease.
17.11 Reduce diabetes to an incidence of no more than 2.5 per 1,000 people and a prevalence of no more than 25 per 1,000
people. (Baselines: 2.9 per 1,000 in 1987; 28 per 1,000 in 1987)
Special Population Targets
Prevalence of Diabetes (per 1,000)
1982-84 Baseline⁺ 2000 Target
17.11a American Indians/Alaska Natives
69⁺
62
17.11b Puerto Ricans
55
49
17.11c Mexican Americans
54
49
17.11d Cuban Americans
36
32
17.11e Blacks
36⁸
32
1982-84 baseline for people aged 20-74
# 1987 baseline for American Indians/Alaska Natives aged 15 and older
§ 1987 baseline for blacks of all ages
117
Healthy People 2000
Risk Reduction Objectives
17.12* Reduce overweight to a prevalence of no more than 20 percent among people aged 20 and older and no more than
15 percent among adolescents aged 12 through 19. (Baseline: 26 percent for people aged 20 through 74 in
1976-80, 24 percent for men and 27 percent for women; 15 percent for adolescents aged 12 through 19 in 1976-80)
Special Population Targets
Overweight Prevalence
1976-80 Baseline¹
2000 Target
17.12a Low-income women aged 20 and older
37%
25%
17.12b Black women aged 20 and older
44%
30%
17.12c Hispanic women aged 20 and older
25%
Mexican-American women
39%
Cuban women
34%
Puerto Rican women
37%⁺
17.12d American Indians/Alaska Natives
29-75%
30%
17.12e People with disabilities
36%+
25%
17.12f Women with high blood pressure
50%
41%
17.12g Men with high blood pressure
39%
35%
1976-80 baseline for people aged 20-74
1982-84 baseline for Hispanics aged 20-74
§ 1984-88 estimates for different tribes
+1985 baseline for people aged 20-74 who report any limitation in activity due to chronic conditions
Note: For people aged 20 and older, overweight is defined as body mass index (BMI) equal to or greater than 27.8
for men and 27.3 for women. For adolescents, overweight is defined as BMI equal to or greater than 23.0 for
males aged 12 through 14, 24.3 for males aged 15 through 17, 25.8 for males aged 18 through 19, 23.4 for females
aged 12 through 14, 24.8 for females aged 15 through 17, and 25.7 for females aged 18 through 19. The values for
adolescents are the age- and gender-specific 85th percentile values of the 1976-80 National Health and Nutrition
Examination Survey (NHANES II), corrected for sample variation. BMI is calculated by dividing weight in
kilograms by the square of height in meters. The cut points used to define overweight approximate the 120 percent
of desirable body weight definition used in the 1990 objectives.
17.13* Increase to at least 30 percent the proportion of people aged 6 and older who engage regularly, preferably daily, in
light to moderate physical activity for at least 30 minutes per day. (Baseline: 22 percent of people aged 18 and
older were active for at least 30 minutes 5 or more times per week and 12 percent were active 7 or more times per
week in 1985)
Note: Light to moderate physical activity requires sustained, rhythmic muscular movements, is at least equivalent
to sustained walking, and is performed at less than 60 percent of maximum heart rate for age. Maximum heart rate
equals roughly 220 beats per minute minus age. Examples may include walking, swimming, cycling, dancing, gar-
dening and yardwork, various domestic and occupational activities, and games and other childhood pursuits.
Services and Protection Objectives
17.14 Increase to at least 40 percent the proportion of people with chronic and disabling conditions who receive formal
patient education including information about community and self-help resources as an integral part of the
management of their condition. (Baseline data available in 1991)
Type-Specific Targets
Patient Education
1983-84 Baseline
2000 Target
17.14a People with diabetes
32% (classes)
75%
68% (counseling)
17.14b People with asthma
50%
17.15 Increase to at least 80 percent the proportion of providers of primary care for children who routinely refer or screen
infants and children for impairments of vision, hearing, speech and language, and assess other developmental
milestones as part of well-child care. (Baseline data available in 1992)
17.16 Reduce the average age at which children with significant hearing impairment are identified to no more than 12
months. (Baseline: Estimated as 24 to 30 months in 1988)
17.17 Increase to at least 60 percent the proportion of providers of primary care for older adults who routinely evaluate
people aged 65 and older for urinary incontinence and impairments of vision, hearing, cognition, and functional
status. (Baseline data available in 1992)
17.18 Increase to at least 90 percent the proportion of perimenopausal women who have been counseled about the benefits
and risks of estrogen replacement therapy (combined with progestin, when appropriate) for prevention of
osteoporosis. (Baseline data available in 1991)
17.19 Increase to at least 75 percent the proportion of worksites with 50 or more employees that have a voluntarily
established policy or program for the hiring of people with disabilities. (Baseline: 37 percent of medium and large
companies in 1986)
Note: Voluntarily established policies and programs for the hiring of people with disabilities are encouraged for
worksites of all sizes. This objective is limited to worksites with 50 or more employees for tracking purposes.
118
A. Summary List of Objectives
17.20 Increase to 50 the number of States that have service systems for children with or at risk of chronic and disabling
conditions, as required by Public Law 101-239. (Baseline data available in 1991)
Note: Children with or at risk of chronic and disabling conditions, often referred to as children with special health
care needs, include children with psychosocial as well as physical problems. This population encompasses children
with a wide variety of actual or potential disabling conditions, including children with or at risk for cerebral palsy,
mental retardation, sensory deprivation, developmental disabilities, spina bifida, hemophilia, other genetic disor-
ders, and health-related educational and behavioral problems. Service systems for such children are organized net-
works of comprehensive, community-based, coordinated, and family-centered services.
18. HIV Infection
Health Status Objectives
18.1
Confine annual incidence of diagnosed AIDS cases to no more than 98,000 cases. (Baseline: An estimated 44,000 to
50,000 diagnosed cases in 1989)
Special Population Targets
Diagnosed AIDS Cases
1989 Baseline
2000 Target
18.1a Gay and bisexual men
26,000-28,000
48,000
18.1b Blacks
14,000-15,000
37,000
18.1c Hispanics
7,000-8,000
18,000
Note: Targets for this objective are equal to upper bound estimates of the incidence of diagnosed AIDS cases
projected for 1993.
18.2
Confine the prevalence of HIV infection to no more than 800 per 100,000 people. (Baseline: An estimated 400 per
100,000 in 1989)
Special Population Targets
Estimated Prevalence of HIV Infection (per 100,000)
1989 Baseline
2000 Target
18.2a Homosexual men
2,000-42,000
20,000
18.2b Intravenous drug abusers
30,000-40,000
40,000
18.2c Women giving birth to live-born infants
150
100
⁺Per 100,000 homosexual men aged 15 through 24 based on men tested in selected sexually transmitted disease
clinics in unlinked surveys; most studies find HIV prevalence of between 2,000 and 21,000 per 100,000
⁺Per 100,000 intravenous drug abusers aged 15 through 24 in the New York city vicinity; in areas other than
major metropolitan centers, infection rates in people entering selected drug treatment programs tested in
unlinked surveys are often under 500 per 100,000
Risk Reduction Objectives
18.3* Reduce the proportion of adolescents who have engaged in sexual intercourse to no more than 15 percent by age 15
and no more than 40 percent by age 17. (Baseline: 27 percent of girls and 33 percent of boys by age 15; 50
percent of girls and 66 percent of boys by age 17; reported in 1988)
18.4* Increase to at least 50 percent the proportion of sexually active, unmarried people who used a condom at last sexual
intercourse. (Baseline: 19 percent of sexually active, unmarried women aged 15 through 44 reported that their
partners used a condom at last sexual intercourse in 1988)
Special Population Targets
Use of Condoms
1988 Baseline
2000 Target
18.4a Sexually active young women aged 15-19 (by their partners)
26%
60%
18.4b Sexually active young men aged 15-19
57%
75%
18.4c Intravenous drug abusers
-
60%
Note: Strategies to achieve this objective must be undertaken sensitively to avoid indirectly encouraging or condon-
ing sexual activity among teens who are not yet sexually active.
18.5
Increase to at least 50 percent the estimated proportion of all intravenous drug abusers who are in drug abuse
treatment programs. (Baseline: An estimated 11 percent of opiate abusers were in treatment in 1989)
18.6 Increase to at least 50 percent the estimated proportion of intravenous drug abusers not in treatment who use only
uncontaminated drug paraphernalia ("works"). (Baseline: 25 to 35 percent of opiate abusers in 1989)
18.7 Reduce to no more than 1 per 250,000 units of blood and blood components the risk of transfusion-transmitted HIV
infection. (Baseline: 1 per 40,000 to 150,000 units in 1989)
Services and Protection Objectives
18.8
Increase to at least 80 percent the proportion of HIV-infected people who have been tested for HIV infection.
(Baseline: An estimated 15 percent of approximately 1,000,000 HIV-infected people had been tested at publicly
funded clinics, in 1989)
119
Healthy People 2000
18.9* Increase to at least 75 percent the proportion of primary care and mental health care providers who provide
age-appropriate counseling on the prevention of HIV and other sexually transmitted diseases. (Baseline: 10
percent of physicians reported that they regularly assessed the sexual behaviors of their patients in 1987)
Special Population Target
Counseling on HIV and STD Prevention
1987 Baseline
2000 Target
18.9a Providers practicing in high incidence areas
-
90%
Note: Primary care providers include physicians, nurses, nurse practitioners, and physician assistants. Areas of
high AIDS and sexually transmitted disease incidence are cities and States with incidence rates of AIDS cases, HIV
seroprevalence, gonorrhea, or syphilis that are at least 25 percent above the national average.
18.10 Increase to at least 95 percent the proportion of schools that have age-appropriate HIV education curricula for
students in 4th through 12th grade, preferably as part of quality school health education. (Baseline: 66 percent of
school districts required HIV education but only 5 percent required HIV education in each year for 7th through
12th grade in 1989)
Note: Strategies to achieve this objective must be undertaken sensitively to avoid indirectly encouraging or condon-
ing sexual activity among teens who are not yet sexually active.
18.11 Provide HIV education for students and staff in at least 90 percent of colleges and universities. (Baseline data
available in 1995)
18.12 Increase to at least 90 percent the proportion of cities with populations over 100,000 that have outreach programs to
contact drug abusers (particularly intravenous drug abusers) to deliver HIV risk reduction messages. (Baseline
data available in 1995)
Note: HIV risk reduction messages include messages about reducing or eliminating drug use, entering drug treat-
ment, disinfection of injection equipment if still injecting drugs, and safer sex practices.
18.13* Increase to at least 50 percent the proportion of family planning clinics, maternal and child health clinics, sexually
transmitted disease clinics, tuberculosis clinics, drug treatment centers, and primary care clinics that screen,
diagnose, treat, counsel, and provide (or refer for) partner notification services for HIV infection and bacterial
sexually transmitted diseases (gonorrhea, syphilis, and chlamydia). (Baseline: 40 percent of family planning
clinics for bacterial sexually transmitted diseases in 1989)
18.14 Extend to all facilities where workers are at risk for occupational transmission of HIV regulations to protect workers
from exposure to bloodborne infections, including HIV infection. (Baseline data available in 1992)
Note: The Occupational Safety and Health Administration (OSHA) is expected to issue regulations requiring
worker protection from exposure to bloodborne infections, including HIV, during 1991. Implementation of the
OSHA regulations would satisfy this objective.
19. Sexually Transmitted Diseases
Health Status Objectives
19.1
Reduce gonorrhea to an incidence of no more than 225 cases per 100,000 people. (Baseline: 300 per 100,000 in 1989)
Special Population Targets
Gonorrhea Incidence (per 100,000)
1989 Baseline
2000 Target
19.1a Blacks
1,990
1,300
19.1b Adolescents aged 15-19
1,123
750
19.1c Women aged 15-44
501
290
19.2 Reduce Chlamydia trachomatis infections, as measured by a decrease in the incidence of nongonococcal urethritis to
no more than 170 cases per 100,000 people. (Baseline: 215 per 100,000 in 1988)
19.3 Reduce primary and secondary syphilis to an incidence of no more than 10 cases per 100,000 people. (Baseline: 18.1
per 100,000 in 1989)
Special Population Target
Primary and Secondary Syphilis Incidence (per 100,000)
1989 Baseline
2000 Target
19.3a Blacks
118
65
19.4 Reduce congenital syphilis to an incidence of no more than 50 cases per 100,000 live births. (Baseline: 100 per
100,000 live births in 1989)
19.5 Reduce genital herpes and genital warts, as measured by a reduction to 142,000 and 385,000, respectively, in the
annual number of first-time consultations with a physician for the conditions. (Baseline: 167,000 and 451,000 in
1988)
19.6 Reduce the incidence of pelvic inflammatory disease, as measured by a reduction in hospitalizations for pelvic inflam-
matory disease to no more than 250 per 100,000 women aged 15 through 44. (Baseline: 311 per 100,000 in 1988)
19.7* Reduce sexually transmitted hepatitis B infection to no more than 30,500 cases. (Baseline: 58,300 cases in 1988)
19.8 Reduce the rate of repeat gonorrhea infection to no more than 15 percent within the previous year. (Baseline: 20
percent in 1988)
Note: As measured by a reduction in the proportion of gonorrhea patients who, within the previous year, were
treated for a separate case of gonorrhea.
120
A. Summary List of Objectives
Risk Reduction Objectives
19.9*
Reduce the proportion of adolescents who have engaged in sexual intercourse to no more than 15 percent by age 15
and no more than 40 percent by age 17. (Baseline: 27 percent of girls and 33 percent of boys by age 15; 50
percent of girls and 66 percent of boys by age 17; reported in 1988)
19.10* Increase to at least 50 percent the proportion of sexually active, unmarried people who used a condom at last sexual
intercourse. (Baseline: 19 percent of sexually active, unmarried women aged 15 through 44 reported that their
partners used a condom at last sexual intercourse in 1988)
Special Population Targets
Use of Condoms
1988 Baseline
2000 Target
19.10a Sexually active young women aged 15-19 (by their partners)
25%
60%
19.10b Sexually active young men aged 15-19
57%
75%
19.10c Intravenous drug abusers
-
60%
Note: Strategies to achieve this objective must be undertaken sensitively to avoid indirectly encouraging or condon-
ing sexual activity among teens who are not yet sexually active.
Services and Protection Objectives
19.11* Increase to at least 50 percent the proportion of family planning clinics, maternal and child health clinics, sexually
transmitted disease clinics, tuberculosis clinics, drug treatment centers, and primary care clinics that screen,
diagnose, treat, counsel, and provide (or refer for) partner notification services for HIV infection and bacterial
sexually transmitted diseases (gonorrhea, syphilis, and chlamydia). (Baseline: 40 percent of family planning
clinics for bacterial sexually transmitted diseases in 1989)
19.12 Include instruction in sexually transmitted disease transmission prevention in the curricula of all middle and
secondary schools, preferably as part of quality school health education. (Baseline: 95 percent of schools reported
offering at least one class on sexually transmitted diseases as part of their standard curricula in 1988)
Note: Strategies to achieve this objective must be undertaken sensitively to avoid indirectly encouraging or condon-
ing sexual activity among teens who are not yet sexually active.
19.13 Increase to at least 90 percent the proportion of primary care providers treating patients with sexually transmitted
diseases who correctly manage cases, as measured by their use of appropriate types and amounts of therapy.
(Baseline: 70 percent in 1988)
19.14* Increase to at least 75 percent the proportion of primary care and mental health care providers who provide
age-appropriate counseling on the prevention of HIV and other sexually transmitted diseases. (Baseline: 10
percent of physicians reported that they regularly assessed the sexual behaviors of their patients in 1987)
Special Population Target
Counseling on HIV and STD Prevention
1987 Baseline
2000 Target
19.14a Providers practicing in high incidence areas
-
90%
Note: Primary care providers include physicians, nurses, nurse practitioners, and physician assistants. Areas of
high AIDS and sexually transmitted disease incidence are cities and States with incidence rates of AIDS cases, HIV
seroprevalence, gonorrhea, or syphilis that are at least 25 percent above the national average.
19.15 Increase to at least 50 percent the proportion of all patients with bacterial sexually transmitted diseases (gonorrhea,
syphilis, and chlamydia) who are offered provider referral services. (Baseline: 20 percent of those treated in
sexually transmitted disease clinics in 1988)
Note: Provider referral (previously called contact tracing) is the process whereby health department personnel
directly notify the sexual partners of infected individuals of their exposure to an infected individual.
20. Immunization and Infectious Diseases
Health Status Objectives
20.1
Reduce indigenous cases of vaccine-preventable diseases as follows:
Disease
1988 Baseline
2000 Target
Diphtheria among people aged 25 and younger
1
0
Tetanus among people aged 25 and younger
3
0
Polio (wild-type virus)
0
0
Measles
3,058
0
Rubella
225
0
Congenital Rubella Syndrome
6
0
Mumps
4,866
500
Pertussis
3,450
1,000
20.2 Reduce epidemic-related pneumonia and influenza deaths among people aged 65 and older to no more than 7.3 per
100,000. (Baseline: Average of 9.1 per 100,000 during 1980 through 1987)
Note: Epidemic-related pneumonia and influenza deaths are those that occur above and beyond the normal yearly
fluctuations of mortality. Because of the extreme variability in epidemic-related deaths from year to year, the target
is a 3-year average.
121
Healthy People 2000
20.3* Reduce viral hepatitis as follows:
(Per 100,000)
1987 Baseline
2000 Target
Hepatitis B (HBV)
63.5
40
Hepatitis A
31
23
Hepatitis C
18.3
13.7
Special Population Targets for HBV
HBV Cases
1987 Estimated Baseline
2000 Target
20.3a Intravenous drug abusers
30,000
22,500
20.3b
Heterosexually active people
33,000
22,000
20.3c
Homosexual men
25,300
8,500
20.3d
Children of Asians/Pacific Islanders
8,900
1,800
20.3e
Occupationally exposed workers
6,200
1,250
20.3f Infants
3,500
550 new carriers
20.3g Alaska Natives
15
1
20.4 Reduce tuberculosis to an incidence of no more than 3.5 cases per 100,000 people. (Baseline: 9.1 per 100,000 in
1988)
Special Population Targets
Tuberculosis Cases (per 100,000)
1988 Baseline
2000 Target
20.4a Asians/Pacific Islanders
36.3
15
20.4b Blacks
28.3
10
20.4c Hispanics
18.3
5
20.4d American Indians/Alaska Natives
18.1
5
20.5
Reduce by at least 10 percent the incidence of surgical wound infections and nosocomial infections in intensive care
patients. (Baseline data available in late 1990)
20.6
Reduce selected illness among international travelers as follows:
Incidence
1987 Baseline
2000 Target
Typhoid fever
280
140
Hepatitis A
1,280
640
Malaria
2,000
1,000
20.7
Reduce bacterial meningitis to no more than 4.7 cases per 100,000 people. (Baseline: 6.3 per 100,000 in 1986)
Special Population Target
Bacterial Meningitis Cases (per 100,000)
1987 Baseline
2000 Target
20.7a Alaska Natives
33
8
20.8
Reduce infectious diarrhea by at least 25 percent among children in licensed child care centers and children in
programs that provide an Individualized Education Program (IEP) or Individualized Health Plan (IHP). (Baseline
data available in 1992)
20.9
Reduce acute middle ear infections among children aged 4 and younger, as measured by days of restricted activity or
school absenteeism, to no more than 105 days per 100 children. (Baseline: 131 days per 100 children in 1987)
20.10 Reduce pneumonia-related days of restricted activity as follows:
1987 Baseline
2000 Target
People aged 65 and older (per 100 people)
48 days
38 days
Children aged 4 and younger (per 100 children)
27 days
24 days
Risk Reduction Objectives
20.11 Increase immunization levels as follows:
Basic immunization series among children under age 2: at least 90 percent. (Baseline: 70-80 percent estimated in
1989)
Basic immunization series among children in licensed child care facilities and kindergarten through post-secondary
education institutions: at least 95 percent. (Baseline: For licensed child care, 94 percent; 97 percent for children
entering school for the 1987-1988 school year; and for post-secondary institutions, baseline data available in 1992)
Pneumococcal pneumonia and influenza immunization among institutionalized chronically ill or older people: at
least 80 percent. (Baseline data available in 1992)
Pneumococcal pneumonia and influenza immunization among noninstitutionalized, high-risk populations, as
defined by the Immunization Practices Advisory Committee: at least 60 percent. (Baseline: 10 percent estimated
for pneumococcal vaccine and 20 percent for influenza vaccine in 1985)
Hepatitis B immunization among high-risk populations, including infants of surface antigen-positive mothers to at
least 90 percent; occupationally exposed workers to at least 90 percent; IV-drug users in drug treatment programs
to at least 50 percent; and homosexual men to at least 50 percent. (Baseline data available in 1992)
20.12 Reduce postexposure rabies treatments to no more than 9,000 per year. (Baseline: 18,000 estimated treatments in
1987)
122
A. Summary List of Objectives
Services and Protection Objectives
20.13 Expand immunization laws for schools, preschools, and day care settings to all States for all antigens. (Baseline:
9 States and the District of Columbia in 1990)
20.14 Increase to at least 90 percent the proportion of primary care providers who provide information and counseling
about immunizations and offer immunizations as appropriate for their patients. (Baseline data available in 1992)
20.15 Improve the financing and delivery of immunizations for children and adults so that virtually no American has a
financial barrier to receiving recommended immunizations. (Baseline: Financial coverage for immunizations was
included in 45 percent of employment-based insurance plans with conventional insurance plans; 62 percent with
Preferred Provider Organization plans; and 98 percent with Health Maintenance Organization plans in 1989;
Medicaid covered basic immunizations for eligible children and Medicare covered pneumococcal immunization
for eligible older adults in 1990)
20.16 Increase to at least 90 percent the proportion of public health departments that provide adult immunization for
influenza, pneumococcal disease, hepatitis B, tetanus, and diphtheria. (Baseline data available in 1991)
20.17 Increase to at least 90 percent the proportion of local health departments that have ongoing programs for actively
identifying cases of tuberculosis and latent infection in populations at high risk for tuberculosis. (Baseline data
available in 1991)
Note: Local health department refers to any local component of the public health system, defined as an administra-
tive and service unit of local or State government concerned with health and carrying some responsibility for the
health of a jurisdiction smaller than a State.
20.18 Increase to at least 85 percent the proportion of people found to have tuberculosis infection who completed courses
of preventive therapy. (Baseline: 89 health departments reported that 66.3 percent of 95,201 persons placed on
preventive therapy completed their treatment in 1987)
20.19 Increase to at least 85 percent the proportion of tertiary care hospital laboratories and to at least 50 percent the
proportion of secondary care hospital and health maintenance organization laboratories possessing technologies for
rapid viral diagnosis of influenza. (Baseline data available in 1992)
21. Clinical Preventive Services
Health Status Objective
21.1* Increase years of healthy life to at least 65 years. (Baseline: An estimated 62 years in 1980)
Special Population Targets
Years of Healthy Life
1980 Baseline
2000 Target
21.1a Blacks
56
60
21.1b Hispanics
62
65
21.1c People aged 65 and older
12⁺
14⁺
Years of healthy life remaining at age 65
Note: Years of healthy life (also referred to as quality-adjusted life years) is a summary measure of health that com-
bines mortality (quantity of life) and morbidity and disability (quality of life) into a single measure. For people
aged 65 and older, active life-expectancy, a related summary measure, also will be tracked.
Risk Reduction Objective
21.2
Increase to at least 50 percent the proportion of people who have received, as a minimum within the appropriate
interval, all of the screening and immunization services and at least one of the counseling services appropriate for
their age and gender as recommended by the U.S. Preventive Services Task Force. (Baseline data available in
1991)
Special Population Targets
Receipt of Recommended Services
Baseline
2000 Target
21.2a Infants up to 24 months
I
90%
21.2b Children aged 2-12
-
80%
21.2c Adolescents aged 13-18
-
50%
21.2d Adults aged 19-39
|
40%
21.2e Adults aged 40-64
I
40%
21.2f Adults aged 65 and older
-
40%
21.2g Low-income people
-
50%
21.2h Blacks
-
50%
21.2i Hispanics
-
50%
21.2j Asians/Pacific Islanders
-
50%
21.2k American Indians/Alaska Natives
-
70%
21.21 People with disabilities
-
80%
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Healthy People 2000
Services and Protection Objectives
21.3
Increase to at least 95 percent the proportion of people who have a specific source of ongoing primary care for
coordination of their preventive and episodic health care. (Baseline: Less than 82 percent in 1986, as 18 percent
reported having no physician, clinic, or hospital as a regular source of care)
Special Population Targets
Percentage With Source of Care
1986 Baseline
2000 Target
21.3a Hispanics
70%
95%
21.3b Blacks
80%
95%
21.3c Low-income people
80%
95%
21.4 Improve financing and delivery of clinical preventive services so that virtually no American has a financial barrier to
receiving, at a minimum, the screening, counseling, and immunization services recommended by the U.S.
Preventive Services Task Force. (Baseline data available in 1992)
21.5
Assure that at least 90 percent of people for whom primary care services are provided directly by publicly funded
programs are offered, at a minimum, the screening, counseling, and immunization services recommended by the
U.S. Preventive Services Task Force. (Baseline data available in 1992)
Note: Publicly funded programs that provide primary care services directly include federally funded programs
such as the Maternal and Child Health Program, Community and Migrant Health Centers, and the Indian Health
Service as well as primary care service settings funded by State and local governments. This objective does not in-
clude services covered indirectly through the Medicare and Medicaid programs.
21.6
Increase to at least 50 percent the proportion of primary care providers who provide their patients with the screening,
counseling, and immunization services recommended by the U.S. Preventive Services Task Force. (Baseline data
available in 1992)
21.7
Increase to at least 90 percent the proportion of people who are served by a local health department that assesses and
assures access to essential clinical preventive services. (Baseline data available in 1992)
Note: Local health department refers to any local component of the public health system, defined as an administra-
tive and service unit of local or State government concerned with health and carrying some responsibility for the
health of a jurisdiction smaller than a State.
21.8 Increase the proportion of all degrees in the health professions and allied and associated health profession fields
awarded to members of underrepresented racial and ethnic minority groups as follows:
Degrees Awarded To:
1985-86 Baseline
2000 Target
Blacks
5%
8%
Hispanics
3%
6.4%
American Indians/Alaska Natives
0.3%
0.6%
Note: Underrepresented minorities are those groups consistently below parity in most health profession schools—
blacks, Hispanics, and American Indians and Alaska Natives.
22. Surveillance and Data Systems
Objectives
22.1
Develop a set of health status indicators appropriate for Federal, State, and local health agencies and establish use of
the set in at least 40 States. (Baseline: No such set exists in 1990)
22.2 Identify, and create where necessary, national data sources to measure progress toward each of the year 2000 national
health objectives. (Baseline: 77 percent of the objectives have baseline data in 1990)
Type-Specific Target
1989 Baseline
2000 Target
22.2a State level data for at least two-thirds of the objectives
23 States⁺
35 States
Measured using the 1989 Draft Year 2000 National Health Objectives
22.3
Develop and disseminate among Federal, State, and local agencies procedures for collecting comparable data for each
of the year 2000 national health objectives and incorporate these into Public Health Service data collection
systems. (Baseline: Although such surveys as the National Health Interview Survey may serve as a model, widely
accepted procedures do not exist in 1990)
22.4 Develop and implement a national process to identify significant gaps in the Nation's disease prevention and health
promotion data, including data for racial and ethnic minorities, people with low incomes, and people with
disabilities, and establish mechanisms to meet these needs. (Baseline: No such process exists in 1990)
Note: Disease prevention and health promotion data includes disease status, risk factors, and services receipt data.
Public health problems include such issue areas as HIV infection, domestic violence, mental health, environmental
health, occupational health, and disabling conditions.
124
A. Summary List of Objectives
22.5
Implement in all States periodic analysis and publication of data needed to measure progress toward objectives for at
least 10 of the priority areas of the national health objectives. (Baseline: 20 States reported that they disseminate
the analyses they use to assess State progress toward the health objectives to the public and to health professionals
in 1989)
Type-Specific Target
1989 Baseline
2000 Target
22.5a Periodic analysis and publication of State progress toward the
national objectives for each racial or ethnic group that makes up
at least 10 percent of the State population
-
25 States
Note: Periodic is at least once every 3 years. Objectives include, at a minimum, one from each objectives
category: health status, risk reduction, and services and protection.
22.6 Expand in all States systems for the transfer of health information related to the national health objectives among
Federal, State, and local agencies. (Baseline: 30 States reported that they have some capability for transfer of
health data, tables, graphs, and maps to Federal, State, and local agencies that collect and analyze data in 1989)
Note: Information related to the national health objectives includes State and national level baseline data, disease
prevention/health promotion evaluation results, and data generated to measure progress.
22.7
Achieve timely release of national surveillance and survey data needed by health professionals and agencies to
measure progress toward the national health objectives. (Baseline data available in 1993)
Note: Timely release (publication of provisional or final data or public use data tapes) should be based on the use
of the data, but is at least within one year of the end of data collection.
Age-Related Objectives
*Reduce the death rate for children by 15 percent to no more than 28 per 100,000 children aged 1 through 14, and for
infants by approximately 30 percent to no more than 7 per 1,000 live births. (Baseline: 33 per 100,000 for
children in 1987 and 10.1 per 1,000 live births for infants in 1987)
Reduce the death rate for adolescents and young adults by 15 percent to no more than 85 per 100,000 people aged 15
through 24. (Baseline: 99.4 per 100,000 in 1987)
Reduce the death rate for adults by 20 percent to no more than 340 per 100,000 people aged 25 through 64. (Baseline:
423 per 100,000 in 1987)
*Reduce to no more than 90 per 1,000 people the proportion of all people aged 65 and older who have difficulty in
performing two or more personal care activities (a reduction of about 19 percent), thereby preserving
independence. (Baseline: 111 per 1,000 in 1984-85)
125
B. Contributors to Healthy People 2000
Healthy People 2000: National Health Promotion and Disease Prevention Objectives is the
product of a national effort that has involved professionals and citizens, private organizations and
public agencies from every part of the Nation. Work on the report began in 1987 with the forma-
tion of the Healthy People 2000 Consortium and the convening of public hearings across the
country. Testimony from the public hearings became the primary resource material for working
groups of professionals to use in crafting the health objectives themselves. After extensive public
review and comment, involving more than 10,000 people, the objectives were refined and revised
to produce the report.
Preparation of the report was sponsored by the U.S. Public Health Service, through a project coor-
dinated by the Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion).
Project management was facilitated by the work of the PHS Steering Committee on the Healthy
People 2000 Objectives; the Committee on Health Objectives for the Year 2000, Institute of
Medicine, National Academy of Sciences; and the Secretary's Council on Health Promotion and
Disease Prevention. Principal staff and editorial responsibility for the project was carried out by
James A. Harrell, Lynn M. Artz, Ashley Files, and David Baker. Other staff from the Office of
Disease Prevention and Health Promotion helping in the coordination and development of the
overall project included Barbara Anderson, John Bailar, Amber Barnato, Sandra Buesking, Mary
Jo Deering, Christopher DeGraw, Olga Emgushov, Martha G. Frazier, Toni M. Goodwin, Linda
M. Harris, Douglas B. Kamerow, Thomas Kim, Loretta M. Logan, Patricia Lynch, Caroline Mc-
Neil, Linda D. Meyers, Diane Rittenhouse, Marilyn K. Schulenberg, Sara L. White, Jennifer
Woods, Christina Wypijewski, Michael Yao, and Daniel Yarano.
While it is not possible to recognize herein all those citizens and officials who made contributions
to Healthy People 2000, their efforts were central to development of the final product.
Public Health Service Office Directors and Agency Heads
James O. Mason, Assistant Secretary for Health, Washington, DC
Audrey F. Manley, Deputy Assistant Secretary for Health, Washington, DC
Antonia C. Novello, Surgeon General, Washington, DC
Paul B. Simmons, Deputy Assistant Secretary for Health (Communications), Washington, DC
J. Michael McGinnis, Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion),
Washington, DC
Samuel Lin, Deputy Assistant Secretary for Health (Intergovernmental Affairs), Rockville, MD
John D. Mahoney, Acting Deputy Assistant Secretary for Health (Operations), Washington, DC
Nabers Cabaniss, Deputy Assistant Secretary for Health (Population Affairs), Washington, DC
James M. Friedman, Acting Deputy Assistant Secretary for Health (Planning and Evaluation), Washington, DC
Frank E. Young, Deputy Assistant Secretary for Health (Science and Environment), Washington, DC
James R. Allen, Director, National AIDS Program Office, Washington, DC
Harold P. Thompson, Director, Office of International Health, Rockville, MD
William A. Robinson, Director, Office of Minority Health, Washington, DC
Wilmer D. Mizell, Executive Director, President's Council on Physical Fitness and Sports, Washington, DC
Agency Heads
J. Jarrett Clinton, Acting Administrator, Agency for Health Care Policy and Research, Rockville, MD
Frederick K. Goodwin, Administrator, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, MD
William L. Roper, Director, Centers for Disease Control, and Administrator, Agency for Toxic Substances
and Disease Registry, Atlanta, GA
James S. Benson, Acting Commissioner of Food and Drugs, Food and Drug Administration, Rockville, MD
Robert G. Harmon, Administrator, Health Resources and Services Administration, Rockville, MD
Everett R. Rhoades, Director, Indian Health Service, Rockville, MD
William F. Raub, Acting Director, National Institutes of Health, Bethesda, MD
127
Healthy People 2000
Public Health Service Steering Committee on the Healthy
People 2000 Objectives
PHS Members, by Agency
James A. Harrell, Chair, Office of Disease Prevention and Health Promotion, Washington, DC
Martha F. Katz, Vice-Chair, Office of Program Planning and Evaluation, Centers for Disease Control,
Atlanta, GA
Elaine M. Johnson, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, MD
Mary A. Jansen (alternate), Alcohol, Drug Abuse, and Mental Health Administration, Rockville, MD
Dennis D. Tolsma (alternate), Centers for Disease Control, Atlanta, GA
Ronald W. Wilson, National Center for Health Statistics, Centers for Disease Control, Hyattsville, MD
Ronald L. Wilson, Food and Drug Administration, Rockville, MD
Ronald H. Carlson, Health Resources and Services Administration, Rockville, MD
Craig Vanderwagen, Indian Health Service, Rockville, MD
John H. Ferguson, National Institutes of Health, Bethesda, MD
John T. Kalberer, Jr. (alternate), National Institutes of Health, Bethesda, MD
Edward Sondik, National Cancer Institute, National Institutes of Health, Bethesda, MD
Gregory J. Morosco, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
Joan E. Blair, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
Valerie Welsh, Office of Health Planning and Evaluation, Washington, DC
William A. Robinson, Office of Minority Health, Washington, DC
Robert A. Scholle, Office of Population Affairs, Washington, DC
Christine G. Spain, President's Council on Physical Fitness and Sports, Washington, DC
Other Members
Kathleen A. Loughrey, American Public Health Association, Washington, DC
Michael A. Stoto, Institute of Medicine, National Academy of Sciences, Washington, DC
Secretary's Council on Health Promotion and Disease
Prevention
James O. Mason, Chair, Washington, DC
Edward N. Brandt, Jr., (Former Assistant Secretary for Health), Oklahoma City, OK
Stanley E. Broadnax, U.S. Conference of Local Health Officers, Cincinnati, OH
Theodore Cooper, (Former Assistant Secretary for Health), Kalamazoo, MI
Alan W. Cross, Association of Teachers of Preventive Medicine, Chapel Hill, NC
Gus T. Dalis, Association for the Advancement of Health Education, Downey, CA
Merlin K. Duval, (Former Assistant Secretary for Health), Phoenix, AZ
Charles C. Edwards, (Former Assistant Secretary for Health), LaJolla, CA
Roger O. Egeberg, (Former Assistant Secretary for Health), Rockville, MD
A. Garth Fisher, Provo, UT
Donald A. Henderson, Association of Schools of Public Health, Baltimore, MD
Joyce C. Lashof, Association of Schools of Public Health, Berkeley, CA
Philip R. Lee, (Former Assistant Secretary for Health), San Francisco, CA
Stephen H. Lipson, Indianapolis, IN
Joel L. Nitzkin, National Association of County Health Officials, New Orleans, LA
Kevin M. Patrick, Association of Teachers of Preventive Medicine, San Diego, CA
Thomas M. Vernon, Jr., Association of State and Territorial Health Officials, Denver, CO
Julius B. Richmond, (Former Assistant Secretary for Health), Boston, MA
Robert Rodale (deceased), Emmaus, PA
H. Denman Scott, Association of State and Territorial Health Officials, Providence, RI
F. Douglas Scutchfield, American College of Preventive Medicine, San Diego, CA
Bailus Walker, Jr., American Public Health Association, Oklahoma City, OK
Martin P. Wasserman, National Association of County Health Officials, Rockville, MD
Robert E. Windom, (Former Assistant Secretary for Health), Sarasota, FL
128
B. Contributors to Healthy People 2000
Committee on Health Objectives for the Year 2000, Institute
of Medicine, National Academy of Sciences
Merlin K. Duval, Chair, Phoenix, AZ
Jack Elinson, Rutgers University, New Brunswick, NJ
Robert I. Levy, Sandoz Research Institute, East Hanover, NJ (until 5/88)
Anne Hubbard Mattson, Jefferson County Health Department, Birmingham, AL
Gilbert S. Omenn, University of Washington, Seattle, WA
Katharine Bauer Sommers, Institute of Medicine, Washington, DC
Institute of Medicine Staff
Samuel O. Thier, President
Cynthia Howe
Michael A. Stoto, Study Director
Roseanne Mctyre
Ruth Behrens
Jane S. Durch
Enriqueta C. Bond
Connie Rosemont
Marty Ellington
Renie Schapiro
Gary B. Ellis
Donna D. Thompson
Kay C. Harris
Coordinators of Priority Area Working Groups
Physical Activity and Fitness
Christine G. Spain, President's Council on Physical Fitness and Sports, Washington, DC
Nutrition
Darla E. Danford, National Institutes of Health (NIH), Bethesda, MD
Marilyn G. Stephenson, Center for Food Safety and Applied Nutrition, Food and Drug Administration
(FDA), Washington, DC
Tobacco
Ronald M. Davis, Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control
(CDC), Rockville, MD
John L. Bagrosky, Center for Chronic Disease Prevention, and Health Promotion (CDC), Rockville, MD
Alcohol and Other Drugs
Mary A. Jansen, Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA), Rockville, MD
Family Planning
Robert A. Scholle, Office of Population Affairs, Washington, DC
Mental Health and Mental Disorders
Mary A. Jansen, Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA), Rockville, MD
Violent and Abusive Behavior
James A. Mercy, Center for Environmental Health and Injury Control (CDC), Atlanta, GA
Mark L. Rosenberg, Center for Environmental Health and Injury Control (CDC), Atlanta, GA
Educational and Community-Based Programs
Dennis D. Tolsma, Centers for Disease Control, Atlanta, GA
Ronald H. Carlson, Health Resources and Services Administration (HRSA), Rockville, MD
Unintentional Injuries
J. Lee Annest, Center for Environmental Health and Injury Control (CDC), Atlanta, GA
Mark L. Rosenberg, Center for Environmental Health and Injury Control (CDC), Atlanta, GA
Occupational Safety and Health
Donald E. Ward, Jr., National Institute for Occupational Safety and Health (CDC), Atlanta, GA
129
Healthy People 2000
Environmental Health
Daniel C. VanderMeer, National Institute of Environmental Health Sciences (NIH), Research Triangle Park, NC
Henry Falk, Center for Environmental Health and Injury Control (CDC), Atlanta, GA
Daniel A. Hoffman, Center for Environmental Health and Injury Control (CDC), Atlanta, GA
Food and Drug Safety
Ronald L. Wilson, Food and Drug Administration, Rockville, MD
I. David Wolfson, Food and Drug Administration, Rockville, MD
Oral Health
Helen C. Gift, National Institute of Dental Research (NIH), Bethesda, MD
Stephen B. Corbin, Center for Prevention Services (CDC), Bethesda, MD
Maternal and Infant Health
Ann M. Koontz, Maternal and Child Health Bureau (HRSA), Rockville, MD
Carol A. Delany, Maternal and Child Health Bureau (HRSA), Rockville, MD
Heart Disease and Stroke
Joan E. Blair, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD
Cancer
Edward Sondik, National Cancer Institute (NIH), Bethesda, MD
Helen I. Meissner, National Cancer Institute (NIH), Bethesda, MD
Diabetes and Chronic Disabling Conditions
Benjamin T. Burton, National Institute of Diabetes and Digestive and Kidney Diseases (NIH), Bethesda, MD
James S. Marks, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA
HIV Infection
Jo Messore, National AIDS Program Office, Washington, DC
Sexually Transmitted Diseases
Willard Cates, Jr., Center for Prevention Services (CDC), Atlanta, GA
Stephen A. Morse, Center for Infectious Diseases (CDC), Atlanta, GA
Immunization and Infectious Diseases
Alan R. Hinman, Center for Prevention Services (CDC), Atlanta, GA
James M. Hughes, Center for Infectious Diseases (CDC), Atlanta, GA
Clinical Preventive Services
Ronald H. Carlson, Health Resources and Services Administration, Rockville, MD
Dennis D. Tolsma, Centers for Disease Control, Atlanta, GA
Surveillance and Data Systems
Ronald W. Wilson, National Center for Health Statistics (CDC), Hyattsville, MD
Patricia M. Golden, National Center for Health Statistics (CDC), Hyattsville, MD
130
B. Contributors to Healthy People 2000
Members of Priority Area Working Groups and Other
Contributors
The following persons participated in development of the Healthy People 2000 objectives as mem-
bers of working groups of professionals and in other significant roles. Many of them served on
two or more working groups (as did a number of the priority area coordinators, who are not listed
again).
Edgar Adams, National Institute on Drug Abuse (ADAMHA), Rockville, MD
Michael Adams, Center for Environmental Health and Injury Control (CDC), Atlanta, GA
David F. Adcock, University of South Carolina Medical School, Columbia, SC
Susan Addiss, Quinnipiack Valley Health District, Hamden, CT
J. Harrison Ager, National Institute of Diabetes and Digestive and Kidney Diseases (NIH), Bethesda, MD
E. Joseph Alderman, Georgia Department of Human Resources, Atlanta, GA
Caffilene Allen, Center for Infectious Diseases (CDC), Atlanta, GA
David Allen, Louisville and Jefferson County Health Department, Louisville, KY
Myron Allukian, Boston Department of Health and Hospitals, Boston, MA
Zili Amsel, National Institute on Drug Abuse (ADAMHA), Rockville, MD
Henry Anderson, Wisconsin Department of Health and Social Services, Madison, WI
Douglas L. Archer, Center for Food Safety and Applied Nutrition (FDA), Washington, DC
Katherine L. Armstrong, Western Consortium for Public Health, Berkeley, CA
Janet Arrowsmith, Food and Drug Administration, Rockville, MD
George Arsnow, Rehabilitation Services Administration, U.S. Department of Education, Washington, DC
Victor Avitto, Health Resources and Services Administration, Rockville, MD
Christine A. Bachrach, National Institute for Child Health and Human Development (NIH), Bethesda, MD
Shirley Bagley, National Institute on Aging (NIH), Bethesda, MD
Wendy Baldwin, National Institute for Child Health and Human Development (NIH), Bethesda, MD
Claudia Baquet, National Cancer Institute (NIH), Bethesda, MD
Robert Battjes, National Institute on Drug Abuse (ADAMHA), Rockville, MD
John A. Beare, Washington State Department of Social and Health Services, Olympia, WA
Robert W. Beck, Public Health Service, Rockville, MD
Christopher Benjamin, Office of Program Planning and Evaluation (CDC), Atlanta, GA
Heinz Berendes, National Institute of Child Health and Human Development (NIH), Bethesda, MD
Leonard Berg, Washington University School of Medicine, St. Louis, MO
Nancy Zinneman Berger, Association of State and Territorial Public Health Nutrition Program Directors,
Hartford, CT
Lawrence Bergner, National Cancer Institute (NIH), Bethesda, MD
Betty Jo Berland, National Institute on Disability and Rehabilitation Research, U.S. Department of Education,
Washington, DC
Darryl Bertolucci, National Institute on Alcohol Abuse and Alcoholism (ADAMHA), Rockville, MD
Richard M. Biery, Kansas City Health Department, Kansas City, MO
Rick Birkel, National Resource Center for Worksite Health Promotion, Washington, DC
Carl H. Blank, Training and Laboratory Program Office (CDC), Atlanta, GA
Joseph H. Blount, Center for Prevention Services (CDC), Atlanta, GA
John J. Boren, National Institute on Drug Abuse (ADAMHA), Rockville, MD
George Bouthilet, President's Committee on Mental Retardation, Washington, DC
Noble N. Bowie, National Highway Traffic Safety Administration, U.S. Department of Transportation
(DOT), Washington, DC
Elizabeth Brannon, Health Resources and Services Adminisration, Rockville, MD
Albert Brasile, Center for Environmental Health and Injury Control (CDC), Atlanta, GA
George Brenneman, Indian Health Service, Rockville, MD
Ethel Briggs, National Council on the Handicapped, Washington, DC
Norma T. Brinkley-Staley, Health Resources and Services Administration, Rockville, MD
Martin Brown, National Cancer Institute (NIH), Bethesda, MD
Stuart T. Brown, DeKalb County Health Department, Decatur, GA
Georgia Buggs, Office of Minority Health, Washington, DC
William Bukoski, National Institute on Drug Abuse (ADAMHA), Rockville, MD
131
Healthy People 2000
Thomas Burns, Indian Health Service, Rockville, MD
Richard Carnevale, Food Safety and Inspection Service, U.S. Department of Agriculture (USDA),
Washington, DC
Judith L. Carpenter, Office of Intergovernmental Affairs, Washington, DC
Carl Caspersen, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA
Philip Chao, Food and Drug Administration, Rockville, MD
Bruce R. Chelikowsky, Indian Health Service, Rockville, MD
James Cleeman, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD
Carolyn Clifford, National Cancer Institute (NIH), Bethesda, MD
Ronald F. Coene, National Center for Toxicological Research (FDA) Rockville, MD
Barbara Cohen, Office of Population Affairs, Washington, DC
Elaine Cohen, Health Resources and Services Administration, Rockville, MD
Mitchell L. Cohen, Center for Infectious Diseases (CDC), Atlanta, GA
J. Gary Collins, National Center for Health Statistics (CDC), Hyattsville, MD
Robert J. Collins, Indian Health Service, Rockville, MD
Eileen Connolly, Public Health Service-Region II, New York, NY
Gregory N. Connolly, Massachusetts Department of Public Health, Boston, MA
Frances Cotter, National Institute on Alcohol Abuse and Alcoholism (ADAMHA), Rockville, MD
Nancy F. Couey, Centers for Disease Control, Atlanta, GA
James F. Coyle, Federal Emergency Management Agency, Emmitsburg, MD
George Curlin, National Institute of Allergy and Infectious Diseases (NIH), Bethesda, MD
Dorynne Czechowicz, National Institute on Drug Abuse (ADAMHA), Rockville, MD
Anthony Angelo, Indian Health Service, Rockville, MD
Ada Davis, Bureau of Health Professions (HRSA), Rockville, MD
John Dement, National Institute of Environmental Health Sciences (NIH), Research Triangle Park, NC
Robert W. Denniston, Office for Substance Abuse Prevention (ADAMHA), Rockville, MD
Frank Destefano, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA
Terrence Donahue, Office of Justice Programs (DOT), Washington, DC
Denise Dougherty, Office of Technology Assessment, U.S. Congress, Washington, DC
Joseph S. Drage, National Institute of Neurological and Communicative Disorders and Stroke (NIH),
Bethesda, MD
Frederick R. Drews, U.S. Army War College, Carlisle, PA
Peter Drotman, Center for Infectious Diseases (CDC), Atlanta, GA
Thomas F. Drury, National Institute of Dental Research (NIH), Bethesda, MD
Rosemary E. Duffy, U.S. Department of Veterans Affairs (VA), Washington, DC
Mary C. Dufour, National Institute on Alcohol Abuse and Alcoholism (ADAMHA), Rockville, MD
Allen B. Duncan, Food and Drug Administration, Rockville, MD
Thena M. Durham, Center for Prevention Services (CDC), Atlanta, GA
Spike Duzor, Health Care Financing Administration, Baltimore, MD
William W. Dyal, Public Health Program Practice Office (CDC), Atlanta, GA
Mark Eberhardt, National Center for Health Statistics (CDC), Hyattsville, MD
Brenda Edwards, National Cancer Institute (NIH), Bethesda, MD
Anita Eichler, National Institute of Mental Health (ADAMHA), Rockville, MD
Elaine Eklund, American Association of University Affiliated Programs for Persons with Developmental
Disabilities, Silver Spring, MD
Pennifer Erickson, National Center for Health Statistics (CDC), Hyattsville, MD
Nancy D. Ernst, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD
Joyce D. K. Essien, Public Health Program Practice Office (CDC), Atlanta, GA
David Evans, Agency for Toxic Substances and Disease Registry, Atlanta, GA
Vernard Evans, Administration on Developmental Disabilities, Office of Human Development Services
(OHDS), Washington, DC
Ann Fainsinger, Alliance for Aging Research, Washington, DC
Mary E. Farmer, National Institute for Mental Health (ADAMHA), Rockville, MD
Marcia Fein, American Express, New York, NY
Michael C. Fiore, University of Wisconsin, Madison, WI
Michael Fishman, Maternal and Child Health Bureau (HRSA), Rockville, MD
132
B. Contributors to Healthy People 2000
Rebecca Fitch, Office of Special Education and Rehabilitation Services, U.S. Department of Education,
Washington, DC
William FitzGerald, National Institute on Drug Abuse (ADAMHA), Rockville, MD
Allan L. Forbes, Rockville, MD
Willis R. Foster, National Institute of Diabetes and Digestive and Kidney Diseases (NIH), Bethesda, MD
Judith Fradkin, National Institute of Diabetes and Digestive and Kidney Diseases (NIH), Bethesda, MD
Dolores M. Franklin, Department of Human Services, Washington, DC
Paula Franklin, Office of Disability, Social Security Administration, Baltimore, MD
P. Jean Frazier, University of Minnesota, Minneapolis, MN
Frank J. Frodyma, Occupational Safety and Health Administration, U.S. Department of Labor (DOL),
Washington, DC
Robinson Fulwood, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD
Arthur S. Funke, Maternal and Child Health Bureau (HRSA), Rockville, MD
Lawrence J. Furman, Center for Prevention Services (CDC), Atlanta, GA
Judy Galloway, National Institute on Drug Abuse (ADAMHA), Rockville, MD
J.T. Garrett, Indian Health Service, Rockville, MD
Barbara Gerbert, University of California at San Francisco, San Francisco, CA
Martin Gerry, U.S. Department of Health and Human Services, Washington, DC
George M. Gillespie, Pan American Health Organization, Washington, DC
Evelyn Glass, Office of Population Affairs, Washington, DC
Tom Glynn, National Cancer Institute (NIH), Bethesda, MD
Dorothy Gohdes, Indian Health Service, Albuquerque, NM
Harold Goldsmith, National Institute of Mental Health (ADAMHA), Rockville, MD
Steve Gordon, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIH), Bethesda, MD
Peter Greenwald, National Cancer Institute (NIH), Bethesda, MD
Timothy W. Groza, National Institute for Occupational Safety and Health (CDC), Atlanta, GA
Antoinette Hagey, U.S. Department of Defense, Washington, DC
Carol Haines, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD
Earl H. Handwerker, Center for Infectious Diseases (CDC), Atlanta, GA
Benjamin Hankey, National Cancer Institute (NIH), Bethesda, MD
Kevin S. Hardwick, Public Health Service, Rockville, MD
Thomas Harford, National Institute on Alcohol Abuse and Alcoholism (ADAMHA), Rockville, MD
William Harlan, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD
Mary Harper, National Institute of Mental Health (ADAMHA), Rockville, MD
Peter Hartsock, National Institute on Drug Abuse (ADAMHA), Rockville, MD
Harry W. Haverkos, National Institute on Drug Abuse (ADAMHA), Rockville, MD
Barbara Hawkins, Indiana University, Bloomington, IN
Betty Hawks, Office of Minority Health, Washington, DC
Suzanne G. Haynes, National Cancer Institute (NIH), Bethesda, MD
Arlene P. Hegg, National Institute of Mental Health (ADAMHA), Rockville, MD
James T. Heimbach, Human Nutrition Information Service (USDA), Hyattsville, MD
Gerry Hendershot, National Center for Health Statistics (CDC), Hyattsville, MD
Kenneth L. Herrmann, Center for Infectious Diseases (CDC), Atlanta, GA
Stephen P. Heyse, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIH), Bethesda, MD
Penni St. Hilaire, Office of Intergovernmental Affairs, Rockville, MD
William Hiscock, Health Care Financing Administration, Baltimore, MD
Carol Hogue, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA
John Holland, National Defense University-Fort McNair, Washington, DC
John Holloszy, Washington University School of Medicine, St. Louis, MO
Janet Horan, Bureau of Health Professions (HRSA), Rockville, MD
Margorie C. Horn, National Center for Health Statistics (CDC), Hyattsville, MD
Philip R. Horne, Center for Prevention Services (CDC), Atlanta, GA
Constance Horner, U.S. Department of Health and Human Services, Washington, DC
Alice M. Horowitz, National Institute of Dental Research (NIH), Bethesda, MD
Vernon Houk, Center for Environmental Health and Injury Control (CDC), Atlanta, GA
Bettie Hudson, National Center for Health Statistics (CDC), Hyattsville, MD
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Healthy People 2000
Robert S. Hutchings, Center for Chronic Disease Prevention and Health Promotion (CDC), Rockville, MD
Karen Hymbaugh, Indian Health Service, Albuquerque, NM
George J. Jackson, Food and Drug Administration, Washington, DC
Jack Jackson, Center for Environmental Health and Injury Control (CDC), Atlanta, GA
Joyce Stokes Jackson, Health Care Financing Administration, Baltimore, MD
M. Yvonne Jackson, Indian Health Service, Rockville, MD
William R. Jarvis, Center for Infectious Diseases (CDC), Atlanta, GA
Patrick E. Johannes, Indian Health Service, Albuquerque, NM
Barry L. Johnson, Agency for Toxic Substances and Disease Registry, Atlanta, GA
Clifford Johnson, National Center for Health Statistics (CDC), Hyattsville, MD
Ernest W. Johnson, National Institute of Diabetes and Digestive and Kidney Diseases (NIH), Bethesda, MD
Sandie Johnson, Office for Substance Abuse Prevention (ADAMHA), Rockville, MD
Rhys Burton Jones, Wisconsin Division of Health, Madison, WI
James P. Kallenborn, Occupational Safety and Health Administration (DOL), Washington, DC
Glenn Kamber, Office for Treatment Improvement (ADAMHA), Rockville, MD
Robert Kane, University of Minnesota, Minneapolis, MN
George A. Kanuck, Office of Communication and Extramural Affairs (ADAMHA), Rockville, MD
Murray L. Katcher, Wisconsin Department of Health, Madison, WI
Wendy Kaye, Agency for Toxic Substances and Disease Registry (ATSDR), Atlanta, GA
Juliette S. Kendrick, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA
Miller H. Kerr, Centers for Disease Control, Atlanta, GA
Larry Kessler, National Cancer Institute (NIH), Bethesda, MD
Henry M. Kissman, National Library of Medicine, Bethesda, MD
Dushanka V. Kleinman, National Institute of Dental Research (NIH), Bethesda, MD
Joel Kleinman, National Center for Health Statistics (CDC), Hyattsville, MD
Robert N. Kohmescher, Center for Prevention Services (CDC), Atlanta, GA
Andrea Kopstein, National Institute on Drug Abuse (ADAMHA), Rockville, MD
John M. Korn, Jr., Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA
Richard Kotomori, Indian Health Service, Rockville, MD
Nicholas Kozel, National Institute on Drug Abuse (ADAMHA), Rockville, MD
Marie Fanelli Kuczmarski, National Center for Health Statistics (CDC), Hyattsville, MD
George A. Kupfer, National Sanitation Foundation, Ann Arbor, MI
Thomas Lalley, National Institute of Mental Health (ADAMHA), Rockville, MD
Elizabeth Lambert, National Institute on Drug Abuse (ADAMHA), Rockville, MD
Garland Land, Missouri Department of Health, Jefferson City, MO
Elaine Lanza, National Cancer Institute (NIH), Bethesda, MD
Lynn A. Larsen, Center for Food Safety and Applied Nutrition (FDA), Washington, DC
Joyce Lazar, National Institute of Mental Health (ADAMHA), Rockville, MD
Bonnie Lee, Office of Health Affairs (FDA), Rockville, MD
Claude Lenfant, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD
Bruce Leonard, Indian Health Service, Albuquerque, NM
Alan Leshner, National Institute on Mental Health (ADAMHA), Rockville, MD
Joel T. Levine, Health Resources and Services Administration, Rockville, MD
Luise Light, National Cancer Institute (NIH), Bethesda, MD
James A. Lipton, National Institute of Dental Research (NIH), Bethesda, MD
Barbara Lockhart, University of Iowa, Iowa City, IA
Beverly B. Long, National Prevention Coalition, Atlanta, GA
Gloriana M. Lopez, Bureau of Health Care Delivery and Assistance (HRSA), Rockville, MD
Max R. Lum, Office of External Affairs (ATSDR), Atlanta, GA
Geraldine Maccannon, Office of Minority Health, Washington, DC
Mark J. Magenheim, Sarasota County Public Health Unit, Sarasota, FL
Dolores M. Malvitz, Center for Prevention Services (CDC), Atlanta, GA
Ronald Manderscheid, National Institute of Mental Health (ADAMHA), Rockville, MD
Ann C. Maney, National Institute of Mental Health (ADAMHA), Rockville, MD
Michael Marge, National Commission on Disability, Syracuse University, Syracuse, NY
James Y. Marshall, American Dental Association, Chicago, IL
134
B. Contributors to Healthy People 2000
Carol A. Martin, Indian Health Service, Rockville, MD
Laura Y. Martin, Center for Environmental Health and Injury Control (CDC), Atlanta, GA
William J. Martone, Center for Infectious Diseases (CDC), Atlanta, GA
James Massey, National Center for Health Statistics (CDC), Hyattsville, MD
William J. Mayer, The Wyatt Company, Washington, DC
Robert McAlister, Association of State and Territorial Health Officials, McLean, VA
Sheila McCarthy, Maternal and Child Health Bureau (HRSA), Rockville, MD
Patrick McConnon, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA
George McCoy, Indian Health Service, City?
Sandra McElhaney, National Mental Health Association, Alexandria, VA
Steve Uranga McKane, Hartford Health Department, Hartford, CT
Jeffrey W. McKenna, National Cancer Institute (NIH), Bethesda, MD
John McKinlay, New England Research Institute, Watertown, MA
Mary McLean, Health Care Financing Administration, Washington, DC
Laura McNally, Health Resources and Financing Administration, Rockville, MD
Merle McPherson, Maternal and Child Health Bureau (HRSA), Rockville, MD
Robert E. Mecklenburg, Potomac, MD
Florence Meltzer, Office of Population Affairs, Washington, DC
Ronald B. Merrill, Health Resources and Services Administration, Rockville, MD
Walter Mertz, Human Nutrition Research Center (USDA), Beltsville, MD
Dorothy Meyer, Indian Health Service, Phoenix, AZ
C. Arden Miller, University of North Carolina at Chapel Hill, Chapel Hill, NC
William Modzeleski, U.S. Department of Education, Washington, DC
Judy Mohsberg, Office of Legislation and Policy (HCFA), Washington, DC
Mary Moien, National Center for Health Statistics (CDC), Hyattsville, MD
James M. Monroe, Center for Infectious Diseases (CDC), Atlanta, GA
Laura E. Montgomery, National Center for Health Statistics (CDC), Hyattsville, MD
John Moore, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA
Julian M. Morris, National Eye Institute (NIH), Bethesda, MD
James A. Mortimer, VA Medical Center, Minneapolis, MN
Eve K. Moscicki, National Institute of Mental Health (ADAMHA), Rockville, MD
Alanna Moshfegh, Human Nutrition Information Service (USDA), Hyattsville, MD
Doris Mosley, Health Resources and Services Administration, Rockville, MD
Barbara Nelson, National Institute for Occupational Safety and Health (CDC), Atlanta, GA
Gary Nelson, Centers for Disease Control, Atlanta, GA
Susan Newcomer, National Institute for Child Health and Human Development (NIH), Bethesda, MD
Linda C. Niessen, VA Medical Center, Perry Point, MD
Annette M. Nieves, Office of Minority Health, Washington, DC
Yuth Nimit, National Vaccine Program Office, Rockville, MD
Charles Q. North, Albuquerque Indian Hospital, Indian Health Service, Albuquerque, NM
Ruth Nowjack-Raymer, National Institute of Dental Research (NIH), Bethesda, MD
Godfrey P. Oakley, Jr., Center for Environmental Health and Injury Control (CDC), Atlanta, GA
Joanne Odenkirchen, National Cancer Institute (NIH), Bethesda, MD
Richard Olson, Indian Health Service, Rockville, MD
Walter A. Orenstein, Center for Prevention Services (CDC), Atlanta, GA
Marcia C. Ory, National Institute on Aging (NIH), Bethesda, MD
Donald C. Parks, Maternal and Child Health Bureau (HRSA), Rockville, MD
Sandra S. Parrino, National Commission on Disability, Briarcliff Manor, NY
Clifford H. Patrick, U.S. Department of Veteran Affairs, Durham, NC
Gregory Pawlson, George Washington University Medical Center, Washington, DC
Terry F. Pechacek, National Cancer Institute (NIH), Bethesda, MD
Marian Perlmutter, University of Michigan, Ann Arbor, MI
John P. Pierce, University of California, San Diego, La Jolla, CA
Anita Pikus, National Institute of Deafness and Other Communication Disorders (NIH), Bethesda, MD
Margaret Porter, Office of the Assistant Secretary for Planning and Evaluation, Washington, DC
Barry Portnoy, National Cancer Institute (NIH), Bethesda, MD
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Curtis Posphisil, National Institute of Environmental Health Sciences (NIH), Research Triangle Park, NC
Arnold Potosky, National Cancer Institute (NIH), Bethesda, MD
Morris Potter, Center for Infectious Diseases (CDC), Atlanta, GA
Kenneth Powell, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA
William Pratt, National Center for Health Statistics (CDC), Hyattsville, MD
Ann E. Prendergast, Maternal and Child Health Bureau (HRSA), Rockville, MD
Philip Prorok, National Cancer Institute (NIH), Bethesda, MD
Glenn Provost, Center for Environmental Health and Injury Control (CDC), Atlanta, GA
James F. Quilty, Ohio Department of Public Health, Columbus, OH
Joan White Quinlan, Office for Substance Abuse Prevention (ADAMHA), Rockville, MD
Thomas C. Quinn, Johns Hopkins Hospital, Baltimore, MD
Amelie G. Ramirez, University of Texas Health Sciences Center at Houston, San Antonio, TX
Juan Ramos, National Institute of Mental Health (ADAMHA), Rockville, MD
David C. Ramsey, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA
Betty Reid, State Department of Education, Baltimore, MD
Nicholas P. Reuter, Food and Drug Administration, Rockville, MD
Peter H. Rheinstein, Center for Food Safety and Applied Nutrition (FDA), Rockville, MD
Carolyn Rimes, Office of the Actuary (HCFA), Baltimore, MD
Alice R. Ring, Centers for Disease Control, Atlanta, GA
Laverdia Roach, President's Committee on Mental Retardation, Washington, DC
David A. Robinson, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD
Edward Roccella, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD
Rose Mary Romano, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA
Joan Rosenbach, Health Resources and Services Administration, Rockville, MD
Harry Rosenberg, National Center for Health Statistics (CDC), Hyattsville, MD
Zeda Rosenberg, National Institute of Allergy and Infectious Diseases (NIH), Bethesda, MD
Louis Rossiter, Health Care Financing Administration, Washington, DC
Richard Rothenberg, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA
Charles Rothwell, National Center for Health Statistics (CDC), Hyattsville, MD
Kathy Roy, National Council on the Handicapped, Washington, DC
George W. Rutherford, Jr., U.S. Consumer Product Safety Commission, Washington, DC
Ruth Sanchez-Way, Office of Population Affairs, Washington, DC
Richard Sattin, Centers for Disease Control, Atlanta, GA
Steven L. Sauter, National Institute for Occupational Safety and Health (CDC), Atlanta, GA
James Scanlon, Office of Health Planning and Evaluation, Washington, DC
Charles Schade, American Public Health Association, Washington, DC
Peter C. Scheidt, National Institute for Child Health and Human Development (NIH), Bethesda, MD
Susan Schober, National Institute on Drug Abuse (ADAMHA), Rockville, MD
Edyth Schoenrich, The Johns Hopkins University, Baltimore, MD
Bettina Scott, Office for Substance Abuse Prevention (ADAMHA), Rockville, MD
Melvin Segal, Office for Substance Abuse Prevention (ADAMHA), Rockville, MD
Raymond Seltser, Agency for Health Care Policy and Research, Rockville, MD
Fred R. Shank, Center for Food Safety and Applied Nutrition (FDA), Washington, DC
Moira Shannon, National Center for Nursing Research (NIH), Bethesda, MD
Donald Shopland, National Cancer Institute (NIH), Bethesda, MD
Carl Shy, University of North Carolina at Chapel Hill, Chapel Hill, NC
Mervyn Silverman, American Foundation for AIDS Research, San Francisco, CA
Robert Silverman, National Institute of Diabetes and Digestive and Kidney Diseases (NIH), Bethesda, MD
John S. Small, National Institute of Dental Research (NIH), Bethesda, MD
Charles Smart, National Cancer Institute (NIH), Bethesda, MD
Richard J. Smith, Indian Health Service, Rockville, MD
Dixie E. Snider, Center for Prevention Services (CDC), Atlanta, GA
Harrison C. Spencer, Center for Infectious Diseases (CDC), Atlanta, GA
Jack N. Spencer, Center for Prevention Services (CDC), Atlanta, GA
Barry S. Stern, Bureau of Health Professions (HRSA), Rockville, MD
David Stevens, Bureau of Health Care Delivery and Assistance (HRSA), Rockville, MD
136
B. Contributors to Healthy People 2000
Dorothy Stephens, Health Resources and Services Administration, Rockville, MD
John A. Steward, Center for Environmental Health and Injury Control (CDC), Atlanta, GA
Deborah Jane Stokes, Association of Maternal and Child Health Programs, Gahanna, OH
Bob Stovenour, Administration on Developmental Disabilities (OHDS), Washington, DC
Nancy Stroup, Center for Environmental Health and Injury Control (CDC), Atlanta, GA
Linda A. Suydam, Center for Devices and Radiological Health (FDA), Rockville, MD
Elsie Taylor, National Institute on Alcohol Abuse and Alcoholism (ADAMHA), Rockville, MD
Glenn Taylor, Health Resources and Services Administration, Rockville, MD
William Taylor, Center for Environmental Health and Injury Control (CDC), Atlanta, GA
Steven Teutsch, Epidemiology Program Office (CDC), Atlanta, GA
J. Paul Thomas, National Institute on Disability and Rehabilitation Research, U.S. Department of Education,
Washington, DC
Susan B. Toal, Centers for Disease Control, Atlanta, GA
Jerome Tobis, University of California Medical Center, Irvine, Orange, CA
Frederick T. Trowbridge, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA
Jeanne Trumble, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, MD
Joan Van Nostrand, National Center for Health Statistics (CDC), Hyattsville, MD
Lyman Van Nostrand, Health Resources and Services Administration, Rockville, MD
Tina Vanderveen, National Institute on Drug Abuse (ADAMHA), Rockville, MD
Ecford Voit, National Institute of Mental Health (ADAMHA), Rockville, MD
Diane Wagener, National Center for Health Statistics (CDC), Hyattsville, MD
John B. Waller, Wayne State University, Detroit, MI
Larry Wannemacher, Health Resources and Services Administration, Rockville, MD
Nancy Wartow, Administration on Aging, (OHDS), Washington, DC
Judith N. Wasserheit, National Institute of Allergy and Infectious Diseases (NIH), Bethesda, MD
Nancy Watkins, Office of Program Planning and Evaluation (CDC), Atlanta, GA
Bill Weber, Bureau of Labor Statistics (DOL), Washington, DC
Linda Webster, Information Resource Management Office (CDC), Atlanta, GA
Jane A. Weintraub, University of North Carolina, Chapel Hill, NC
James A. Weixel, Food and Drug Administration, Rockville, MD
Thomas Wells, Utah Department of Health, Salt Lake City, UT
Janet Wetmore, National Institutes of Health, Bethesda, MD
Daniel F. Whiteside, Bureau of Resources Development (HRSA), Rockville, MD
Judith P. Wilkenfeld, Division of Advertising Practices, Federal Trade Commission, Washington, DC
James Willet, George Mason University, Fairfax, VA
T. Franklin Williams, National Institute on Aging (NIH), Bethesda, MD
Donna Wilson, National Institute for Occupational Safety and Health (CDC), Atlanta, GA
Deborah M. Winn, National Center for Health Statistics (CDC), Hyattsville, MD
Steven H. Woolf, Office of Disease Prevention and Health Promotion, Washington, DC
Marilyn Woolfolk, University of Michigan, Ann Arbor, MI
Catherine E. Woteki, Institute of Medicine, National Academy of Sciences, Washington, DC
James Young, President's Committee on Mental Retardation, Washington, DC
Jim F. Young, Administration on Children, Youth, and Families (OHDS), Washington, DC
K. Lum Young, Nebraska Department of Health, Lincoln, NE
Phyllis Zucker, Office of the Assistant Secretary for Planning and Evaluation, Washington, DC
Healthy People 2000 Consortium
National Organizations
Academy of General Dentistry
American Academy of Child and Adolescent
Aerobics and Fitness Association of America
Psychiatry
Alcohol and Drug Problems Association of North
American Academy of Family Physicians
America
American Academy of Ophthalmology
Alliance for Aging Research
American Academy of Orthopaedic Surgeons
Alliance for Health
American Academy of Pediatric Dentistry
Amateur Athletic Union of the United States
American Academy of Pediatrics
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Healthy People 2000
American Alliance for Health, Physical Education,
American Lung Association
Recreation, and Dance
American Meat Institute
American Art Therapy Association
American Medical Association
American Association for Clinical Chemistry
American Medical Student Association
American Association for Dental Research
American Nurses' Association
American Association for Marriage and Family
American Nutritionists Association
Therapy
American Occupational Therapy Association
American Association for Respiratory Care
American Optometric Association
American Association for the Advancement of
American Orthopaedic Society for Sports Medicine
Science
American Osteopathic Academy of Sports Medicine
American Association of Certified Orthoptists
American Osteopathic Association
American Association of Colleges of Osteopathic
American Osteopathic Hospital Association
Medicine
American Pharmaceutical Association
American Association of Colleges of Pharmacy
American Association of Dental Schools
American Physical Therapy Association
American Physiological Society
American Association of Homes for the Aging
American Podiatric Medical Association
American Association of Occupational Health
Nurses
American Psychiatric Association
American Association of Pathologists' Assistants
American Psychiatric Nurses Association
American Association of Public Health Dentistry
American Psychological Association
American Public Health Association
American Association of Public Health Physicians
American Association of Retired Persons
American Red Cross
American Association of School Administrators
American Rehabilitation Counseling Association
American Association of Suicidology
American School Food Service Association
American Association of University Affiliated
American School Health Association
Programs for Persons with Developmental
American Social Health Association
Disabilities
American Society for Clinical Nutrition
American Association on Mental Retardation
American Society for Microbiology
American Cancer Society
American Society for Parenteral and Enteral
American College Health Association
Nutrition
American College of Cardiology
American Society for Psycoprophylaxis in Obstetrics
American College of Clinical Pharmacy
American Society of Acupuncture
American College of Health Care Administrators
American Society of Addiction Medicine
American College of Healthcare Executives
American Society of Allied Health Professions
American College of Nurse-Midwives
American Society of Hospital Pharmacists
American College of Nutrition
American Society of Human Genetics
American College of Obstetricians and
American Society of Ocularists
Gynecologists
American Speech-Language-Hearing Association
American College of Occupational Medicine
American Spinal Injury Association
American College of Physicians
American Statistical Association
American College of Preventive Medicine
American Thoracic Society
American College of Radiology
Arthritis Foundation
American College of Sports Medicine
Asian American Health Forum
American Council on Alcoholism
Association for Applied Psychophysiology and
American Dental Association
Biofeedback
American Dental Hygienists' Association
Association for Fitness in Business
American Diabetes Association
Association for Hospital Medical Education
American Dietetic Association
Association for Practitioners in Infection Control
American Federation of Teachers
Association for Retarded Citizens of the United States
American Geriatrics Society
Association for the Advancement of Automotive
Medicine
American Heart Association
American Home Economics Association
Association for the Advancement of Health
Education
American Hospital Association
Association for Vital Records and Health Statistics
American Indian Health Care Association
Association of Academic Health Centers
American Institute for Preventive Medicine
Association of American Indian Physicians
American Institute of Nutrition
Association of American Medical Colleges
American Kinesiotherapy Association
Association of Clinical Scientists
138
B. Contributors to Healthy People 2000
Association of Community Health Nursing Educators
Maternal and Child Health Network
Association of Food and Drug Officials
Maternity Center Association
Association of Maternal and Child Health Programs
Midwives' Alliance of North America
Association of Pediatric Oncology Nurses
Migrant Clinicians Network
Association of Rehabilitation Nurses
Mothers Against Drunk Driving
Association of Schools of Public Health
NAACOG-The Organization of Obstetric,
Association of State and Territorial Dental Directors
Gynecologic, and Neonatal Nurses
Association of State and Territorial Directors of
NARD-formerly National Association of Retail
Nursing
Druggists
Association of State and Territorial Directors of
National AIDS Network
Public Health Education
National Alliance for the Mentally Ill
Association of State and Territorial Health Officials
National Alliance of Black School Educators
Association of State and Territorial Public Health
National Alliance of Nurse Practitioners
Laboratory Directors
National Association for Hispanic Elderly
Association of State and Territorial Public Health
National Association for Home Care
Nutrition Directors
National Association for Human Development
Association of State and Territorial Public Health
National Association for Music Therapy
Social Work
National Association for Sport and Physical
Association of Teachers of Preventive Medicine
Education
Association of Technical Personnel in
National Association of Biology Teachers
Ophthalmology
National Association of Childbearing Centers
Black Congress on Health, Law, and Economics
National Association of Community Health Centers
Blue Cross and Blue Shield Association
National Association of Counties
Boys Scouts of America
National Association of County Health Officials
Business Roundtable
National Association of Elementary School Principals
Camp Fire
National Association of Governors Councils on
Cardiovascular Credentialing International/National
Physical Fitness and Sports
Board of Cardiovascular Technology
National Association of Neonatal Nurses
Catholic Health Association of the United States
National Association of Optometrists and Opticians
Children's Hospital National Medical Center
National Association of Pediatric Nurse Associates
College of American Pathologists
and Practitioners
Council for Responsible Nutrition
National Association of RSVP Directors
Council of Medical Specialty Societies
National Association of School Nurses
Dairy and Food Nutrition Council of the Southeast
National Association of Secondary School Principals
Emergency Nurses Association
National Association of Social Workers
Eye Bank Association of America
National Association of State Alcohol and Drug
Federation of American Societies for Experimental
Abuse Directors
Biology
National Association of State Boards of Education
Federation of Nurses and Health Professionals
National Association of State NET Program
Food Marketing Institute
Coordinators
Future Homemakers of America
National Association of State School Nursing
Gerontological Society of America
Consultants
Girl Scouts of the United States of America
National Black Nurses Association
Great Lakes Association of Clinical Medicine
National Board of Medical Examiners
Grocery Manufacturers of America
National Center for Health Education
Group Health Association of America
National Coalition of Hispanic Health and Human
Health Industry Manufacturers Association
Services Organization
Health Insurance Association of America
National Commission Against Drunk Driving
Highway Users Federation for Safety and Mobility
National Committee for Adoption
Institute of Food Technologists
National Committee for Prevention of Child Abuse
International Association for Enterostomal Therapy
National Conference of State Legislatures
International Lactation Consultant Association
National Consumers League
International Life Sciences Institute
National Council for International Health
International Patient Education Council
National Council for the Education of Health
La Leche League International
Professionals in Health Promotion
Learning Disabilities Association of America
National Council on Alcoholism and Drug
March of Dimes Birth Defects Foundation
Dependence
139
Healthy People 2000
National Council on Disability
National Society of Allied Health
National Council on Health Laboratory Services
National Society to Prevent Blindness
National Council on Patient Information and
National Strength and Conditioning Association
Education
National Stroke Association
National Council on Self-Help and Public Health
National Wellness Institute
National Council on the Aging
National Women's Health Network
National Dairy Council
NEA Health Information Network
National Environmental Health Association
Nursing Network on Violence Against Women
National Extension Homemakers Council
Oncology Nursing Society
National Family Planning and Reproductive Health
Paralyzed Veterans of America
Association
People's Medical Society
National Federation of State High School
Pharmaceutical Manufacturers Association
Associations
Planned Parenthood Federation of America
National Food Processors Association
Population Association of America
National Head Injury Foundation
Produce Marketing Association
National Health Council
Salt Institute
National Health Lawyers Association
Salvation Army
National Hearing Aid Society
Society for Nutrition Education
National Institute for Fitness and Sport
Society for Public Health Education
National Kidney Foundation
Society of Behavioral Medicine
National League for Nursing
Society of Hospital Epidemiologists of America
National Lesbian and Gay Health Foundation
Society of Prospective Medicine
National Medical Association
Society of State Directors of Health, Physical
National Mental Health Association
Education, and Recreation
National Museum of Health and Medicine
South Cove Community Health Center
National Nurses Society on Addictions
State Family Planning Administrators
National Organization for Women
United States Chamber of Commerce
National Organization on Adolescent Pregnancy and
United States Conference of Mayors
Parenting
United Way of America
National Osteoporosis Foundation
Visiting Nurse Associations of America
National Pest Control Association
Voluntary Hospitals of America
National Pressure Ulcer Advisory Panel
Washington Business Group on Health
National PTA
Wellness Councils of America-WELCOA
National Recreation and Park Association
Western Consortium for Public Health
National Safety Council
Women's Sports Foundation
National School Boards Association
State and Territorial Health Departments
Alabama
Kansas
North Dakota
Alaska
Kentucky
Ohio
American Samoa
Louisiana
Oklahoma
Arizona
Maine
Oregon
Arkansas
Maryland
Pennsylvania
California
Massachusetts
Puerto Rico
Colorado
Michigan
Rhode Island
Connecticut
Minnesota
South Carolina
Delaware
Mississippi
South Dakota
District of Columbia
Missouri
Tennessee
Florida
Montana
Texas
Georgia
Nebraska
Utah
Guam
Nevada
Vermont
Hawaii
New Hampshire
Virginia
Idaho
New Jersey
Washington
Illinois
New Mexico
West Virginia
Indiana
New York
Wisconsin
Iowa
North Carolina
Wyoming
140
C. Priority Area Lead Agencies
1.
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
5.
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
141
Healthy People 2000
142
Index to Summary List of Objectives
Abuse, Physical and Sexual
fetal alcohol syndrome 14.4a
children 7.4, 7.14
gingivitis 13.5b
emergency housing for victims 7.15
hepatitis B 20.3g
emergency room identification of victims 7.12
homicide 7.1f
intergenerational cycle 7.14
infant mortality 14.1b
women 7.5
limitation in major activity 17.2b
Abuse, Substance (see Alcohol; Drugs)
meningitis 20.7a
Accidents (see Injury)
motor vehicle crash deaths 9.3d
Acquired Immunodeficiency Syndrome (see HIV
overweight 2.3d
Infection)
prenatal care 14.11b
Activity Limitation (see Disability)
postneonatal mortality 14.1i
Adoption 5.9
recommended primary care services 21.2k
Advertising
smokeless tobacco use 3.9a
alcoholic beverages 4.17
suicide 6.1d
tobacco products 3.15
tuberculosis 20.4d
African Americans (see Black Americans;
unintentional injury 9.1a
Minority Groups, Racial And Ethnic)
Anabolic Steroids (see Steroids, Anabolic)
Agency for Toxic Substances and Disease
Asbestosis (see Lung Disease)
Registry 11.7
Asians and Pacific Islanders (see also Minority
AIDS (see HIV Infection)
Groups, Racial and Ethnic)
Airbags (see Occupant Protection Systems)
cigarette smoking 3.4g
Air Pollutants 11.5
growth retardation 2.4d, 2.4e
Alaska Natives (see American Indians and Alas-
hepatitis B 20.3d
ka Natives)
recommended clinical preventive services 21.2j
Alcohol (see also Alcohol and Other Drugs sec-
tuberculosis 20.4a
tion, page 97)
Assault
abstinence during pregnancy 14.10
injuries 7.6
access by minors 4.16
victims 7.12
average age of first use 4.5
Asthma
consumption per person 4.8
limitation in major activity 17.4
deterrence for driving under the influence 4.15
morbidity 11.1
discussion in family 8.9
Athletics (see Sporting Events)
educational programs in schools 4.13
Automobiles (see Motor Vehicles)
heavy drinking by high school and college students 4.7
legal blood alcohol concentration tolerance levels 4.18
Babies (see Infants)
perception of harm associated with heavy use 4.10
Baby Bottle Tooth Decay 2.12, 13.11
perception of social disapproval among high
Back Conditions
school seniors 4.9
activity limitation 17.5
promotion to young people 4.17
worksite injury and rehabilitation programs 10.13
recent use by young people 4.6
Back Injury and Rehabilitation (see Back Condi-
related motor vehicle crashes 4.1
tions)
treatment programs for underserved 4.12
Birth Control (see Contraception)
worksite policies 4.14
Black Americans (see also Minority Groups, Ra-
American Indians and Alaska Natives (see also
cial and Ethnic)
Minority Groups, Racial and Ethnic)
adolescent pregnancy 5.1a
alcohol-related motor vehicle crash deaths 4.1a
AIDS 18.1b
anemia 2.10d
anemia 2.10e
baby bottle tooth decay 13.11b
amputation of lower-extremities due to diabetes 17.10a
breastfeeding 14.9d
asthma 11.1a
cigarette smoking 3.4f
blood lead levels 11.4a
cirrhosis 4.2b
breastfeeding 14.9
dental caries 13.1b, 13.1d
breast examination and mammogram 16.11e
dental caries, untreated 13.2b
cigarette smoking 3.4d
diabetes 17.11a
cirrhosis 4.2a
diabetes-related deaths 17.9b
coronary heart disease 15.1a
end-stage renal disease due to diabetes 17.10b
diabetes 17.11e
143
Healthy People 2000
diabetes-related deaths 17.9a
Cavities (see Dental Caries)
dental caries 13.1c
Cervical Cancer (see Cancer)
dental caries, untreated 13.2c
Cesarean Delivery 14.8
drowning 9.5c
Child Abuse (see Abuse, Physical and Sexual)
end-stage renal disease 15.3a
Child Care Centers
end-stage renal disease due to diabetes 17.10a
childhood immunization levels 20.11
falls and fall-related injury 9.4c
food services 2.17
fetal alcohol syndrome 14.4b
immunization laws 20.13
fetal death 14.2a
infectious diarrhea 20.8
gonorrhea 19.1a
Child Death Review Systems 7.13
growth retardation 2.4a
Child Neglect
high blood pressure control 15.5b
evaluation and followup 7.14
homicide 7.1c, 7.1e
incidence 7.4
infant mortality 14.1a
Child Safety Seats (see Occupant Protection Sys-
infertility 5.3a
tems)
limitation in major activity 17.2c
Chlamydia Trachomatis Infection 19.2
low birth weight 14.5a
provider referral services 19.15
maternal mortality 14.3a
Cholesterol, Blood
neonatal mortality 14.1e
high levels 15.7
overweight 2.3b
laboratory standards for measurement 15.17
post neonatal mortality 14.1h
management by diet/drug therapies 15.15
prenatal care 14.11a
mean serum 15.6
recommended clinical preventive services 21.2h
reduction 15.8
residential fire deaths 9.6c, 9.6d
screening 15.14
source of ongoing primary care 21.3b
worksite education and control programs 15.16
stroke 15.2a
Chronic Disabling Conditions (see also Dis-
syphilis, primary and secondary 19.3a
ability; Diabetes and Chronic Disabling
tuberculosis 20.4b
Conditions section, page 116)
unintended pregnancy 5.2a
patient education about community resources
17.14
unintentional injury 9.1b
years of healthy life 8.1a
service systems for children 17.20
Blood Lead Levels 11.4
Chronic Obstructive Pulmonary Disease (see
Lung Disease)
Blood Pressure
Cigarette Smoking (see Smoking)
control 15.4, 15.5
Cirrhosis
education programs at worksite 15.16
deaths 4.2
screening 15.13
Cities (see also Community; Counties)
Blood Transfusions
building codes 9.16, 11.12
HIV infection 18.8
comprehensive violence prevention programs 7.17
Breastfeeding 2.11, 14.9
HIV risk reduction outreach programs to drug
Breast Cancer (see Cancer)
abusers 18.12
Breast Examinations (see Examinations, Routine;
Clearinghouses (see Mutual Help Clearin-
Mammography)
ghouses)
Building Codes
Cleft Lip/Palate 13.15
fire suppression sprinklers 9.16
Clinical Preventive Services (see also Examina-
radon levels 11.12
tions, Routine; Primary Care Providers;
Byssinosis 10.11
Clinical Preventive Services section,
page 123)
Calcium
financial barriers 21.4
dietary intake 2.8
from primary care providers 21.6
Campylobacter Jejuni 12.1
from publicly funded programs 21.5
Cancer (see also Cancer section, page 114)
local health department assurance of access 21.7
breast 16.3
Clinicians (see Primary Care Providers)
cervical 16.4
Cocaine (see also Drugs)
colorectal 16.5
abstinence during pregnancy 14.10
deaths 2.2, 16.1
perception of harm associated with experimenta-
lung 3.2, 16.2
tion 4.10
oral cavity and pharynx 13.7
perception of social disapproval among high
Cancer Prevention Screening (see Examinations,
school seniors 4.9
Routine; Primary Care Providers)
recent use by young people 4.6
144
Index to Summary List of Objectives
College (see Schools; School Health Promotion)
protective sealants 13.8
Colorectal Cancer (see Cancer)
untreated 13.2
Communication, Health (see Educational
Dentist (see Oral Health Care Provider)
Programs)
Depressive Disorders 6.7
Community (see also Cities; Counties; Educa-
Detention Facilities (see Institutional Facilities)
tional and Community-Based Programs
Diabetes (see also Diabetes and Chronic Disa-
section, page 101)
bling Conditions section, page 116)
building codes 9.16, 11.12
complications 17.10
fluoridated water systems 13.9
incidence and prevalence 17.11
health promotion programs
related deaths 17.9
addressing Healthy People 2000 priorities 8.10
Diarrhea, infectious 20.8
hospital-based patient education 8.12
Dietary Guidelines for Americans 2.16, 2.17
serving older people 8.8
Dietary Intake
serving racial and ethnic populations 8.11
cholesterol 15.15
television partnership for health communi-
complex carbohydrates and fiber-containing
cation 8.13
foods 2.6
violence prevention 7.17
fat 2.5, 15.9, 16.7
patient education about available resources 17.14
Digital Rectal Examinations (see Examinations,
physical activity and fitness facilities 1.11
Routine)
prevalence of mental disorders 6.4
Diphtheria
programs for recyclable materials and household
indigenous cases 20.1
hazardous waste 11.15
immunization 20.16
resources for people with chronic and disabling
Disability
conditions 17.14
activity limitation
support for people with mental disorders 6.6
due to asthma 17.4
Comparable Data (see Surveillance and Data
due to chronic back conditions 17.5
Systems)
due to chronic conditions 17.2
Complex Carbohydrates
due to pneumonia 20.10
dietary intake 2.6, 16.8
detection
Condoms (see also Contraception)
newborns 14.15
use among adolescents 18.4, 19.10
infants and children 17.15
Conflict Resolution, Non-Violent 7.16
older people 17.3
Congenital Rubella Syndrome 20.1
people with disabilities
Contact Tracing 19.15
adverse health effects from stress 6.5a
Contamination, Solid Waste-Related 11.8
national disease prevention and health
Contraception (see also Family Planning)
promotion data 22.4
effective use 5.7
overweight 2.3e
use among adolescents 5.6, 18.4, 19.10
patient education programs 17.14
Coronary Heart Disease (see Heart Disease)
preschool programs for children 8.3
Correctional Facilities (see also Institutional
programs for children with or at risk 17.20
Facilities)
sedentary lifestyles 1.5b
suicide in jails 6.10, 7.18
policies
Counseling by Clinicians (see Primary Care
worksite hiring policies 17.19
Providers)
secondary
Counties (see also Communities; Cities)
associated with head and spinal cord
air quality standards 11.5
injuries 9.11
building codes 9.16, 11.12
sensory impairments
health promotion programs for minorities 8.11
hearing impairment 17.6
programs for recyclable materials and household
visual impairment 17.7
hazardous wastes 11.15
Domestic Violence (see Abuse)
violence prevention programs 7.17
Drinking Water (see Water)
Craniofacial Anomaly Teams 13.15
Drowning 9.5
Criteria Air Pollutants (see Air Pollutants)
Cumulative Trauma Disorder (see Trauma)
Drugs (see also Alcohol; Cocaine; Marijuana;
Medication; Alcohol and Other Drugs
Data Systems (see Surveillance and Data Sys-
section, page 97)
tems)
abuse related deaths 4.3
Dental Caries
abuse related emergency room visits 4.4
loss of permanent teeth 13.3
average age at first use 4.5
prevalence 13.1
deterrents for driving under the influence 4.15
145
Healthy People 2000
discussion in family 8.9
restaurant menu choices 2.16
educational programs in schools 4.13
Fecal Occult Blood Testing (see Examinations,
intravenous drug abuse 18.5, 18.6, 18.12
Routine)
prescription medications 12.5
Fetal Abnormalities
screening, counseling, and referral by clinicians
detection 14.13
4.19
Fetal Alcohol Syndrome 14.4
treatment centers addressing HIV and sexually
Fetal Death 14.2
transmitted diseases 5.11, 18.13, 19.11
Fiber
treatment programs for underserved 4.12
dietary intake 2.6, 16.8
use by youth 4.6
Fighting, Physical 7.9
worksite policies 4.14
Financial Barriers
Ear Infection (see Infection)
to clinical preventive services 21.4
Educational Programs (see also Community;
to immunizations 20.15
Patient Education; School; Worksite;
Firearms (see Weapons)
Educational and Community-Based
Fires
Programs section, page 101)
deaths 9.6
Emergency Room
protection 9.16, 9.17
drug abuse-related emergency room visits 4.4
Fitness Programs and Facilities
emergency medical services and trauma sys-
community 1.11
tems 9.22
education in schools 1.8, 1.9
protocols for suicide attempts 7.12
worksite 1.10
protocols for victims of abuse and assault 7.12
Flexibility (see Physical Activity)
Employer-Sponsored Programs (see Worksite)
Fluoride
End-Stage Renal Disease (see Renal Disease,
community water systems 13.9
End-Stage)
topical or dietary 13.10
Endurance (see Physical Activity)
Foodborne Pathogens (see Food Poisoning)
Environmental Diseases, Sentinel
Food and Drug Safety (see Food and Drug
States' plans to define and track 11.16
Safety section, page 107)
Environmental Health (see Environmental
Food Labeling 2.13, 2.14
Health section, page 105)
Food Poisoning
Environmental Protection Agency
incidence 12.1
air quality standards 11.5
salmonella outbreaks 12.2
safe drinking water standards 11.9
Food Preparation in Home
Escherichia Coli 0157:H7 12.1
difficulty with 2.18
Estrogen Replacement Therapy (see Os-
low-sodium 2.9
teoporosis)
safe practices 12.3
Examinations, Routine
Food Safety
breast 16.11
household practices 12.3
cervical (Pap test) 16.12
State codes 12.4
colorectal 16.13
Food Service
dental 13.14
home delivery for older people 2.18
digital rectal 16.14
low-fat, low-calorie food choices 2.16
oral 16.14
model food codes 12.4
skin 16.14
school and child care 2.17
Exercise (see Physical Activity)
Fractures, Hip
Falls
older people 9.7
deaths 9.4
Fruit
Family
daily intake 2.6, 16.8
discussion of human sexuality 5.8
Genetic Disorders
discussion of health issues 8.9
newborn screening and follow-up 14.15
Family Planning (see also Family Planning sec-
Genital Herpes (see Herpes, Genital)
tion, page 98)
Genital Warts (see Warts, Genital)
clinics addressing HIV infection and sexually trans-
mitted diseases 5.11, 18.13, 19.11
Gingivitis (see Periodontal Disease)
Gonorrhea
effectiveness of use 5.7
incidence 19.1
preconception care and counseling 5.10, 14.12
Fat, Dietary
provider referral services 19.15
availability of low-fat processed foods 2.15
repeat infection 19.8
dietary intake 2.5, 15.9, 16.7
146
Index to Summary List of Objectives
Grain Products
breast examination and mammography 16.11a
daily intake 2.6, 16.8
breastfeeding 14.9c
Growth Retardation 2.4
cigarette smoking 3.4e
dental caries, untreated 13.2d
Handguns (see Weapons)
diabetes 17.11b, 17.11c, 17.11d
Hazardous Waste
gingivitis 13.5c
health risk at sites 11.14
growth retardation 2.4b, 2.4c
community collection of household 11.15
homicide 7.1d
Head Injuries 9.9
infant mortality 14.1c
secondary disabilities 9.11
infertility 5.3b
Health Communication (see Educational Programs)
neonatal mortality 14.1f
Health Departments (see Public Health Depart-
overweight 2.3c
ments)
pap testing 16.12a
Health Maintenance Organizations 8.12
postneonatal mortality 14.1j
Health Objectives (see National Disease Preven-
prenatal care 14.11c
tion and Health Promotion Objectives)
recommended clinical preventive services 21.2i
Health Professions
source of ongoing primary care 21.3a
racial/ethnic minority representation 21.8
tuberculosis 20.4c
Health Promotion Programs (see Community;
years of healthy life 8.1b
Patient Education; Schools; Worksite)
HIV Infection (see also HIV infection section,
Health Status Indicators
page 119)
set for Federal, State, local use 22.1
addressed in health clinics 5.11, 18.13, 19.11
counseling on prevention of sexually trans-
AIDS incidence 18.1
mitted 18.9, 19.14
Homes
occupational exposure 18.14
buyer notification of lead-based paint and radon
prevalence 18.2
concentration 11.13
testing 18.8
children's exposure to tobacco smoke 3.8
transfusion-transmitted 18.7
fire suppression sprinkler systems 9.16
Healthy Life Span (see Quality-Adjusted Life
meal delivery for older people 2.18
Years)
nutritious food preparation 2.9
Healthy People 2000 (see National Disease
Prevention and Health Promotion Objec-
residential fires, deaths 9.6
tives)
safe food preparation practices 12.3
smoke detectors 9.17
Hearing Impairment
detection in children 17.15, 17.16
testing for lead-based paint 11.11
detection in older people 17.17
testing for radon concentrations 11.6
Homicide 7.1
prevalence 17.6
Heart Disease (see Heart Disease and Stroke sec-
Hospitals
tion, page 112)
community health promotion 8.12
coronary 1.1, 2.1, 3.1, 15.1
drug abuse-related emergency department
visits 4.4
Helmets
State laws 9.14
emergency medical and trauma systems 9.22
use by motorcyclists and bicyclists 9.13
patient education programs 8.12
Hepatitis, Viral
protocols for addressing needs of victims of
violence and abuse 7.12
among international travelers 20.6
Human Immunodeficiency Virus (see HIV Infec-
immunizations by public health depart-
tion)
ments 20.16
immunization levels 10.9, 20.11
Immunization (see also Immunization and Infec-
reduction 20.3
tious Diseases section, page 121)
sexually transmitted infection 19.7
counseling and services by primary care provi-
worksite exposure 10.5
ders 20.14
Herpes, Genital 19.5
financial barriers 20.15, 21.4
High Blood Pressure (see Blood Pressure)
Hepatitis B 10.9
Highway Design Standards 9.20
laws 20.13
High School (see School)
levels among high-risk populations 20.11
Hip Fractures (see Fractures, Hip)
provision by Public Health Departments 20.16
Hispanic Americans (see also Minority Groups,
receipt of recommended services 21.2
Racial and Ethnic)
Immunization Practices Advisory Committee
adolescent pregnancy 5.1b
20.11
AIDS 18.1c
147
Healthy People 2000
Indoor Air
Laboratories
laws 3.12
clinical 15.17
Infants (see also Maternal and Infant Health sec-
cytology 16.15
tion, page 110)
rapid viral diagnosis of influenza 20.19
baby bottle tooth decay 2.12, 13.11
Lead-Based Paint
breastfeeding 2.11, 14.9
home buyer notification 11.13
immunization 20.11
home testing 11.11
mortality 14.1
Lead Exposure
receipt of recommended primary care ser-
and exposure to other criteria air pollutants 11.5
vices 14.16
children 11.4
referral to craniofacial anomaly teams 13.15
home 11.11
risk-appropriate care 14.14
worksite 10.8
screening for developmental problems 17.15
Limitation in Major Activity (see Disability)
screening for genetic disorders 14.15
Liver Disease (see Cirrhosis)
Infant Mortality 14.1
Low Birth Weight 14.5
Infection
Low Income, People With
diarrhea 20.8
anemia prevalence 2.10e
ear 20.9
blood lead levels 11.4a
nosocomial and wound 20.5
breastfeeding 14.9a
waterborne disease 11.3
breast examinations and mammography 16.11b
Infertility 5.3
cigarette smoking initiation 3.5a
Influenza
financial barriers to primary care 21.4
epidemic-related deaths 20.2
gingivitis prevalence 13.5a
immunization 20.11, 20.16
growth retardation 2.4
laboratory capability for rapid viral diag-
iron deficiency 2.10a, 2.10c
nosis 20.19
limitation in major activity 17.2a
Injury (see also Unintentional Injuries section,
loss of all natural teeth 13.4a
page 103)
national disease prevention and health promotion
assault 7.6
data 22.4
back 10.13
overweight 2.3a
deaths 9.1
pap testing 16.12d
head, non-fatal 9.9
preschool programs for children 8.3
hospitalizations 9.2
recommended clinical preventive services 21.2g
prevention and control instruction in schools 9.18
sedentary lifestyle 1.5c
prevention counseling by primary care
source of ongoing primary care 21.3c
providers 9.21
vigorous physical activity 1.4a
secondary disabilities 9.11
Lung Disease
spinal cord, non-fatal 9.10
cancer 3.2, 16.2
suicide attempts 6.2, 7.8
chronic obstructive pulmonary disease 3.3
work-related 10.1, 10.2
occupational 10.11
Inmates (see Correctional Facilities)
Lysteria Monocytogenes 12.1
Institutional Facilities
food services 2.4, 2.16
Malaria 20.6
immunizations 20.11
Mammography
provision of oral health care 13.13
and clinical breast examinations 16.11
suicide in jails 6.10, 7.18
quality standards for facilities 16.16
Intensive Care Units
Marijuana
and nosocomial infections 20.5
abstinence during pregnancy 14.10
Intravenous Drug Abuse
average age of first use 4.5
outreach programs to prevent HIV infection 18.12
perception of harm associated with regular
treatment programs 18.5
use 4.10
uncontaminated drug paraphernalia 18.6
perception of social disapproval among high
Iron Deficiency 2.10
school seniors 4.9
IV Drug Abuse (see Intravenous Drug Abuse)
recent use by young people 4.6
Maternal and Infant Health (see also Infants;
Jail (see Correctional Facilities)
Maternal and Infant Health section,
Juvenile Homes (see Institutional Facilities)
page 110)
clinics addressing HIV infection 5.11, 18.13, 19.11
Knives (see Weapons)
Maternal Mortality 14.3
148
Index to Summary List of Objectives
Meals (see Food Service; Restaurants)
Nursing Homes (see Institutional Facilities)
Measles 20.1
Nutrient Intake (see Dietary Intake)
Media (see Health Promotion Programs)
Nutrition (see also Nutrition section, page 93)
Medication
discussion in family 8.9
anabolic steroid use 4.11
education in schools 2.19
linked pharmacy systems 12.5
education at worksite 2.20
review for older patients 12.6
Nutrition Labeling (see Food Labeling)
Meningitis, Bacterial 20.7
Mental Disorders (see also Mental Health and
Occupant Protection Systems
Mental Disorders section, page 99)
requirement by employers 10.6
among adults living in community 6.4
use 9.12
among children and adolescents 6.3
Occupational Hazards
community support programs 6.6
bloodborne infections, including HIV 18.14
mental retardation 11.2, 17.8
counseling by primary care providers 10.15
Mental Health (see Mental Health and Mental
hepatitis B 10.5, 10.9
Disorders section, page 99)
injuries, fatal 10.1
personal and emotional problems 6.8
injuries, non-fatal 10.2
Mental Retardation 11.2, 17.8
lead 10.8
Middle Ear Infection (see Infection)
major occupational lung diseases 10.11
Minority Groups, Racial and Ethnic (see also
noise 10.17
American Indians and Alaska Natives;
Occupational Safety and Health (see also Oc-
Asian and Pacific Islanders; Black
cupational Hazards; Occupational Safety
Americans; Hispanic Americans)
and Health section, page 104)
community-based health promotion programs 8.11
state plans addressing 10.10
national disease prevention and health promotion
Oral Cancer (see Cancer)
data 22.4
Oral Health (see also Oral Health section,
racial/ethnic representation in health profes-
page 108)
sions 21.8
care at institutional facilities 13.13
Motor Vehicles
dental visits 13.14
alcohol-related crash deaths 4.1
screening for children entering school 13.12
crash-related deaths 9.3
Oral Health Care Provider
occupant protection systems 9.12
tobacco-cessation counseling 3.16
work-related travel 10.6
Osteoporosis
Mumps 20.1
estrogen replacement therapy to prevent 17.18
Muscular Strength and Endurance (see Physical
Overweight 1.2, 2.3, 15.10, 17.12
Activity)
weight loss 1.7, 2.7
Mutual Help Clearinghouses 6.12
Pacific Islander Americans (see Asians and
National Disease Prevention and Health Promotion
Pacific Islanders)
Objectives
Pap Smear (see Pap Testing)
community programs addressing 8.10
Pap Testing
comparable data at Federal, State, and local level
quality standards 16.15
for each objective 22.3
screening 16.12
national data sources to measure progress 22.2
Park and Recreation Space 1.11
periodic analysis and publication of data 22.5
Partner Notification (see Sexually Transmitted
television partnerships with community organiza-
Diseases)
tions 8.13
Pathogens, Foodborne (see Food Poisoning)
National Health Objectives (see National Disease
Patient Education (see also Education; Primary
Prevention and Health Promotion Objec-
Care Providers)
tives)
by HMOs, hospitals, and group practices 8.12
National Priorities List Hazardous Waste
for people with chronic and disabling condi-
Sites 11.14
tions 17.14
Native Americans (see American Indians and
Pelvic Inflammatory Disease 19.6
Alaska Natives)
Periodontal Disease
Newborns (see Infants)
gingivitis 13.5
Noise Exposure
loss of permanent teeth 13.3
at worksite 10.7
prevalence 13.6
Nosocomial Infections (see Infection)
Pertussis 20.1
Nurse (see Primary Care Provider)
Pharmacies
Nurse Practitioner (see Primary Care Provider)
linked information systems 12.5
149
Healthy People 2000
Physical Activity (see also Physical Activity and
cancer 16.10
Fitness section, page 91)
child development 17.15
community fitness facilities 1.11
children's cognitive, emotional and parent-child
counseling by physicians 1.12
functioning 6.14
discussion in family 8.9
function in older adults 17.17
lack of 1.5
nutrition 2.21
regular moderate 1.3, 15.11, 17.13
occupational health exposures 10.15
regular vigorous 1.4
patients' mental functioning 6.13
school physical education class 1.9
counseling, treatment, and referral
strength, endurance, and flexibility 1.6
alcohol and other drug use problems 4.19
weight loss 1.7, 2.7
cholesterol management 15.15
worksite programs 1.10
craniofacial anomalies 13.15
Physical Education
detection of fetal abnormalities 14.13
daily, in schools 1.8
diet modification 16.10
active 1.9
HIV and other sexually transmitted disease preven-
Physician (see Primary Care Provider)
tion 18.9, 19.14
Physician's Assistant (see Primary Care Provider)
immunizations 20.14
Pneumoconiosis 10.11
injury prevention 9.21
Pneumonia
nutrition 2.21
days of restricted activity 20.10
occupational health exposures 10.15
epidemic-related deaths 20.2
physical activity 1.12
immunization levels 20.11
preconception 5.10, 14.12
immunization by public health departments 20.16
sexually transmitted diseases 19.13
Poisoning
tobacco-use cessation 3.16, 16.10
chemical 11.3
provision of clinical preventive services 21.6
non-fatal 9.8
Prisons (see Correctional Facilities)
Polio 20.1
Processed Foods
Pollution (see also Environmental Health sec-
nutrition labeling 2.14
tion, page 105)
low-fat 2.15
clean indoor air laws 3.12
Proctosigmoidoscopy (see Examinations,
Pregnancy
Routine)
adolescents 5.1
Protective Equipment
breastfeeding 2.11, 14.9
sports and recreational 9.19, 13.16
calcium intake 2.8
Provider Referral Services 19.15
cesarian delivery 14.8
Public Health Departments
counseling on adoption 5.9
local
fetal death rate 14.2
assessment of and assurance of access to clinical
maternal mortality rate 14.3
preventive services 21.7
preconception care and counseling 14.12
effective service by 8.14
prenatal care during first trimester 14.11
small business safety and health programs 10.14
prenatal detection of fetal abnormalities 14.13
programs for identification of tuberculosis 20.17
risk-appropriate care 14.14
use of health status indicators 22.1
severe complications 14.7
provision of adult immunizations 20.16
smoking cessation 3.7
Public Law 101-239 17.20
tobacco, alcohol, and illicit drug use 14.10
Public Swimming Pools 1.11
unintended 5.2
weight gain 14.6
Quality Adjusted Life Years 8.1, 17.1, 21.1
Prenatal Care 14.11
Rabies
Prescription Medications (see Medication)
treatment 20.12
Primary Care
Radon Concentration
clinics addressing HIV infection and sexually trans-
construction standards and techniques to
mitted diseases 5.11, 18.13, 19.11
reduce 11.12
preventive services 21.6
required disclosure to home buyers 11.13
preventive services in publicly funded
testing in homes 11.6
programs 21.5
Rape and Attempted Rape 7.7
services for babies 14.16
Rectal Examination (see Examinations, Routine)
specific ongoing source 21.3
Recycling Programs 11.15
Primary Care Provider
Renal Disease, End-Stage 15.3
assessment and screening
Residences (see Homes)
150
Index to Summary List of Objectives
Restaurants
condom use 18.4, 19.10
low-fat, low-calorie food choices 2.16
Sexually Transmitted Diseases (see also HIV In-
Roadway Safety
fection; Sexually Transmitted Diseases sec-
design standards 9.20
tion, page 120)
Routine Examinations (see Examinations,
barrier method protection against 5.6
Routine)
correct patient management by primary care
Rubella 20.1
providers 19.13
partner notification 5.11, 18.13, 19.11
Safety
prevention counseling by clinicians 18.9, 19.14
counseling by primary care providers 9.21
provider referral services 19.15
discussion in family 8.9
Sexuality
roadway design standards 9.20
discussion in family 5.8
worksite programs 10.12
Shelters
Safety Belt (see Seat Belt)
battered women and children 7.15
Salmonella Enteritidis
Silicosis 10.11
incidence rate 12.1
Skin Disorders/Diseases 10.4
outbreaks 12.2
Skin Examinations (see Examinations, Routine)
Salt
Smoke Detectors 9.17
dietary intake 2.9
Smoking
Saturated Fat (see Fat)
cessation counseling by clinicians 3.16
Schools
children's exposure at home 3.8
food services 2.17
cigarettes 3.4, 15.12, 16.6
graduation rate 8.2
average age of first use 4.5
health education
cessation attempts 3.6
alcohol and other drug 4.9, 4.10, 4.13
cessation during pregnancy 3.7
conflict resolution 7.16
initiation by children and youth 3.5
HIV, education curricula grades 4 through
State policies limiting or prohibiting in public
12 18.10
places 3.12
HIV, education at colleges and
worksite policies 3.11
universities 18.11
Sodium (see Salt)
injury prevention 9.18
Solid Waste (see Waste)
nutrition 2.19
Speech and Language Impairment
physical education 1.8, 1.9
detection in children 17.15
quality, grades K through 12 8.4
Spinal Cord Injuries (see Injury)
sexuality 5.8
Sprinkler Systems, Fire Suppression
sexually transmitted disease prevention 19.12
residential 9.16
tobacco-use prevention 3.10
Sporting Events
health promotion in post-secondary institutions 8.5
use of protective equipment 9.19, 13.16
heavy drinking among high schools seniors and
States
college students 4.7
community health promotion programs 8.10
immunization laws 20.13
data
immunization levels 20.11
comparable to Federal and local 22.3
oral health screening 13.12
health status indicators 22.1
preschool programs for disabled or disadvantaged
periodic analysis and publication 22.5
children 8.3
evaluation and followup of abused children 7.14
tobacco-free 3.10
laws
Screening (see Examinations, Routine)
disclosure of lead and radon concentrations to
Sealants, Protective Dental 13.8
home-buyers 11.13
Seat Belt
driver's license revocation for driving under the
laws 9.14
influence 4.15
use 9.12
handgun design 9.15
Sedentary Lifestyle 1.5
immunization in schools and day care
Self-Help (see also Mutual Help Clearinghouses)
centers 20.13
patient education about resources 17.14
legal blood alcohol concentration tolerance
Sexual Abuse (see Abuse)
levels 4.18
Sexual Behavior (see Sexuality)
promotion of alcohol to youth 4.17
Sexual Intercourse
safety belt and helmet use laws 9.14
abstinence 5.5
sale and distribution of tobacco to youth 3.13
among adolescents 5.4, 18.3, 19.9
smoking in public places 3.12
151
Healthy People 2000
mutual help clearinghouses 6.12
Tanning Booths (see Ultraviolet Radiation)
plans
Teeth
access to alcohol and drug treatment programs
loss of all natural 13.4
4.12
maintenance of all permanent 13.3
defining and tracking environmental dis-
protective sealants for children 13.8
eases 11.16
Television
occupational health and safety 10.10
health communication 8.13
tobacco use reduction 3.14
Tetanus
policies to reduce minors' access to alcohol 4.16
indigenous cases 20.1
programs
immunization 20.16
screening for genetic disorders 14.15
Tobacco (see also Tobacco section, page 95)
small business safety and health 10.14
abstinence during pregnancy 14.10
protocols to prevent suicide in jails 6.10, 7.18
cessation counseling 3.16
standards
children's exposure to smoke in home 3.8
construction 11.12
discussion in family 8.9
occupational exposure 10.11
prevention education 3.10
food operations 12.4
product sale and distribution 3.13
roadway environment 9.20
restrictions on product advertising and promo-
systems
tion 3.15
child death review 7.13
smoke-free environment 3.9
emergency medical service and trauma
State plans for reduction of use especially among
systems 9.22
youth 3.14
infant referral to craniofacial anomaly
Tooth Loss (see Teeth)
team 13.15
Toxic Agents 11.7
services for children with or at risk of chronic
Trauma
and disabling conditions 17.20
emergency medical services 9.22
Steroids, Anabolic 4.11
cumulative trauma disorders 10.3
Stress
Tuberculosis
adverse health effects 6.5
clinics addressing HIV infection and sexually trans-
reduction and control 6.9
mitted diseases 5.11, 18.3, 19.11
reduction programs at worksite 6.11
identification programs 20.17
Stroke (see also Heart Disease and Stroke sec-
incidence 20.4
tion, page 112)
preventive therapy 20.18
deaths 15.2
Typhoid Fever 20.6
Substance Abuse (see Alcohol; Drugs)
Suicide
Ultraviolet Radiation 16.9
injuries attempts by adolescents 6.2, 7.8
Unicode Food Protection Code 12.4
prevention in jails 6.10, 7.18
Unintentional Injuries (see Injury)
protocols in hospital emergency rooms 7.12
Universities (see Schools)
rates 6.1, 7.2
Urinary Incontinence 17.17
Sun Exposure (see Ultraviolet Radiation)
Urethritis, Nongonococcal (see Chlamydia
Sun Lamps (see Ultraviolet Radiation)
Trachomatis Infection)
Surface Water (see Water)
U.S. Department of Health and Human Ser-
Surgical Wound Infections 20.5
vices 11.7
Surveillance and Data Systems (see also Surveil-
U.S. Preventive Services Task Force
lance and Data Systems section,
recommendations 21.2, 21.4, 21.5, 21.6
page 124)
data transfer systems 22.6
Vaccine-Preventable Diseases
comparable Federal, State, and local data 22.3
reduction 20.1
national data sources 22.2
Vegetables
national process to identify gaps 22.4
daily intake 2.6, 16.8
periodic analysis and publication to measure
Violent and Abusive Behavior (see Violent and
progress towards objectives 22.5
Abusive Behavior section, page 100)
timely release of national data 22.7
Vision Impairment
Syphilis
detection in children 17.15
congenital 19.4
detection in older people 17.17
primary and secondary 19.3
prevalence 17.7
provider referral services 19.15
Warts, Genital 19.5
152
Index to Summary List of Objectives
Waste
Worksite
sites, hazardous 11.14
food services 2.16
solid, exposure and production 11.8
policies
Water
alcohol 4.14
drinking
drug 4.14
fluoridation 13.9
hiring of people with disabilities 17.19
safety standards 11.9
occupant protection systems 10.6
surface 11.10
smoking 3.11
Waterborne Disease Outbreaks 11.3
health promotion programs
Weapons
back injury prevention and rehabilitation 10.13
carrying 7.10
blood cholesterol education 15.16
handguns 9.15
blood pressure education 15.16
inappropriate storage 7.11
health and safety 10.12, 10.14
related violent deaths 7.3
hiring of people with disabilities 17.19
Weight
nutrition education 2.20
gain during pregnancy 14.6
participation by hourly workers 8.7
loss 1.7,2.7
physical activity and fitness 1.10
management programs for employees 2.20
proportion of worksites that offer 8.6
Women
stress reduction 6.11
clinical breast exam and mammogram 16.11
weight management 2.21
iron deficiency 2.10
Wound Infection (see Infection)
pap testing 16.12
physical abuse by male partners 7.5
Years of Healthy Life (see Quality-Adjusted Life
prevention of osteoporosis 17.18
Years)
rape and attempted rape 7.7
shelters 7.15
153
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Healthy Communities 2000:
Model Standards (3rd edition)
1991
Guidelines for Community Attainment of the Year 2000
National Health Objectives
Healthy Communities 2000: Model Standards is the guidebook for successfully
applying the objectives set out in Healthy People 2000 at the community level. It
is a practical tool for planning programs to prevent illness, injury, and premature
death. It provides comprehensive goals and objectives to help health profes-
sionals and leaders work cooperatively to improve the health, environment, and
quality of life in their communities.
Special Features
Prepared by national professional organizations as a companion document for Healthy
People 2000.
Provides community implementation strategies for the Year 2000 National Health Objectives.
Incorporates 10 years of field experience and testing of Model Standards.
Specifies goals, objectives, and indicators for the 22 priority areas contained in Healthy
People 2000.
Offers a Community Implementation section detailing the necessary services required to
support effective public health programming.
Allows communities flexibility in quantifying outcome and risk factor objectives and in
prioritizing services based on their own needs and resources.
Maintains the concept basic to Model Standards of the importance of government and
the "residual guarantor" responsible for assuring provision of preventive services through
community agencies.
Please send me information about obtaining the 3rd edition of Healthy Communities
2000: Model Standards when it is published in 1991.
Name
Organization
Address
City
State/Province
Zip
Country
Phone ( )
A collaborative project of:
Send your request to:
American Public Health Association
Association of Schools of Public Health
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Association of State and Territorial Health Officials
American Public Health Association
National Association of County Health Officials
1015 15th Street NW.
United States Conference of Local Health Officers
Washington, DC 20005
Centers for Disease Control, Public Health Service,
Available Spring 1991
U.S. Department of Health and Human Services
ENT DEPARTMENT OF HEALTH
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
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"ocrText": "Originally Processed With FOIA(s):\nFOIA Number:\n2021-0094-F\n2021-0094-F\nFOIA\nMARKER\nThis is not a textual record. This is used as an\nadministrative marker by the George Bush Presidential\nLibrary Staff.\nRecord Group/Collection:\nGeorge H.W. Bush Presidential Records\nCollection/Office of Origin:\nCabinet Affairs, White House Office of\nSeries:\nPorter, Richard, Files\nSubseries:\nOA/ID Number:\n07136\nFolder ID Number:\n07136-012\nFolder Title:\nHealthy People 2000\nStack:\nRow:\nSection:\nShelf:\nPosition:\nG\n15\n16\n2\nHEALTHY\nPEOPL\nE\nNational Health Promotion and\nDisease Prevention Objectives\nHEALTHY\nPEOPLE\n2000\nNational Health Promotion and\nDisease Prevention Objectives\nU.S. Department of Health and Human Services\nPublic Health Service\nHealthy People 2000 is a statement of national opportunities. Although the\nFederal Government facilitated its development, it is not intended as a\nstatement of Federal standards or requirements. It is the product of a\nnational effort, involving 22 expert working groups, a consortium that has\ngrown to include almost 300 national organizations and all the State health\ndepartments, and the Institute of Medicine of the National Academy of\nSciences, which helped the U.S. Public Health Service to manage the\nconsortium, convene regional and national hearings, and receive testimony\nfrom more than 750 individuals and organizations. After extensive public\nreview and comment, involving more than 10,000 people, the objectives\nwere revised and refined to produce this report.\nSERVICES\nHUMAN\nVSN\nHEALTH\nDEPARTMENT OF HEALTH & HUMAN SERVICES\nPublic Health Service\nOF\nDEPARTMENT\nOffice of the Assistant Secretary\nfor Health\nWashington DC 20201\nThe Honorable Louis W. Sullivan\nSecretary of Health and Human Services\nDear Mr. Secretary:\nI am pleased to submit to you Healthy People 2000: National Health\nPromotion and Disease Prevention Objectives. This document contains a\nnational strategy for significantly improving the health of the Nation\nover the coming decade. It addresses the prevention of major chronic\nillnesses, injuries, and infectious diseases.\nThe Public Health Service has served as leader, convener, and facilitator\nover the three-year period of this report's development. However, it can\ntruly be labelled a national, not just a Federal, initiative to focus\nexisting knowledge, resources, and commitment to capitalize on our\nopportunities to prevent premature death and needless disease and\ndisability. Thousands of professionals from many different disciplines,\nas well as many health advocates and consumers, have contributed\nsubstantially to produce this set of measurable targets to be achieved by\nthe year 2000. They have voluntarily testified at public hearings,\nwritten eloquent letters and papers, engaged in extensive reviews of draft\nmaterials, and organized and attended informational forums in support of\nHealthy People 2000. The comprehensiveness and depth of this report stand\nas a tribute to their commitment to better health for Americans through\nprevention. In addition to their contribution, Federal staff from other\ndepartments, other Operating Divisions of this Department, and the Public\nHealth Service Agencies, have worked above and beyond the call of duty to\nproduce this national prevention strategy. The Institute of Medicine of\nthe National Academy of Sciences has served as an important partner in our\nefforts to involve a broad consortium of participants in the process.\nEach deserves a special note of appreciation.\nI commend Healthy People 2000 to you and through you to the American\npeople. This set of objectives for the year 2000 makes an important,\ncompelling point to us and to all health policy makers: we can no longer\nafford not to invest in prevention. From the perspective of avoiding\nhuman suffering as well as saving wasteful costs for treating diseases and\ninjuries that could have been prevented, the 1990s should be the decade of\nprevention in the United States.\nWith the submission of Healthy People 2000, I commit the Public Health\nService to work toward achievement of these objectives for the coming\ndecade.\nSincerely yours,\nJames James O. Mason, M.D., Dr.P.H.\n0.\nmaton\nAssistant Secretary for Health\nEnclosure\nForeword\nAmericans today are taking a more active interest in their health than ever before. They\nare coming to realize the influence that they, themselves, can have on their own health\ndestinies and on the overall health status of the Nation.\nIt wasn't always thus. Until fairly recently, we Americans gave little thought to health as\na positive concept. The past 15 years or so, however, have witnessed important changes\nin our thinking about the protection and enhancement of personal health. Three of those\nchanges are of great importance for the well-being of our people as we move into the\nfinal decade of this century.\nFirst, personal responsibility, which is to say responsible and enlightened behavior by\neach and every individual, truly is the key to good health. Evidence of this still-evolving\nperspective abounds in our concern about the dangers of smoking and the abuse of alco-\nhol and drugs; in the emphasis that we are placing on physical and emotional fitness; in\nour growing interest in good nutritional practices; and in our concern about the quality of\nour environment. We have become, in a word, increasingly health-conscious, increasing-\nly appreciative of the extent to which our physical and emotional well-being is dependent\nupon measures that only we, ourselves, can affect.\nWe can control our health destinies in significant ways, then, but if we are to realize,\nfully, the benefits of assuming that control, and this is the second of the three points I\nwould make, we must find the means of extending the benefits of good health to the most\nvulnerable among us.\nThe correlation between poor health and lower socio-economic status has been well docu-\nmented, but that does not make it right or inevitable. Good health should not be seen, or,\nfor that matter, be permitted to exist in fact, as a benefit for only those who can afford it;\nit should be available and accessible to every citizen.\nMedical care, alone, will not eliminate the devastating impact of chronic disease on the\ndisadvantaged, nor will it reduce, as much as we would like, the rate of infant mortality\nor the burden of homicide and violence or any of the other \"health\" problems that are\nborne by the poor in our society. If we are to extend the benefits of good health to all our\npeople, it is crucial that we build in our most vulnerable populations what I have called a\n\"culture of character,\" which is to say a culture, or a way of thinking and being, that ac-\ntively promote responsible behavior and the adoption of lifestyles that are maximally con-\nducive to good health. This is \"prevention\" in the broadest sense. It is also an absolute\nnecessity, both because we are a humane and caring society and because, if we are to\nremain a vital society, we cannot afford to waste human resources. Good health must be\nan equal opportunity, available to all Americans.\nFinally, health promotion and disease prevention comprise perhaps our best opportunity\nto reduce the ever-increasing portion of our resources that we spend to treat preventable\nillness and functional impairment. Smoking, for example, is the single most preventable\ncause of death and illness in this country. Smoking-related illnesses cost our health care\nsystem more than $65 billion annually.\nAIDS is an almost entirely preventable disease. The cost of caring for a person with\nAIDS for his or her lifetime is, today, about $75,000. The annual cost of treating all diag-\nnosed AIDS patients, about $4.3 billion this year, could climb as high as $13 billion by\n1992, the Public Health Service estimates.\nV\nHealthy People 2000\nThe yearly cost of treating alcohol and drug abuse is at least $16 billion. The total\neconomic impact of alcohol and drug abuse, including not only treatment but premature\ndeath, accidents, crime, and lost productivity, is more than $110 billion annually.\nWe would be terribly remiss if we did not seize the opportunity presented by health\npromotion and disease prevention to dramatically cut health-care costs, to prevent the\npremature onset of disease and disability, and to help all Americans achieve healthier,\nmore productive lives.\nHealthy People 2000: National Health Promotion and Disease Prevention Objectives\naddresses these three points. It lays out a series of national opportunities. To support\nthe development of these opportunities, a national consortium composed of nearly 300\nnational membership organizations and all of the State health departments joined the\nDepartment's Public Health Service to solicit and analyze comments and suggestions\nfrom people across the Nation. The Federal Departments of Agriculture, Defense, Edu-\ncation, Interior, Labor, and Transportation and the Environmental Protection Agency par-\nticipated generously in the development of the national objectives. In regional and na-\ntional hearings, the Public Health Service and its partner in this venture, the Institute of\nMedicine of the National Academy of Sciences, learned what people from many sectors\nof society consider to be the priorities for prevention in the coming decades.\nThis input has shaped the content of Healthy People 2000 as it has evolved from its first\ndrafts through extensive public review and comment to the final publication. Participants\nincluded health professionals and others in health-related industries. The Department has\nhad the honor of serving as a convener and facilitator in developing these goals, but they\ntruly belong to the Nation.\nI commend this document for your consideration, to use as appropriate in your com-\nmunity. All those who participated in its development over the past three years can take\npride in its clarity of vision. All of us can feel humility in the face of its monumental\nchallenges, but we also can share a new sense of resolve to move forward to achieve a\nnation of healthy people.\nLouis W. Sullivan, M.D.\nSecretary\nSeptember 1990\nvi\nContents\nForeword\nV\nAcronyms and Abbreviations\nviii\nPart I\nHealthy People 2000\n1.\nIntroduction\n1\n2. The Nation's Health: Age Groups\n9\n3. The Nation's Health: Special Populations\n29\n4. Goals for the Nation\n43\n5. Priorities for Health Promotion and Disease Prevention\n53\n6.\nShared Responsibilities\n85\nAppendices\nA. Summary List of Objectives\n91\nB. Contributors to Healthy People 2000\n127\nC. Priority Area Lead Agencies\n141\nIndex to Summary List of Objectives\n143\nContents of the Full Report\nPart I\nHealthy People 2000\nPart II\nNational Health Promotion and Disease Prevention Objectives\nHealth Promotion\n1.\nPhysical Activity and Fitness\n6. Mental Health and Mental\n2. Nutrition\nDisorders\n3. Tobacco\n7.\nViolent and Abusive Behavior\n4.\nAlcohol and Other Drugs\n8.\nEducational and\n5.\nFamily Planning\nCommunity-Based Programs\nHealth Protection\n9. Unintentional Injuries\n12. Food and Drug Safety\n10. Occupational Safety and Health\n13. Oral Health\n11. Environmental Health\nPreventive Services\n14. Maternal and Infant Health\n18. HIV Infection\n15. Heart Disease and Stroke\n19. Sexually Transmitted Diseases\n16. Cancer\n20. Immunization and Infectious\n17. Diabetes and Chronic Disabling\nDiseases\nConditions\n21. Clinical Preventive Services\nSurveillance and Data Systems\n22. Surveillance and Data Systems\nAge-Related Objectives\nChildren\nAdolescents and Young Adults\nAdults\nOlder Adults\nSpecial Population Objectives\nPeople with Low Income\nBlacks\nHispanics\nAsians and Pacific Islanders\nAmerican Indians and Native Americans\nPeople with Disabilities\nAdditional Appendices\nD.\nMortality Objectives Technical\nE.\nRecommendations of the U.S.\nAppendix\nPreventive Services Task Force\nAcronyms and Abbreviations\nADAMHA\nAlcohol, Drug Abuse, and Mental Health Administration\nAHCPR\nAgency for Health Care Policy and Research\nATSDR\nAgency for Toxic Substances and Disease Registry\nCDC\nCenters for Disease Control\nDOD\nDepartment of Defense\nDoEd\nDepartment of Education\nDOI\nDepartment of the Interior\nDOL\nDepartment of Labor\nDOT\nDepartment of Transportation\nEPA\nEnvironmental Protection Agency\nFDA\nFood and Drug Administration\nFSA\nFamily Support Administration\nHCFA\nHealth Care Financing Administration\nHRSA\nHealth Resources and Services Administration\nIHS\nIndian Health Service\nNIH\nNational Institutes of Health\nOHDS\nOffice of Human Development Services\nPHS\nPublic Health Service\nSSA\nSocial Security Administration\nUSDA\nDepartment of Agriculture\nPart I\nHealthy\nPeople\n2000\nContents\n1.\nIntroduction\n2.\nThe Nation's Health:\nAge Groups\n3.\nThe Nation's Health:\nSpecial Populations\n4.\nGoals for the Nation\n5.\nPriorities for Health\nPromotion and Disease\nPrevention\n6.\nShared Responsibilities\n1.\nIntroduction\nThe year 2000 appears ahead on the calendar of our Nation's history as a turning point.\nIt may well be like any other year in the ongoing lives of people who inhabit this country\nand the world. But from the perspective of history, the year 2000 will bring to its con-\nclusion a tumultuous century, characterized by astounding scientific achievements, devas-\ntating world wars, and explosive population growth. It will inaugurate at once a new cen-\ntury and a new millennium, a future so vast in its human and historic dimensions that it\ndefies prediction while posing momentous questions about social and economic viability\nand human vitality in the face of a new era.\nThe year 2000 connotes change. Its arrival contains enough power to shape that change,\nmotivating actions that can improve American lives. The beginning of the twenty-first\ncentury beckons both with challenge and opportunity for improved health of Americans.\nWe began the current century with a sense of fatalism about the Nation's health problems.\nAs we reach its conclusion, we do so with confidence in our ability to control many of\nthe events that form our health prospects. A century of biomedical research has made\navailable sophisticated techniques for diagnosing and intervening against disease. Scien-\ntific studies of even the last generation have revealed much about the factors that\npredispose to various health threats and therefore about actions that each of us can take to\ncontrol our risks for disease or disability.\nWe have learned that a fuller measure of health, a better quality of life, is within our per-\nsonal grasp. If tobacco use in this country stopped entirely today, an estimated 390,000\nfewer Americans would die before their time each year. If all Americans reduced their\nconsumption of foods high in fat to well below current levels and engaged in physical ac-\ntivity no more strenuous than sustained walking for 30 minutes a day, additional results\nof a similar magnitude could be expected. If alcohol were never carelessly used in our\nsociety, about 100,000 fewer people would die from unnecessary illness and injury.\nTogether, deaths from these causes comprise a sizable share of the 2.1 million deaths that\noccur annually and are examples of the impact of personal lifestyle choices on the health\ndestiny of individual Americans and the future of the Nation.\nNew knowledge has brought with it both a keen sense of potential and a keen apprecia-\ntion of how far most Americans, especially those with low incomes, are from that poten-\ntial. Moreover, we are already feeling the effects of momentous new issues emerging on\nthe horizon-the aging of our society, the prohibitive costs of many of the technologies\ndeveloped for diagnosing and treating disease, and the ecologic consequences of in-\ndustrialization and population growth.\nThese problems compel careful engagement on the national agenda. This report frames\nthe elements of that agenda from the perspective of the potential to prevent unnecessary\ndisease and disability and to achieve a better quality of life for all Americans. It grows\nout of a health strategy initiated in 1979 with the publication of Healthy People: The Sur-\ngeon General's Report on Health Promotion and Disease Prevention⁷ and expanded with\npublication in 1980 of Promoting Health/Preventing Disease: Objectives for the Na-\ntion⁸, which set out an agenda for the ten years leading up to 1990.\nHealthy People 2000 offers a vision for the new century, characterized by significant\nreductions in preventable death and disability, enhanced quality of life, and greatly\nreduced disparities in the health status of populations within our society. It is the product\nof a national effort, involving professionals and citizens, private organizations and public\nagencies from every part of the country. Work on the report began in 1987 with the con-\nvening of a consortium that has grown to include almost 300 national membership or-\n1\nHealthy People 2000\nganizations and all the State health departments (see Appendix B). The Healthy People\n2000 Consortium, facilitated by the Institute of Medicine of the National Academy of\nSciences, helped the United States Public Health Service to convene 8 regional hearings\nand received testimony from over 750 individuals and organizations. This testimony be-\ncame the primary resource material for working groups of professionals to use in crafting\nthe health objectives. After extensive public review and comment, involving more than\n10,000 people, the objectives were refined and revised to produce this report.\nThis report does not reflect the policies or opinions of any one organization, including the\nFederal government, or any one individual. It is the product of a national process. It is\ndeliberately comprehensive in addressing health promotion and disease prevention oppor-\ntunities in order to allow local communities and States to choose from among its recom-\nmendations in addressing their own highest priority needs.\nThe Year 2000: A Profile of The American People\nOver the course of the 1990s, the profile of the American population will change. Bar-\nring unforeseeable major events, the demographic contrasts between 1990 and 2000 will\nbe evident, if not dramatic. Based on the best available information:\nBy the year 2000, the overall population of the United States will have grown about\n7 percent to nearly 270 million people, with the slowest rate of growth in the\nNation's history projected between 1995 and 2000. 12 Average household size is ex-\npected to decline from 2.69 in 1985 to 2.48 in 2000, 1 with husband-wife households\ndecreasing from 58 to 53 percent of all households.\nBy the year 2000, the American population will be older, continuing the aging\ntrend of the present century, with a median age of more than 36 years, compared to\n29 years in 1975. The number of children under age 5 will actually decline from\nmore than 18 million to fewer than 17 million between 1990 and 2000. By 2000,\nthe 35 million people over age 65 will represent about 13 percent of the population,\nin contrast to 8 percent in 1950. The population of the \"oldest old\"-those over\nage 85-will have increased by about 30 percent to a total of 4.6 million by\n12\n2000.\nBy the year 2000, the racial and ethnic composition of the American population\nwill form a different pattern. Whites, not including Hispanic Americans, will repre-\nsent a smaller proportion of the total, declining from 76 to 72 percent of the popula-\ntion. One particularly fast-growing population group will be Hispanics, some es-\ntimates forecasting a rise from 8 to 11.3 percent, to more than 31 million Hispanic\npeople by 2000. Blacks will increase their proportion from 12.4 to 13.1 percent.\nOther racial groups, including American Indians and Alaska Natives and Asians\nand Pacific Islanders, will increase from 3.5 to 4.3 percent of the total. 11,12\nBy the year 2000, economic expansion will create up to 18 million new jobs, but\nthe number of young job seekers will decline due to a shift in birth rates. Reflect-\ning changes in racial and ethnic populations, the entry rate of blacks, Hispanics,\nAsians and Pacific Islanders, and American Indians and Alaska Natives into the\nworkforce will be higher than for whites. Women of all racial and ethnic groups\nwill be the major source of new entrants into the labor force, comprising 47 percent\nof the total workforce by 2000, compared to 45 percent in 1988. Half of women in\nthe workforce will be between the ages of 35 and 54, a shift from 1986 when the\nmajority were between 25 and 44. Between 1988 and the year 2000, white men\nwill comprise only 25 percent of the net growth of the labor force. 4 Occupations\nmost likely to grow include service, professional, technical, sales, and executive\nand management positions.\n2\n1. Introduction\nBy the year 2000, the American population may increase by up to 6 million people\nthrough immigration. Certain States and cities, especially those on the east and\nwest coasts, can be expected to receive a disproportionately large number of these\nimmigrants.⁶\nWhile 10 years in the history of a nation seems a comparatively short time, it is long\nenough to alter population patterns in ways that are of great importance to current and fu-\nture decision-makers seeking to design an effective program of health promotion and dis-\nease prevention. Informed estimates about the changes in households and family constel-\nlations, age groups, racial and ethnic populations, the workforce, and immigration can\nprovide a context that is crucial to decisions and programs to achieve a nation of healthy\npeople.\nPromoting Health and Preventing Disease: Progress\nTen years is also long enough to bring about marked changes in the Nation's health (Fig.\n1.1). During the 1980s, there were major declines in death rates for three of the leading\ncauses of death among Americans: heart disease, stroke, and unintentional injuries.\nInfant mortality also decreased, and some childhood infectious diseases were nearly\neliminated. Gains in these areas give hope that the 1990s will see more progress, espe-\ncially for diseases such as cancer that have so far not declined.\nHeart disease\nCancer\nFig. 1.1\nInjuries\nLeading causes of\nStroke\ndeath, U.S. popula-\nChronic lung disease\ntion (age-adjusted)\nPneumonia/influenza\nSuicide\nDiabetes\n1987\nLiver disease\n1977\nSource: Health, United\nAtherosclerosis\nStates, 1989 and Preven-\ntion Profile and National\n0\n50\n100\n150\n200\n250\nCenter for Health Statis-\nRate per 100,000\ntics (CDC)\nMuch of our progress mirrors reductions in risk factors. The more than 40-percent drop\nin heart disease mortality since 1970 reflects dramatic increases in high blood pressure\ndetection and control, a decline in cigarette smoking, and increasing awareness of the\nrole of blood cholesterol and dietary fats. The precipitous drop in stroke death rates—\nover 50 percent in the same period-also reflects gains in hypertension control and\ndeclines in smoking.\nUnintentional injuries have declined. In the last decade and a half, traffic fatalities\ndropped by one-third, partly reflecting increased use of seatbelts, lower speed limits, and\ndeclines in alcohol abuse. Recent reductions in fatal occupational injuries have been\nfacilitated by enhanced occupational safety standards. Studies are beginning to yield\npromising approaches to alcohol and other drug problems.\nProgress has been made in the health status of children as well. In 1987, we achieved a\nrecord low rate of 10.1 infant deaths per 1,000 live births. Although still higher than\nrates in many other developed countries, this figure represents a 65-percent decline since\n1950. Preventable childhood diseases, such as mumps, measles, and rubella, are now un-\n3\nHealthy People 2000\nusual in this country due to widespread use of vaccines. Immunization levels among\nschool children exceed 95 percent for most of these diseases.\nIn other areas, progress is mixed. Lung cancer deaths have increased steadily since 1960,\nalthough rates among men aged 50 and younger began to turn around in the 1980s, a sign\nthat changes in smoking patterns are beginning to have an effect. Breast cancer death\nrates remain stubbornly high, as they have for 35 years, despite the fact that early detec-\ntion and treatment could reduce deaths due to breast cancer by an estimated 30 percent. 10\nFor cervical cancer, the widespread use of Pap tests has contributed to a 73-percent reduc-\ntion in death rates from the disease since 1950.\nChanging trends point to still other areas that require attention. In the past decade, rising\nrates of syphilis and the emergence of HIV infection point to the need for new strategies\nto address these public health problems. Air and water quality have improved since the\nEnvironmental Protection Agency and the States began regulating them in the early\n1970s. However, the last decade has seen increasing concern expressed by individuals,\ncommunities, and public agencies about toxic substances, solid waste, and global environ-\nmental change.\nWhen taken together, the progress of the last ten years has brought the Nation a consider-\nable distance toward the health goals set forth in Healthy People in 1979. That report tar-\ngeted for the year 1990 a 35-percent reduction in infant mortality, a 20-percent reduction\nin death rates for children aged 1 through 14, a 20-percent reduction in death rates for\nadolescents and young adults aged 15 through 24, and a 25-percent reduction in death\nrates for adults aged 25 through 64. For older adults, aged 65 and older, the target was a\n20-percent reduction in days of disability. Figure 1.2 summarizes progress toward these\ngoals, as of the most recent year for which data are available.\nLife Stage\n1990 Target*\n1987 Status\nInfants\n35% lower death rate\n28% lower\nFig. 1.2\nChildren\n20% lower death rate\n21% lower\nAdolescents/\n20% lower death rate\n13% lower\nProgress toward\nYoung Adults\n1990 life stage\nAdults\n25% lower death rate\n21% lower\ngoals-1987\nOlder Adults\n20% fewer days of\n17% lower\nrestricted activity\nSource: Health, United\n* Relative to baseline (1977 data)\nStates, 1989 and Preven-\ntion Profile\nA more detailed record of national efforts in health promotion and disease prevention is\nprovided by tracking progress toward achievement of the 226 measurable objectives that\nwere laid out in Promoting Health/Preventing Disease: Objectives for the Nation in\n1980-objectives established to achieve the broad goals of Healthy People. As of 1987,\nit appeared that nearly half of the objectives had been achieved or were well on their way\ntoward achievement by 1990; about one-quarter appeared unlikely to be achieved; and\nthe status of the other quarter was uncertain because data were unavailable for tracking\ntheir progress. 5 Among the 15 priority areas that were the focus of the 1990 objectives,\nareas in which progress seemed to lag included pregnancy and infant health, nutrition,\nphysical fitness and exercise, family planning, sexually transmitted diseases, and occupa-\ntional safety and health. On the other hand, priority areas related to high blood pressure\ncontrol, immunization, control of infectious diseases, unintentional injury prevention and\ncontrol, smoking, and alcohol and drugs showed substantial progress. 5\n4\n1. Introduction\nHealthy People: The Economics of Prevention\nDespite the overall health improvements achieved as a result of preventive interventions,\nthe Nation continues to be burdened by preventable illness, injury, and disability. In\n1960, the share of the Gross National Product (GNP) going to medical services was 5 per-\ncent. It is estimated to reach nearly 12 percent in 1990. 2 Lost economic productivity at-\ntendant to illness and early death compounds the impact of this problem, so that in 1980\nthe total costs of illness equalled nearly 18 percent of GNP. Injury alone now costs the\nNation well over $100 billion annually, cancer over $70 billion, and cardiovascular dis-\nease $135 billion. 3,9\nSophisticated technology for the diagnosis and treatment of disease conditions has out-\nstripped society's ability to pay for it. But many of these expenses are avoidable (Fig.\n1.3). Coronary artery disease affects approximately 7 million Americans and causes\nabout 1.5 million heart attacks and 500,000 deaths a year. The number of coronary\nOverall\nAvoidable\nCost per\nCondition\nmagnitude\nintervention\n1\npatient 2\nHeart\n7 million with coronary\nCoronary bypass surgery\n$30,000\ndisease\nFig. 1.3\nartery disease\n500,000 deaths/yr\nCosts of\n284,000 bypass\nprocedures/yr\ntreatment\nfor selected\nCancer\n1 million new\nLung cancer treatment\n$29,000\ncases/yr\npreventable\n510,000 deaths/yr\nCervical cancer treatment\n$28,000\nconditions\nStroke\n600,000 strokes/yr\nHemiplegia treatment\n$22,000\n150,000 deaths/yr\nand rehabilitation\nInjuries\n2.3 million\nQuadriplegia treatment\n$570,000\nhospitalizations/yr\nand rehabilitation\n(lifetime)\n142,500 deaths/yr\n177,000 persons with\nHip fracture treatment\n$40,000\nspinal cord injuries\nand rehabilitation\nin the United States\nSevere head injury treat-\n$310,000\nment and rehabilitation\nHIV\n1-1.5 million infected\nAIDS treatment\n$75,000\ninfection\n118,000 AIDS cases\n(lifetime)\n(as of Jan 1990)\nAlcoholism\n18.5 million abuse\nLiver transplant\n$250,000\nalcohol\n105,000 alcohol-related\ndeaths/yr\nDrug\nRegular users:\nTreatment of drug-\n$63,000\nabuse\n1-3 million, cocaine\naffected baby\n(5 years)\n900,000, IV drugs\n500,000, heroin\nDrug-exposed babies:\n375,000\nLow birth\n260,000 LBWB born/yr\nNeonatal intensive care\n$10,000\nweight baby\n23,000 deaths/yr\nfor LBWB\nInadequate\nLacking basic\nCongenital rubella\n$354,000\nimmunization\nimmunization series:\nsyndrome treatment\n(lifetime)\nSource: Data\n20-30%, aged 2 and\ncompiled from\nyounger\nvarious sources\n3%, aged 6 and older\nby the Office of\n1 Examples (other interventions may apply).\nDisease Pre-\n²Representative first-year costs, except as noted. Not indicated are non-\nvention and\nmedical costs, such as lost productivity to society.\nHealth Promo-\ntion\n5\nHealthy People 2000\nbypass procedures performed each year is approaching 300,000, each one of these proce-\ndures at a cost of approximately $30,000. A representative cost for treating a single case\nof lung cancer is $29,000 and $28,000 for invasive cervical cancer. A liver transplant for\nalcoholic cirrhosis can cost $250,000 or more. The lifetime treatment costs per patient\nare $570,000 for quadriplegia from a spinal cord injury, $354,000 for congenital rubella\nsyndrome, and $75,000 for Acquired Immunodeficiency Syndrome (AIDS). Yet virtual-\nly all of these conditions are preventable. Mobilizing the considerable energies and\ncreativity of the Nation in the interest of disease prevention and health promotion is an\neconomic imperative.\nHealthy People 2000: The Challenge and Goals\nThe Nation has within its power the ability to save many lives lost prematurely and need-\nlessly. Implementation of what is already known about promoting health and preventing\ndisease is the central challenge of Healthy People 2000. But Healthy People 2000 also\nchallenges the Nation to move beyond merely saving lives. The health of a people is\nmeasured by more than death rates. Good health comes from reducing unnecessary suf-\nfering, illness, and disability. It comes as well from an improved quality of life. Health\nis thus best measured by citizens' sense of well-being. The health of a Nation is measured by\nthe extent to which the gains are accomplished for all the people.\nThe challenge of Healthy People 2000 is to use the combined strength of scientific know-\nledge, professional skill, individual commitment, community support, and political will\nto enable people to achieve their potential to live full, active lives. It means preventing\npremature death and preventing disability, preserving a physical environment that sup-\nports human life, cultivating family and community support, enhancing each individual's\ninherent abilities to respond and to act, and assuring that all Americans achieve and main-\ntain a maximum level of functioning.\nThe purpose of Healthy People 2000 is to commit the Nation to the attainment of three\nbroad goals that will help bring us to our full potential (Fig. 1.4). We have a broad array\nof opportunities to achieve our goals. This report presents many of these opportunities in\nthe form of measurable targets, or objectives, to be achieved by the year 2000, organized\ninto 22 priority areas. The first 21 of these areas are grouped into three broad categories:\nhealth promotion; health protection; and preventive services (Fig. 1.5).\nIncrease the span of healthy life for Americans\nFig. 1.4\nReduce health disparities among Americans\nHealthy People 2000\nAchieve access to preventive services for all\nGoals\nAmericans\nHealth promotion strategies are those related to individual lifestyle-personal choices\nmade in a social context-that can have a powerful influence over one's health prospects.\nThese priorities include physical activity and fitness, nutrition, tobacco, alcohol and other\ndrugs, family planning, mental health and mental disorders, and violent and abusive be-\nhavior. Educational and community-based programs can address lifestyle in a crosscut-\nting fashion.\nHealth protection strategies are those related to environmental or regulatory measures\nthat confer protection on large population groups. These strategies address issues such as\nunintentional injuries, occupational safety and health, environmental health, food and\ndrug safety, and oral health. Interventions applied to address these issues are generally\n6\n1. Introduction\nHealth Promotion\n1. Physical Activity and Fitness\n2. Nutrition\nFig. 1.5\n3. Tobacco\n4. Alcohol and Other Drugs\nHealthy People 2000\n5. Family Planning\nPriority Areas\n6. Mental Health and Mental Disorders\n7. Violent and Abusive Behavior\n8. Educational and Community-Based Programs\nHealth Protection\n9. Unintentional Injuries\n10. Occupational Safety and Health\n11. Environmental Health\n12. Food and Drug Safety\n13. Oral Health\nPreventive Services\n14. Maternal and Infant Health\n15. Heart Disease and Stroke\n16. Cancer\n17. Diabetes and Chronic Disabling Conditions\n18. HIV Infection\n19. Sexually Transmitted Diseases\n20. Immunization and Infectious Diseases\n21. Clinical Preventive Services\nSurveillance and Data Systems\n22. Surveillance and Data Systems\nAge-Related Objectives\nChildren\nAdolescents and Young Adults\nAdults\nOlder Adults\nnot exclusively protective in nature-there may be a substantial health promotion ele-\nment as well-but the principal approaches involve a communitywide rather than in-\ndividual focus.\nPreventive services include counseling, screening, immunization, or chemoprophylactic\ninterventions for individuals in clinical settings. Priority areas for these strategies include\nmaternal and infant health, heart disease and stroke, cancer, diabetes and chronic disa-\nbling conditions, HIV infection, sexually transmitted diseases, and infectious diseases.\nCrosscutting professional and access considerations in the delivery of clinical preventive\nservices are also addressed.\nA special category has been established for surveillance and data systems. Given the\ncentrality of monitoring progress toward the stated targets in the overall approach of\nHealthy People 2000, the integrity of our data collection efforts at every level is critical.\nObjectives have therefore been established to improve those efforts.\nFinally, because issues and approaches vary by age, chapters are included for each of\nfour age groups: children, adolescents and young adults, adults, and older adults. Objec-\ntives related to each of these age groups are found throughout the priority areas. To give\nthem special emphasis, some of the key targets have been collected and presented accord-\ning to these four ages.\nThe full set of objectives with commentary is presented as Part II of Healthy People\n2000. The material presented here in Part I defines the overall national agenda and out-\nlines goals, objectives, and strategies for change. Chapter 2 of Part I reviews the\n7\nHealthy People 2000\nchallenges for people in various age groups. Chapter 3 addresses high risk populations.\nChapter 4 presents the broad goals. Chapter 5 gives synopses of each of the priority areas\nwith selected examples of the objectives addressed. Chapter 6 reviews the challenge for\nimplementation for various groups throughout the Nation.\nThe last chapter deserves special comment. Healthy People 2000 uses the three ap-\nproaches of health promotion, health protection, and preventive services as organizing\ncategories, but running through the priority areas and the objectives is a common theme\nof shared responsibility for carrying out this national agenda. Achievement of the agenda\ndepends heavily on changes in individual behaviors. It requires use of legislation, regula-\ntion, and social sanctions to make the social and physical environment a healthier place\nto live. It calls on medical and health professionals to prevent, not just to treat, the dis-\neases and conditions that result in premature death and chronic disability. All are neces-\nsary. None is sufficient alone to achieve Healthy People 2000's goals and objectives.\nThe challenge spelled out in Healthy People 2000 calls upon communities to translate na-\ntional objectives into State and local action. To accomplish this, a new edition of Model\nStandards-Healthy Communities 2000: Model Standards, Guidelines for Attainment of\nYear 2000 Objectives for the Nation-provides a flexible planning tool to enable com-\nmunities to share in the various efforts necessary to attain these objectives. The volume\ncovers the priority areas of Healthy People 2000 and includes all of the national objec-\ntives that call for action at the community level. It offers community implementation\nstrategies for putting the objectives of Healthy People 2000 into practice and encourages\ncommunities to establish achievable community health targets.\nReferences\n1\n8\nBureau of the Census. Projections of the Numbers\nPublic Health Service. Promoting\nof Households and Families: 1986 to 2000.\nHealth/Preventing Disease: Objectives for the\nWashington, DC: U.S. Department of\nNation. Washington, DC: U.S. Department of\nCommerce, 1986.\nHealth and Human Services, 1980.\n2\n9\nHealth Care Financing Administration, Office of the\nRice, D.P.; MacKenzie, E.J.; Jones, A.S.; Kaufman,\nActuary. Expenditures and percent of gross\nS.R.; deLissovoy, G.V.; Max, W.; McLoughlin,\nnational product for national health expenditures,\nE.; Miller, T.R.; Robertson, L.S.; Salkever, D.S.;\nby private and public funds, hospital care, and\nand Smith, G.S. Cost of Injury in the United\nphysician services; calendar years 1960-87.\nStates: A Report to Congress, 1989. San\nHealth Care Financing Review 10:2, Winter\nFrancisco, CA: Institute for Health and Aging,\n1988.\nUniversity of California and Injury Prevention\nCenter, The Johns Hopkins University, 1989.\n3\nHodgson, T.A., and Rice, D.P. Economic impact of\n10\ncancer in the United States. In: Schottenfeld, D.,\nShapiro, S.; Venet, W.; Strax, L.; and Roeser, R.\ned. Cancer Epidemiology and Prevention.\nSelection, Followup, and Analysis in the Health\nChapter 13, in press.\nInsurance Plan Study: A Randomized Trial With\nBreast Cancer Screening. National Cancer\n4\nKutscher, R.E. Projections 2000: Overview and\nInstitute Monographs 67:65-74, 1985.\nimplications of the projections to 2000. Monthly\n11\nLabor Review September, 1987.\nSpencer, G. Projections of the Hispanic Population:\n1983-2080. Current Population Reports,\n5\nNational Center for Health Statistics. Health, United\nPopulation Estimates and Projections. Series\nStates, 1989 and Prevention Profile. DHHS Pub.\nP-25, No. 995. Washington, DC: U.S.\nNo. (PHS)90-1232. Hyattsville, MD: U.S.\nDepartment of Commerce, Bureau of the Census,\nDepartment of Health and Human Services, 1990.\n1986.\n6\nPassel, J.E., and Woodrow, K.A.' Immigration to\n12\nSpencer, G. Projections of the population of the\nthe United States.\" Paper presented to the Census\nUnited States, by age, sex, and race: 1988 to\nTable, August 1986.\n2080. Current Population Reports, Population\n7\nPublic Health Service. Healthy People: Surgeon\nEstimates and Projections. Series P-25, No.\nGeneral's Report on Health Promotion and\n1018. Washington, DC: U.S. Department of\nDisease Prevention. Washington, DC: U.S.\nCommerce, Bureau of the Census, 1989.\nDepartment of Health and Human Services, 1979.\n8\n2. The Nation's Health: Age Groups\nResponding effectively to the health challenges of the 1990s will require a clear under-\nstanding of the health-related threats and opportunities facing all Americans. One way to\ngrasp the dimensions and the realities of the tasks laid out in this report is to consider the\nspecial problems of infants, children, adolescents and young adults, adults, and older\nadults. The health profiles of these age groups can help us remember that the improve-\nments envisioned here are not generalizations about the population, but prescriptions for\nhealthier lives for each of us-newborn babies, boys and girls, teenagers and young\npeople, women and men, and people in their later years.\nInfants\nOne of the most heartening indicators of our Nation's improvement in health during the\n20th century has been the steady decline in the infant mortality rate. Between 1950 and\n1987, the infant mortality rate in the United States dropped from 29.2 per 1,000 live\nbirths to 10.1. Eight years after Healthy People (1979) posed the challenge of a 35-per-\ncent reduction in infant mortality by 1990, we had achieved a reduction of 28 percent in\nthat rate. 38\nYet comparison of even our 1987 rate of infant mortality with that of other industrialized\nnations demonstrates the continued importance of efforts in this regard. Moreover, the\ncontinuing disparities between minority and majority populations represent a major\nhealth challenge. In 1987, the mortality rate for black infants was still over twice that\nof whites, and rates for some American Indian tribes and for Puerto Ricans were also\nconsiderably higher than for white infants. 38\nInfant mortality rates provide a summary measure of the effects of major health threats to\nthe developing fetus and newborn baby. But for every 10 babies who die, 990 live.\nSome of those who live have been harmed, often permanently, by unhealthy beginnings.\nThe quality, not just the quantity, of their lives is a function of health during both the\nprenatal and infant periods.\nTechnology has contributed significantly to the improved prospects for infant survival\nover the past several decades. Neonatal intensive care, new surgical techniques, and\nother medical interventions save lives and even overcome conditions that formerly\nguaranteed life-long disability. But opportunities for primary prevention offer new fron-\ntiers for improving infant health in the coming years. Some opportunities will result from\nbreakthroughs in understanding the genetic origins of human diseases; most will be in\nareas of personal lifestyle and use of existing health interventions.\nMajor Health Concerns\nNo period of life is more important to good health than the months before birth. The\nprenatal period can be the starting time for good health or it may be the beginning of a\nlifetime of illness and shortened life expectancy. Each year in the United States, nearly\n39,000 babies-about 1 percent of those born-die before the age of one, two-thirds\nduring their first month. 38 Four causes account for more than half of all infant deaths:\ndisorders relating to low birth weight, congenital anomalies, sudden infant death\nsyndrome (SIDS), and respiratory distress syndrome (Fig. 2.1).\nLow birth weight (less than 2,500 grams) occurs in about 7 percent of all live births and\nis the greatest single hazard to infant health. 38 This dangerous condition has been linked\nto several preventable risks, including lack of prenatal care, maternal smoking, use of\n9\nHealthy People 2000\nCongenital anomalies\nFig. 2.1\nSudden infant death\nLeading causes of\nsyndrome\ninfant mortality\nShort gestation and\n(1987)\nlow birth weight\nRespiratory distress\nsyndrome\nMaternal complications\nof pregnancy\nSource: Health, United\n0\n50\n100\n150\n200\n250\nStates, 1989 and Preven-\nDeaths per 100,000 live births\ntion Profile\nalcohol and other drugs, and pregnancy before age 18. Approximately three-quarters of\ndeaths in the first month and 60 percent of all infant deaths occurred among low-birth-\nweight infants. Low socioeconomic and educational levels are often associated with low\nbirth weight. Black infants are more than twice as likely as white babies to be born\nweighing less than 2,500 grams.³⁸\nVery low birth weight (less than 1,500 grams) is associated with 40 percent of all infant\ndeaths. Very low birth weight declined slightly from 1970 to 1981 but rose by about 0.9\npercent per year from 1981 to 1986. Low-birth-weight babies are nearly twice as likely\nto have severe developmental delay or congenital anomalies. 68 These babies are also at a\nsignificantly greater risk of such long-term disabilities as cerebral palsy, autism, mental\nretardation, and vision and hearing impairments, and other developmental disabilities.\nCongenital anomalies (birth defects) most likely to be lethal include malformations of the\nbrain and spine, heart defects, and combinations of several malformations. Infant mor-\ntality from congenital anomalies has been declining, although the last decade has seen\nslight increases in the incidence of some birth defects. In 1985, about 11,000 babies were\nborn with moderate to severe impairments.⁴ Congenital anomalies, when they do not\nresult in death, may cause disability. One-fourth of all congenital anomalies are caused\nby genetic factors, suggesting a need for preconception genetic counseling for both men\nand women. Environmental hazards and alcohol use during pregnancy are other impor-\ntant factors. Fetal alcohol syndrome (FAS) affects as many as 1 to 3 infants per 1,000\nlive births. 38 In some populations, the incidence is higher. A similar syndrome has been\nobserved in babies born to drug-addicted mothers.\nAfter the first month of life, sudden infant death syndrome (SIDS) is the leading cause of\ninfant mortality, accounting for about one-third of all deaths in this period. 59 The causes\nof SIDS are not known, but risk factors include maternal smoking and drug use, teenage\nbirth, and infections late in pregnancy. Infants born to families with a history of SIDS\nare also at risk.\nRespiratory distress syndrome occurs primarily in premature babies whose lungs are not\nfully developed. Therefore, risk factors for respiratory distress syndrome include those\nfor prematurity.\nIncreasing rates of HIV infection and cocaine addiction in newborns are also of concern.\nBy January 1990, more than 2,000 babies had been born with HIV infection, and some\nhospitals from urban communities reported rates of cocaine-addicted babies as high as 20\npercent. 14 The long term consequences of these alarming trends are inestimable.\n10\n2. The Nation's Health: Age Groups\nMaternal Factors\nSeveral major maternal risk factors are associated with low birth weight, as well as with\nother major causes of infant death and disability, including:\nCigarette smoking;\nAlcohol and other drug use;\nAge;\nNutrition;\nSocioeconomic status;\nEnvironmental hazards.\nAn estimated 25 percent of pregnant women smoke throughout their pregnancies. 66\nThere is some evidence that pregnant women are quitting smoking and that smoking\nprevalence during pregnancy is decreasing for some but not all groups. Women in the\nlowest age and socioeconomic groups have the highest likelihood of smoking during\npregnancy. 32 Maternal cigarette smoking has been linked with from 20 to 30 percent of\nall low-birth-weight births in the United States. 33 If all pregnant women refrained from\nsmoking, fetal and infant deaths would be reduced by approximately 10 percent, saving\nabout 4,000 infants per year.\nHeavy alcohol consumption during pregnancy is associated with increased risk for fetal\nalcohol syndrome, including growth retardation, facial malformations, mental retardation,\nand central nervous system dysfunctions. A safe amount of alcohol consumption during\npregnancy has not been documented; however, adverse effects are associated primarily\nwith heavy consumption during the early months of pregnancy.\nThe effects of maternal drug use on pregnancy outcome have not been fully explored.\nStudies of the effects of maternal drug abuse are hampered by difficulties in distinguish-\ning effects of drug exposure from those resulting from inadequate prenatal care or poor\nmaternal health and nutrition. However, low birth weight and prematurity are the most\nserious known consequences of maternal illicit drug use. Risks due to maternal drug\nabuse are heightened by lack of prenatal care. Between 50 and 75 percent of substance-\nabusing women receive little or no prenatal care.³⁰ Reliable data on the prevalence of\nsubstance abuse by pregnant women is also difficult to obtain. Extrapolations of local\nstudies suggest that mothers of as many as 10 percent of babies born each year have used\none or more illicit substances during their pregnancy. 14,15,25\nBoth pregnant women and newborn infants are particularly vulnerable to poor nutrition.\nWomen who gain less than 21 pounds during pregnancy are more than twice as likely to\ndeliver low-birth-weight infants than those who gain more.⁷¹ Nutrition is also vital to\ngrowth and development of infants, including brain function. For most mothers,\nbreastfeeding is an ideal way of nurturing their infants.\nMaternal age is a risk factor at both ends of the childbearing years: under age 17 and over\nage 40. Teenage women, more than a million of whom become pregnant each year in the\nUnited States, are at particular risk of having low-birth-weight babies. 58 Birth rates for\nwomen aged 15 through 19 are virtually unchanged since 1980, remaining at more than\n50 live births per 1,000 women.² Infants born to women over age 40 experience higher\nrates of congenital anomalies, such as Downs Syndrome.\nWomen with less than 12 years of education, an important element of socioeconomic\nstatus, are about 70 percent more likely to give birth to a low-birth-weight baby or ex-\nperience an infant death than women with more than 12 years of education. 31 Similarly,\n11\nHealthy People 2000\npoor pregnancy outcomes have been linked to other indicators of lower socioeconomic\nstatus such as lack of health insurance and poor nutrition.\nCongenital anomalies may be caused by environmental factors such as viruses, chemi-\ncals, and radiation. Toxic substances can affect the fetus directly, through exposure of\nthe mother, and indirectly, by altering maternal and paternal germ cell chromosomes.\nIndustrial toxins, such as lead, vinyl chloride, and hydrocarbons, may affect workers in\nindustrial plants. The reproductive effects of workplace toxins, however, are still uncer-\ntain and controversial.\nPrenatal Care\nNumerous studies have demonstrated that early and comprehensive prenatal care reduces\nrates of infant death and low birth weight. An expectant mother with no prenatal care is\nthree times as likely to have a low-birth-weight baby. The effect of early prenatal care is\nespecially evident in studies of high-risk groups, such as adolescents and poor women. 27,58\nAbout 76 percent of women receive prenatal care, but rates are considerably lower for\nmany minority groups. 73\nThe 1970s saw significant increases in early prenatal care, especially in groups with the\nlowest levels of care. Since 1980, however, the proportion of women who begin prenatal\ncare in the first 3 months of pregnancy has reached a plateau among all racial and ethnic\n38\ngroups.\nPrenatal care can save money. The Office of Technology Assessment has studied the\npotential effectiveness of prenatal care for all pregnant women living in poverty. Its\nfindings indicate that for every instance of low birth weight averted by prenatal care, the\nUnited States health care system saves between $14,000 and $30,000 in health care costs\nassociated with this condition. 58\nChildren\nThe health profile of American children has shifted markedly in the past 40 years. Once\ndominated by the threat of major infectious diseases, such as polio, diphtheria, scarlet\nfever, pneumonia, measles, and whooping cough, today, widespread immunization has\nvirtually eliminated many of these diseases. Others are in steep decline.\nBetween 1977 and 1987, the rate of childhood deaths declined 21 percent, exceeding the\n1990 target set in Healthy People. Unintentional injuries have now replaced infectious\ndiseases as the cause of greatest concern for the health of children. But even for the lead-\ning cause of injury-related deaths among children-motor vehicle crashes-heartening\nprogress has occurred. Since 1970, the rate of childhood deaths from motor vehicle\ncrashes has declined 41 percent for children aged 1 through 4, and 31 percent for those\naged 5 through 14, primarily due to the use of car seats and seatbelts. 38 Other causes of\ninjury-related deaths among children-drowning, falls, poisoning, fires-have also\ndeclined as a result of improved protections, with the sole exception of child homicide.\nSeveral threats to children's health are associated with low socioeconomic status.\nMental retardation, learning disorders, emotional and behavioral problems, and vision\nand speech impairments all appear to be more prevalent among children living in pover-\nty, often in inner cities, than among those at higher socioeconomic levels. 62 An accurate\nprofile of the health of U.S. children, therefore, must go beyond mortality and morbidity\ndata. It must also consider emotional, psychological, and learning problems, the social\nand environmental risks to which they are related, and the total costs to the Nation.\n12\n2. The Nation's Health: Age Groups\nMajor Health Concerns\nThe leading cause of death in childhood-unintentional injuries-not only accounts for\nthe most deaths but also is among the most preventable (Fig. 2.2). Other major, prevent-\nable problems include homicide, suicide, child abuse and neglect, developmental problems,\nand lead poisoning.\nInjuries\nCancer\nFig. 2.2\nCongenital anomalies\nLeading causes of\nHomicide\ndeath for children\nHeart disease\naged 1 through 14\nPneumonia/influenza\n(1987)\nSuicide\nMeningitis\nChronic lung disease\nHIV infection\n0 2 4 6 8 10 12 14 16 18\nSource: National Center\nDeaths per 100,000 children\nfor Health Statistics (CDC)\nNearly half of all childhood deaths are due to unintentional injuries, and about half of\nthese stem from motor vehicle crashes. Declines in childhood deaths from motor vehicle\ncrashes are due in part to increasing use of child safety seats and safer automobile design.\nIn one of the major public health successes of the decade, all 50 States now require safety\nrestraints for young children, contributing to a 36-percent decline in motor vehicle fatalities\nin this age group between 1980 and 1984.⁴⁷ However, many States still do not mandate\nchild restraints for children over age 5, and in some States there is no requirement after\nage 3 or 4. Furthermore, although studies suggest that 4 out of 5 passengers under age 5\nnow use occupant protection systems, many of the child safety seats in use have been\nfound to be either not attached to the car seat or attached incorrectly.48\nDrownings and fires account for most other injury-related deaths among children. Drown-\nings are most frequent in swimming pools and home spas among children under 5.\nHousehold fires are a particular risk to children because they have more difficulty escap-\ning than adults and are less likely to survive fire-related injuries. Deaths from fires are\noften due to asphyxiation and traumatic injuries, as well as burns. Children under age 5\nwho live in substandard housing without smoke detectors are at special risk.²⁴\nInjuries from falls and poisonings are not major causes of death in children but do cause\nmany nonfatal injuries. Playground equipment and upper-story windows are frequently\nimplicated in fall-related injuries in children.\nMany injuries can be and are being prevented. During the last decade, improved safety\nmeasures have reduced fatalities. These measures include swimming pool and spa covers\nand childproof enclosures; child-resistant packaging for prescription drugs and some\nother hazardous materials; safer playground equipment; and smoke detectors. All of\nthese, plus increased public awareness of injuries and their prevention, have helped save\nlives, and their wider use could save many more.\nSome infections and respiratory illnesses remain problems for children. For example,\ninfluenza and other respiratory problems are the chief illness-related reasons that children\nmiss school. In addition, the increased number of reports of asthma among children,\nespecially those living in cities, has raised concern in recent years.³⁸\n13\nHealthy People 2000\nViolence toward children has become of increasing concern as an American health issue,\nwith rapidly rising rates of reported cases of child deaths due to violence. The periodic\nStudy of National Incidence of Child Abuse and Neglect estimated that, in 1986, nearly 2\npercent of children-or more than 1,000,000-were demonstrably harmed by abuse or\nneglect. The most common kind of abuse identified was physical, followed by emotional\nand sexual; the most common kind of neglect was educational, followed by physical and\nemotional. Substantial increases in reported physical and sexual abuse cases have oc-\ncurred since 1980, but the 1986 study concluded that this was due more to improved\nreporting, reflecting greater public and professional awareness of the problem, than to an\nactual increase in child abuse. On the other hand, the study also demonstrated that many\nincidents of child maltreatment still go unreported.⁷⁵\nDevelopmental Problems\nPsychological, emotional, and learning disorders are on the rise among children, as are\nchronic physical conditions such as hearing and speech impairment. Low-income\nchildren are at a significantly higher risk for such problems. 62\nOne contributor to developmental problems in children is lead poisoning. In 1984, an\nestimated 3,000,000 children between 6 months and 5 years of age had blood lead levels\nabove 15 µg/dL and 250,000 had levels above 25 µg/dL, making lead poisoning one of\nthe Nation's most prevalent childhood threats. Severe lead poisoning can lead to pro-\nfound mental retardation, coma, seizures, and death. Even low levels of exposure can\nimpair central nervous system function, causing delayed cognitive development, hearing\nproblems, growth retardation, and metabolic disorders. 1 Reduced lead in gasoline, air,\nand food, and reduced industrial emissions have produced lower mean blood lead levels\nnationwide. Nevertheless, homes and play areas, particularly in substandard housing\nareas, remain a significant source of this toxin in children's blood. The chief sources of\nlead exposure are thought to be old flaking lead-based paint, dust, and soil.\nHealthy Child Development\nChildhood is the prime time of human development. This is no less true for development\nof good health than it is for social, educational, emotional, and moral development. It\nmay be easier to prevent the initiation of some behaviors, such as smoking and alcohol\nand drug abuse, than to intervene once they have become established. Likewise, it may\nbe easier to establish healthful habits, such as those related to basic hygiene and those re-\nlated to dietary and physical activity patterns, during childhood than later in life. Child-\nhood is the opportune period for such healthy development.\nEarly use of tobacco, alcohol, and marijuana is associated with alcohol and other drug\nabuse later in adolescence or adulthood. 17 While most smokers start when they are\nyoung teenagers, many start even earlier. About one-quarter of high school seniors who\nhave ever smoked report that they smoked their first cigarette by grade 6, over half by\ngrades 7 or 8, and three-quarters by grade 9. Although cigarette smoking is declining\namong all age groups, those who do smoke are starting at younger ages. A wide array of\nfactors promote smoking by children, including peer pressure, parental smoking be-\nhavior, lack of knowledge and understanding of health consequences, advertising and\npromotion, and the easy availability of cigarettes in unsupervised vending machines. 57\nAlthough the average age of first use of alcohol and marijuana is 13, pressure to begin\nuse starts at even younger ages. Elementary school students report peer pressure to try\nbeer, wine, and distilled spirits. Moreover, 26 percent of 4th graders and 40 percent of\n6th graders reported that many of their peers had tried beer, wine, distilled spirits, or wine\ncoolers.\n51\n14\n2. The Nation's Health: Age Groups\nLifetime diet and exercise patterns may also be established in childhood. Fat makes up\nmore than 36 percent of calories in the average American diet, a figure that is too high ac-\ncording to most experts. It is recommended that children over 2, as well as adults, reduce\nthat figure to no more than 30 percent and that saturated fats be reduced to less than 10\npercent of calories. Exercise habits established in childhood may help in maintaining a\nphysically active lifestyle throughout adolescence and adulthood. Both moderate and\nvigorous physical activity on a regular basis help promote overall fitness and control\nweight. In 1984, a little more than two-thirds of children aged 10 through 17 engaged\nregularly in vigorous physical activity. 72 A comparison of body composition among\nchildren between 1965 and 1985 showed a steady increase in skinfold thicknesses, a\nmeasure of body fat.\nMost schools provide some health education, although the amount and content vary\namong States and school districts. According to recent data:\n75 percent of school districts have antismoking education in elementary schools; 54\n63 percent of school districts and private schools provide some instruction concern-\ning alcohol and other drugs and 39 percent provide related counseling;64\n12 States require nutrition education from preschool through grade 12;4\n32 percent of children in grades 1 through 6 and 44 percent of those in grades 7\nthrough 9 participate in daily physical education programs, but only 1 State re-\nquires daily physical education from kindergarten through grade 12;72\n25 States require comprehensive school health education programs and 9 States\nrecommend that local school districts implement such programs. 18\nAppropriate educational strategies vary according to community and age group, but age-\nappropriate health education curricula can change attitudes and behavior.\nSchools can also be used to facilitate children's access to basic health services. Although\nthe traditional childhood infectious diseases have declined steeply since vaccines became\navailable, immunization is still incomplete. Better school-based programs, information\nfor the public, and more immunization education for physicians and health professionals\nare needed.\nImproving the health of American children requires a wide range of social and economic\ninterventions. For example, more and better preschool education for disadvantaged\nchildren and children with disabilities could help to detect and prevent developmental\nproblems. Educational and support programs for parents in high-risk environments hold\npromise for reducing child abuse and other health problems, such as lead poisoning. The\ncomplex developmental problems besetting children in these environments demand con-\ncerted efforts by many different sectors of society. Primary care health providers, social\nservice professionals, health educators, housing officials, community groups, and con-\ncerned individuals can each make a difference in the health of American children.\n15\nHealthy People 2000\nAdolescents and Young Adults\nThe years from 15 through 24 are a time of changing health hazards. Caught up in\nchange and experimentation, young people also develop behaviors that may become per-\nmanent. Attitudes and patterns related to diet, physical activity, tobacco use, safety, and\nsexual behavior may persist from adolescence into adulthood.\nThe dominant preventable health problems of adolescents and young adults fall into two\nmajor categories: injuries and violence that kill and disable many before they reach age\n25 and emerging lifestyles that affect their health many years later.\nTwo major causes of death in older age groups, heart disease and cancer, have declined\nsharply among adolescents since 1950-heart disease by 60 percent and cancer by 40 per-\ncent.³⁸ Although they are still important threats in this age group, these diseases are over-\nshadowed by the three leading causes of death: unintentional injuries, homicide, and\nsuicide (Fig. 2.3).\nInjuries\nHomicide\nFig. 2.3\nSuicide\nLeading causes of\nCancer\ndeath for youth aged\nHeart disease\n15 through 24 (1987)\nCongenital anomalies\nHIV infection\nPneumonia/influenza\nStroke\nChronic lung disease\nSource: Monthly Vital\n0\n10\n20\n30\n40\n50\n60\nStatistics Report, Supple-\nDeaths per 100,000 youth\nment, September 26, 1989\nMotor Vehicle Crash Injuries\nUnintentional injuries account for about half of all deaths among people aged 15 through\n24; three-quarters of these deaths involve motor vehicles. More than half of all fatal\nmotor vehicle crashes among people in this age group involve alcohol. Young white men\nhad the highest death rates for motor vehicle crashes in 1987, at 59 per 100,000. The rate\nfor young black men was much lower: 36 per 100,000. The rate was lower yet for\nwomen of both races.³⁸\nMotor vehicle crash deaths decreased in this age group in the early 1980s, possibly be-\ncause of the raised minimum drinking age in many States and decreasing alcohol use.\nThe recent trend, however, is upward. 38 The raised speed limit on rural interstate high-\nways may be a factor in this trend. Further, nearly 60 percent of 8th and 10th graders\nreported not using seatbelts on their most recent ride.⁵\nHomicide and Suicide\nHomicide is the second leading cause of death among all adolescents and young adults,\nand it is the number one cause among black youth. The homicide rate for young black\nmen increased by 40 percent between 1984 and 1987 to nearly 86 per 100,000, more than\n7 times the rate for young white men. Race, however, appears not to be as important a\nrisk factor for violent death as socioeconomic status. Racial differences in homicide rates\nare significantly reduced when socioeconomic factors are taken into account.\n16\n2. The Nation's Health: Age Groups\nAs with motor vehicle accidents, about half of all homicides are associated with alcohol\nuse. Nationwide, 10 percent are drug-related, but in many cities this rate is substantially\nhigher. Over half of all homicide victims are relatives or acquaintances of the perpetrators.\nMost are killed with firearms. 11\nSuicide is the second leading cause of death among young white men aged 15 to 24, and\nrates continue to climb. From 1950 to 1987 the death rate from suicide in this group in-\ncreased from under 7 to about 23 per 100,000 population. The rate of suicides among\nblack adolescents and young adults is half of that among whites. White men between 20\nand 24 years of age are more likely to commit suicide than their counterparts aged 15\nthrough 19, but the gap between these two groups is narrowing. In general, suicides have\ndecreased among older youth and increased among the younger cohort. 35\nBoth white and black young women have relatively low suicide rates (4.7 and 2.3 respec-\ntively in 1987), although young women attempt suicide unsuccessfully approximately\nthree times more often than young men.³⁵ As is the case with homicides, 60 percent of\nsuicides among adolescents and young adults are committed with firearms.\nTobacco, Alcohol, and Drugs\nMany of the most important risk factors for chronic disease in later years also have their\nroots in youthful behavior. The earlier cigarette smoking begins, for example, the less\nlikely the smoker is to quit. Three-fourths of high school seniors who smoke report that\nthey smoked their first cigarette by grade 9. Young people, especially teenage girls, are\ntaking up smoking at younger ages. The age of initiation for regular smoking among\nfemales is now roughly the same as for males.⁵⁷\nIn 1976, about 29 percent of high school seniors reported daily smoking. Between 1977\nand 1981, the rate of smoking dropped to 19 percent and has since leveled off. The an-\nnual surveys of high school seniors do not gather information on school dropouts-about\n15 percent of white youths and 23 percent of black youths whom smoking is\nmore prevalent. 61 But data for young adults aged 20 through 24 have shown a continued\nsteady decline in cigarette smoking for young men and a recent equivalent decline for\nyoung women.\nThe use of snuff and chewing tobacco has increased dramatically in recent years among\nteenage boys. Between 1970 and 1986, snuff use increased fifteen-fold and chewing\ntobacco use increased fourfold among young men aged 17 through 19. In 1987, the\nprevalence of smokeless tobacco use among young men aged 18 through 24 was nearly 9\npercent. Among younger adolescent boys aged 12 through 17, nearly 7 percent had used\nsome form of smokeless tobacco within the last month. 65\nAlcohol consumption among teenagers and young adults is declining slowly, but it remains\na major problem for both. It is a particular problem among school dropouts. Alcohol is\na major contributor to both motor vehicle crashes and violence, two of the leading causes\nof death and disability among young people. In 1989, about 60 percent of high school\nseniors reported drinking alcohol in the previous month, while 33 percent reported oc-\ncasions of heavy drinking-having five or more drinks on one occasion in the last 2\nweeks; both figures represented slight declines from 1988 survey results.⁴⁹\nAlcohol use is also prevalent both among younger teenagers and those who are beyond\nhigh school age. In a 1987 national survey, 28 percent of 8th graders and 38 percent of\n10th graders reported occasions of heavy drinking.⁵ Among young people aged 18 to 24,\ndrinking is more prevalent than in any other age group. In 1988, more than 65 percent of\nthis group reported alcohol use during the past month.³⁸\nThe use of illicit drugs among adolescents has been declining since the late 1970s, at\nleast among young people who remain in school. 51 The number of high school seniors\n17\nHealthy People 2000\nreporting illicit drug use reached a record low of about 20 percent in 1989, indicating a\n50 percent drop in drug use over the last decade. Marijuana use, which peaked in 1978 at\n37 percent, was down to 17 percent at the close of the 1980s. Only 3 percent of the class\nof 1989 reported using cocaine at least once in the last 30 days, a significant decline from\nthe 1985 peak of 6.7 percent. Use of crack cocaine declined slightly, from 1.6 percent of\nhigh school seniors in 1988 to 1.4 percent in 1989. A more dramatic drop occurred the\nprevious year, however, when the percentage of seniors who reported having ever used\ncrack declined by 20 percent. 49\nExperimentation with illicit drugs often starts early. For example, in a 1987 survey of 8th\nand 10th graders, 6 and 10 percent, respectively, reported using marijuana in the preced-\ning month. Slightly smaller percentages reported trying cocaine, and about a third of\nthese had tried crack. Students' attitudes toward drugs, as toward alcohol, underwent a\nchange during the 1980s. 5\nSexual Behavior\nAn estimated 78 percent of adolescent girls and 86 percent of adolescent boys have\nengaged in sexual intercourse by age 20. 53,69 The risks of early sexual activity include\nnot only unwanted pregnancy, but also infection by sexually transmitted diseases. Of the\napproximately 1.1 million girls aged 15 through 19 who become pregnant each year, an\nestimated 84 percent did not intend pregnancies. Many of these young women face\nserious health and psychosocial risks. Teenage mothers are more likely than others not to\nfinish school, to be unemployed, to have low-birth-weight babies, and to lack parental\nskills.\n23,29\nClearly for young adolescents the most effective means of preventing possible physical\nand psychosocial problems related to sexual intercourse is to delay sexual activity. But,\nteenage sexual activity is a complex issue, embedded in family, social, and economic fac-\ntors. Interventions to prevent associated negative health outcomes must address those fac-\ntors if they are to succeed. For example, it has become clear to many that such interven-\ntions cannot be successful without the full support and involvement of parents and others\nwho serve in advisory and role-model capacities with teenagers.\nLifelong Health Habits\nIt is important for adolescents and young adults to lay the foundation for chronic disease\nprevention by the promotion and maintenance of healthy lifestyles. The adoption of low-\nfat and low-salt dietary patterns are important for many people in the prevention of\ncoronary heart disease and high blood pressure, and certain cancers. Further, the adop-\ntion of dietary and physical activity habits that will reduce the onset of obesity will help\nreduce the likelihood of coronary heart disease, diabetes, and high blood pressure. The\ncase of physical activity is important because as students leave the school setting they\nlose the physical and social supports and incur time constraints that can result in decreased\nlevels of physical activity. It is especially important for adolescents and young adults to\nrecognize the importance of regular light to moderate physical activity in the prevention\nof weight gain associated with leaving the high school setting.\nAlthough the 1980s brought some improvements in the health status of adolescents and\nyoung adults, many other young people still must confront a constellation of problems,\nincluding alcohol and other drug abuse, school failure, delinquency, peer group violence,\nand unwanted pregnancy. While education about risks to health is important, programs\nfor adolescents and young adults must go beyond education to include in-depth counsel-\ning and support. Especially for youth in high-risk environments, comprehensive pro-\ngrams are needed to provide positive alternatives to alcohol and other drug abuse,\nteenage pregnancy, and lifestyles conducive to violence.\n18\n2. The Nation's Health: Age Groups\nAdults\nPerhaps more than any other age group, adults have the opportunity to assume personal\nresponsibility for their health. Many of the leading causes of death for people between\nthe ages of 25 and 65 are preventable, wholly or in part, through changes in lifestyle. Not\nonly can adults change established lifestyles, social norms related to health can be\nchanged as well.\nBehavioral changes have saved many adult lives in the past two decades. For example,\nthe declines, by more than 40 percent and 50 percent, respectively, in coronary heart dis-\nease and stroke death rates since 1970, are associated with reduced rates of cigarette\nsmoking, lower mean blood cholesterol, and increased control of high blood pressure. In\nthe same period, deaths from motor vehicle crashes declined by almost 30 percent. Lower\nrates of alcohol use, increased seatbelt use, and changes in speed limits contributed to this\nreduction. Accompanying these trends were reduced public acceptance of certain risks,\nsuch as smoking and drinking and driving.\nAs deaths from heart disease have declined, cancer has became the leading cause of death\nfor people aged 25 through 64 (Fig. 2.4). These and the other top causes of death between\nthe ages of 25 and 65-unintentional injuries, stroke, and chronic liver disease and cir-\nrhosis-have all been associated with risk factors related to lifestyle.\nCancer\nHeart disease\nFig. 2.4\nInjuries\nLeading causes of\nStroke\ndeath of adults aged\nSuicide\n25 through 64 (1987)\nLiver disease\nChronic lung disease\nHomicide\nHIV infection\nDiabetes\n0\n50\n100\n150\n200\nSource: National Center\nDeaths per 100,000 adults\nfor Health Statistics (CDC)\nCancer\nCancer, which is actually not one but many diseases, is associated with a variety of risk\nfactors. Although cancer mortality rates overall have changed little since 1950, there\nhave been significant changes in mortality for some age groups and cancers. Several\nprevalent forms of cancer can be either prevented or diagnosed early enough to prevent\nspread to other organs. It is estimated that 30 percent of cancer deaths are linked to smok-\ning and that another large proportion, perhaps 35 percent, may be associated with diet. 19\nLung cancer is the most common-and most preventable-cancer in the United\nStates for both men and women, and is increasing as large numbers of smokers\ngrow older. Smoking is responsible for more than 85 percent of all lung cancer\ndeaths. Since 1975, lung cancer incidence has risen more than 15 percent for black\nmen, about 12 percent for black women, 12 percent for white men, and 8 percent\nfor white women.⁵⁷\nColorectal cancer is the second leading cause of death due to cancer. Some\nstudies have suggested that high fat and/or low fiber diets increase the risk of\n19\nHealthy People 2000\ncolorectal cancer. Since 1969, death rates from these cancers have fallen among\nwhite men and women, remained about the same for black women, and increased\nmarkedly for black men. 36 Although there is no general agreement that screening\nfor colon cancer definitely reduces mortality among those not at high risk, consen-\nsus recommendations have suggested screening by digital rectal exams, fecal occult\nblood testing, and sigmoidoscopy for those over age 50.\nBreast cancer has become the second most common cause of cancer deaths among\nwomen, having been surpassed by lung cancer in the past decade. However, the in-\ncidence of breast cancer is more than twice that of lung cancer in women. 3 Early\ndiagnosis of breast cancer improves the chance of survival significantly, with 90\npercent of those diagnosed when the cancer was localized reaching the 5-year sur-\nvival mark. 67 Breast cancer death rates could be reduced 30 percent with regular\nscreening. Some evidence suggests that high-fat diets may increase the risk of\nbreast cancer.\nCervical cancer can be cured if detected early. Increased use of the Pap test has\ncontributed to a 50-percent drop in cervical cancer deaths among both black and\nwhite women since 1969. However, black women continue to have 3 times the\ncervical cancer death rate of white women. Although the death rates have been\ndecreasing, the in situ rates have risen in younger women aged 15 through 19.³\nOropharyngeal cancer-cancer of the mouth and throat-accounts for 13.2 per\n100,000 in 1987. Increased risk has been linked both to use of tobacco products\nand to heavy alcohol use. 70\nHeart Disease and Stroke\nDespite a recent decline, coronary heart disease still kills more than 500,000 Americans\nannually. Another 1,250,000 people suffer nonfatal heart attacks each year. About 20\npercent of those who die from heart attacks are between the ages of 25 and 65, and most\nare between 55 and 64.³⁸ Quitting smoking, reducing dietary fat (especially saturated\nfat), and controlling high blood pressure can reduce the risk of heart disease.\nApproximately 13 percent of the nearly 150,000 Americans who died of stroke in 1986\nwere between the ages of 25 and 64, and the majority of these were aged 55 through 64.\nBlack men have the highest rate of stroke among all population groups, with a death rate\nfrom stroke about twice that of white men and a substantially higher rate than for black\nwomen. A much smaller gap exists between the stroke death rates of white men and\nwhite women.³⁸\nHigh blood pressure is a well-defined risk factor for both heart disease and stroke among\nadults. Approximately half of all heart attack victims and two-thirds of all stroke victims\nhave high blood pressure. 46 About 30 percent of adults have high blood pressure (over\n140/90 mm Hg or taking high blood pressure medication), but most do not have it under\ncontrol.⁴³ It is estimated that, during 1982-84, only about 24 percent of hypertensive\nadults between 20 and 75 had achieved blood pressure control for 2 or more years. 46\nWeight control, physical activity, lower intake of alcohol and sodium, and if necessary,\nmedication are means of controlling blood pressure.⁴⁵\nHealth Habits\nSeveral major health risk factors, sometimes alone and sometimes in combination, are\nassociated with the 5 major causes of death in the United States: cancer, heart disease,\nstroke, injury, and chronic lung disease. Reducing these risks has already significantly\nreduced the number of years of life lost before age 65, and greater reductions are possible.\n20\n2. The Nation's Health: Age Groups\nCertain eating patterns-especially excessive consumption of fats-are linked to a higher\nrisk of heart disease, breast and colon cancer, and gallbladder disease. 63 Total dietary fat,\nincluding saturated and unsaturated fats, now accounts for more than 36 percent of the\ntotal calories consumed in the United States. A fat intake of no more than 30 percent of\ncalories is recommended by most groups, including the American Heart Association, the\nAmerican Cancer Society, and the United States Departments of Agriculture and Health\nand Human Services. 63 These groups recommend that the major reduction in dietary fat\ncome from saturated fats, which are common in foods from animal sources, such as\nmeats and dairy products.\nOverweight is a problem for about one-quarter of American adults, affecting about 27\npercent of women and 24 percent of men.⁴¹ This problem is associated with high blood\npressure, elevated blood cholesterol, diabetes, heart disease, stroke, some cancers, and\ngall bladder disease. It also may be a factor in osteoarthritis of the weight-bearing joints.\nSocioeconomic status has been linked to overweight. One national survey found that 37\npercent of women below the poverty level were overweight, compared with 25 percent of\nthose above the poverty level. Overweight is especially prevalent among members of\nsome minority groups. 41\nTo reduce this risk factor, both exercise and diet are important. As of 1985, however,\nonly about 25 percent of overweight men and 30 percent of overweight women, among\npeople 18 and over, were combining regular physical activity with sound dietary prac-\ntices to lose weight. 66 Fewer than half of adult Americans exercise regularly (3 or more\ndays a week, sustained for at least 20 minutes each time regardless of intensity)⁷ a matter\nof concern because a sedentary lifestyle appears to be an independent risk factor for\ncoronary heart disease. Older adults are less likely to be physically active than younger\nadults. Research increasingly suggests that even moderate physical activity can decrease\nthe risk of coronary heart disease, especially among the sedentary. Regular physical ac-\ntivity can also help to prevent and manage hypertension, diabetes, osteoporosis, and\nobesity. 10 Further, it may play a role in mental health, having a favorable effect on\nmood, depression, anxiety, and self-esteem.\nCigarette smoking is an important risk factor for heart disease, stroke, and some forms of\ncancer. In 1965, 40 percent of all Americans smoked cigarettes. Today, that figure is\nbelow 30 percent. This dramatic decline is credited with saving nearly 800,000 lives be-\ntween 1964 and 1985, with an average gain in life expectancy of 21 years for each death\navoided or postponed. Despite these gains, smoking is still responsible for one of every\nsix deaths in the United States. Moreover, it is still placing certain groups at greater risk\nof disease than others, and it is still the single most important preventable cause of death\nin our society. 57\nMore than 50 million Americans still smoke. In 1987, 29 percent of adults aged 20 years\nand older smoked cigarettes. Almost as many have quit. By 1987, nearly half of those\nwho ever smoked cigarettes (45 percent) had stopped. Since 1974, the rate of change for\nquitting has been similar for blacks and whites and for men and women. 60 Though more\nmen smoke than women, the gender gap is decreasing. Prevalence of cigarette smoking\nhas declined sharply among men since 1965 (from 50 to 32 percent) but only slightly\namong women (32 to 27 percent). In general, smoking rates are higher among blacks,\nHispanics, blue-collar workers, and people with fewer years of education. 22\nAlcohol is a major factor in thousands of preventable deaths, including motor vehicle\nfatalities, homicides and suicides, cirrhosis of the liver, and some cancers, such as\nesophageal and liver cancer. Alcohol is also the leading preventable cause of birth\ndefects.\n21\nHealthy People 2000\nThere is evidence that the use of alcohol is beginning to decline. Based on alcoholic\nbeverage sales and tax data, the consumption of hard liquor declined 21 percent between\n1978 and 1986. Wine sales increased and beer sales remained about the same. While the\noverall trend in the consumption of alcoholic beverages is down, it is estimated that about\n9 percent of people aged 21 and older consume more than two drinks daily. 50\nIncreasing public concern about alcohol and other drugs, evident in many opinion polls,\nhas helped galvanize organized action on the part of parent groups, government agencies,\ncommunity groups, schools, and businesses. 6 Drinking and driving has been the focus of\nmuch of the attention: the Surgeon General has called for stricter regulation of advertis-\ning for alcoholic beverages; citizen groups have lobbied for and legislators have passed\nlaws raising the drinking age and establishing stiff penalties for driving while intoxicated;\nthe news media have devoted much coverage to the problem, and even the entertainment\nmedia have incorporated messages about drinking and driving into television programs. 56\nThis widespread public concern and the programs that accompany it have had an impact.\nThe proportion of motor vehicle deaths related to alcohol dropped by 10 to 15 percent be-\ntween 1982 and 1986. 38 More recently, however, the decline has slowed, indicating the\nneed for continued efforts.\nHospital emergency room visits related to use of illicit drugs, one indication of the health\nimpact of drug abuse, rose sharply in the 1980s, and this high rate is expected to continue\nfor some years. Cocaine is responsible for many of these visits. In 1987, cocaine-related\nemergency room visits constituted 32 percent of all visits related to drugs. 20 Other data\nindicate that young men between the ages of 25 and 44 are at a higher risk than the total\npopulation of being killed or injured by illicit drugs. In addition, drugs are implicated in\nabout 10 percent of all homicides, many of which occur in this age group.\nSeatbelt use is an important health habit, saving an estimated 4,000 lives in 1987, a year\nin which only about 42 percent of motor vehicle passengers used their seatbelts. Most of\nthe crashes in which lives were saved by seatbelts occurred in States with mandatory seat-\nbelt laws. 39 Passage of such laws in other States should increase usage and save many\nmore lives. In addition, beginning with 1990 models, automobile manufacturers are\nequipping all passenger vehicles with automatic crash protection-automatic belts or air-\nbags-in response to a new Federal requirement. Automatic belts are expected to in-\ncrease overall usage to about 85 percent.\nHealth Services\nPreventing chronic disease depends often on individual decisions-to quit smoking, to\ndrink in moderation if at all, to consume less saturated fat, to increase physical activity.\nWhat then is the role of health services?\nOne answer is patient education and counseling. Clinical studies have demonstrated that\ncounseling by health professionals is effective in helping people change dietary and\nsmoking behaviors. The U.S. Preventive Services Task Force, in surveying the effective-\nness of 169 clinical interventions to prevent disease, concluded that counseling may be\neven more valuable overall than conventional clinical activities to prevent disease, such\nas many screening tests. 74\nScreening can be extremely important, when tailored appropriately to an individual's age\nand risk. Early diagnosis of disease can have a significant impact on mortality rates, as\nshown by the results of screening for high blood pressure and high blood cholesterol.\nThe means are also available to detect various cancers when they are still curable, such as\nthe Pap test for cervical cancer, mammography and physical examination for breast can-\ncer, fecal occult blood testing and sigmoidoscopy for colorectal cancer, and skin examina-\ntion for skin cancer. In 1987, just 75 percent of women aged 18 and over had received a\n22\n2. The Nation's Health: Age Groups\nPap test in the preceding one to three years, and this was by far the highest proportion of\nadults screened for any type of cancer.³⁷\nOnly about 25 percent of women aged 50 and older surveyed in 1987, had received a\nmammogram and clinical breast exam in the preceding two years. The percentage of\nadults aged 50 and older who received a digital rectal exam and fecal occult blood testing\nin the preceding two years was estimated at 27 percent. 37\nIncreasing awareness about preventive services by both health professionals and the\npublic is essential to increasing their use. More and better insurance coverage for screen-\ning and counseling would also encourage wider use of these services. Expansion of\nmanaged care systems such as health maintenance organizations (HMOs) and preferred\nprovider organizations (PPOs) can also provide basic preventive services to more people.\nThe challenge facing adults as individuals is to modify their lifestyles to maintain health\nand prevent disease. But even in adulthood, individual decisions are subject to many for-\nces. Lifestyles once established are difficult to change, addictions even more difficult.\nResolution of many of these difficulties is compounded by factors beyond the control of\nindividuals. Socioeconomic status, the environment, community norms, media images\nand coverage, advertising, worksite standards, access to health care and counseling are\npowerful influences on adult behavior. So the other challenge facing adults, as members\nof society, is to work together to create an environment that facilitates and supports\nhealthful behavior.\nMany sectors of society have made a beginning. Some employers support smoking cessa-\ntion, stress management, nutrition and exercise, screening for high blood pressure and\nhigh blood cholesterol, and other health-related programs. Hospitals provide patient\neducation services and community health promotion programs. Community groups and\nchurches sponsor classes and support groups. State agencies have initiated community-\nbased prevention programs in many areas. In particular, minority communities, rural\ncommunities, and people with low incomes need relevant information and programs that\naddress their particular risks and their need for preventive services.\nOlder Adults\nIn 1900, people over 65 constituted 4 percent of the population. By 1988, that proportion\nwas up to 12.4 percent, by 2000 it will be 13 percent and by 2030, 22 percent. The most\nrapid population increase over the next decade will be among those over 85 years of\n28\nage.\nPeople who reach the age of 65 can now expect to live into their eighties. 38 However, it\nis likely that not all those years will be active and independent ones. Thus, improving the\nfunctional independence, not just the length, of later life is an important element in promoting\nthe health of this age group.\nOne measure of health that considers quality as well as length of life is the years of heal-\nthy life. While people aged 65 and older have 16.4 years of life remaining on average,\nthey have about 12 years of healthy life remaining 21,38 (Fig. 2.5). Another indicator of\nquality of life is an individual's ability to perform activities required for daily living, such\nas bathing, dressing, and eating. Difficulty in performing these necessary tasks leads to\nthe need for assistance and often limits opportunity for remaining independent in the com-\nmunity. People aged 85 and older constitute a substantial share of all people who are not\nindependent in physical functioning.\n23\nHealthy People 2000\nYears\n20\n18.7\n18\n1960\n1987\nFig. 2.5\n15.8\n16\n14.8\nLife expectancy at\n14\n12.8\nage 65 by gender\n12\n10\n8\n6\n4\n2\nSource: Health, United\n0\nMen\nWomen\nStates, 1989 and Preven-\ntion Profile\nWhile many people think of health problems in old age as inevitable, a substantial num-\nber are either preventable or can be controlled. The major causes of death among people\naged 65 and older are heart disease, cancer, stroke, chronic obstructive pulmonary dis-\nease, pneumonia, and influenza. Chronic problems, such as arthritis, osteoporosis, incon-\ntinence, visual and hearing impairments, and dementia, are of equal concern because of\ntheir significant impact on day-to-day living. To accommodate the changing needs of an\nincreasingly older society, we must prevent the ill from being disabled and help people\nwith disabilities preserve function and prevent further disability.²⁶\nA growing body of evidence shows that changing certain health behaviors, even in old\nage, can benefit health and quality of life. Cigarette smoking is one of these habits.\nStudies have shown that when older smokers quit, they increase their life expectancy,\nreduce their risk of heart disease, and improve respiratory function and circulation. 57\nGood nutrition is also important in the promotion and maintenance of health for older\nadults. Diet can play an important role in mitigating existing health problems with older\npeople. Reducing sodium intake and losing weight, for example, can help keep blood\npressure under control, and there is growing evidence that nutrition counseling and food\nprograms can reduce the risk of disease among older adults. 28\nPhysical Activity\nA key ingredient to healthy aging is physical activity. Often physiological decline associ-\nated with aging may actually be the result of inactivity. Over 40 percent of people over\nage 65 report no leisure time physical activity.⁷ Less than a third participate in regular\nmoderate physical activity, such as walking and gardening, on a regular basis, and less\nthan 10 percent engage routinely in vigorous physical activity. Yet regular physical ac-\ntivity and exercise are critical elements of health promotion for older adults. Increased\nlevels of physical activity are associated with a reduced incidence of coronary heart dis-\nease, hypertension, noninsulin-dependent diabetes mellitus, colon cancer, and depression\nand anxiety which are diseases prominent in older adult populations. 10\nMoreover, increased physical activity increases bone mineral content, reduces the risk for\nosteoporotic fractures, helps maintain appropriate body weight, and increases longevity.\nIt may also be that increased physical activity levels can improve balance, coordination,\nand strength, factors that may reduce the likelihood of falls in the older adult. Recent\nstudies of exercise training among this age group have shown that older persons can\nadapt to increased levels of exercise with positive health benefits resulting from both\nhigh and low intensity exercise. In addition to these health benefits, a more important\n24\n2. The Nation's Health: Age Groups\nresult of regular physical activity appears to be the maintenance of functional inde-\npendence throughout the later years of life.\nHealth Services\nPeople over age 65 need regular primary health care services to help them maintain their\nhealth and prevent disabling and life-threatening diseases and conditions. Clinical pre-\nventive services include the control of high blood pressure, screening for cancers, im-\nmunization against pneumonia and influenza, counseling to promote healthy behaviors,\nand therapies to help manage chronic conditions such as arthritis, osteoporosis, and incon-\ntinence. For example, skin cancer screening can detect the majority of malignant\nmelanomas and basal cell carcinomas.\nEspecially important among these clinical services are those to detect breast cancer:\nscreening mammography and clinical breast examination. These screening interventions\nare estimated to reduce mortality from breast cancer in women over age 50 by about 30\npercent. 67 In addition, Pap tests to detect cervical cancer are important for older as well\nas for younger women.\nBecause pneumococcal disease is 3 times more prevalent among those over 65 than\namong younger people and takes many older lives, immunization of older adults is an im-\nportant preventive service. Pneumonia was responsible for an average 48 days of\nrestricted activity per 100 people aged 65 and older in 1987 42 Likewise, immunization\nagainst influenza is recognized now as a basic preventive intervention for older adults.\nDuring 6 flu epidemics from 1972 to 1982, the death rate was 34 to 104 times higher in\nthis age group than in younger people. Only about 10 percent of older adults living in the\ncommunity receive pneumococcal vaccine and 20 percent receive influenza vaccines. 13\nThe number of medicines prescribed to persons over the age of 65 increases the risk of ad-\nverse drug reactions, drug interactions, and other health problems associated with the use\nand misuse of medications. The risk of adverse reactions may be exacerbated by the\nphysiological changes associated with aging. For example, decreased kidney and liver\nfunction can change the way the body processes medications. In some cases, the adverse\neffects of medication can be prevented by using a different drug or lower dose.\nPhysicians, nurses, pharmacists and other health professionals can help reduce this risk\nthrough careful reviews of medication use and patient counseling.\nPrimary health care providers are necessary partners in the maintenance of good health\nand functional independence for older adults. In addition to ensuring appropriate screen-\ning, counseling, and immunization, they can monitor health status to detect early signs of\nother health problems that can threaten independence such as dementia or depression, as\nwell as ensure an accurate distinction between the two in diagnosis. Alzheimer's disease\nis the best known and leading cause of cognitive impairment in older adults, but there are\nother, more treatable forms of dementia, characterized by deterioration of memory, orien-\ntation, general intellect, specific cognitive capacities, and social functioning. The preva-\nlence of dementia ranges from about 5 to 10 percent of people over age 65, to 20 to 40\npercent of those who have reached age 80. While most cases are not treatable, 10 to 20\npercent of them-those caused by drug toxicity, metabolic disorders, depression, or hy-\nperthyroidism-may be reversible. 16,34\nProviders can play an important role in identifying patients at risk for conditions for\nwhich interventions may be appropriate, e.g., counseling women at high risk for osteo-\nporosis about the benefits and risks of estrogen replacement therapy. Urinary incon-\ntinence is another condition that can have serious consequences for functional inde-\npendence. It affects many noninstitutionalized older adults and about half of all nursing\nhome residents. 52 The risk of incontinence increases with age but it often is a sign of\n25\nHealthy People 2000\nother problems. Various treatments are available, including pelvic muscle exercises and\nother behavioral treatments, drug therapy, and surgery. A major impediment is that only\nabout half the people with incontinence report it to their physicians. Increased awareness\nof available treatments could reduce this often incapacitating problem.\nSocial Networks\nSocial isolation is both a risk factor for disease and a measure of reduced functional inde-\npendence. Social support networks are of critical importance in promoting the health and\nindependence of older adults. 28 Life changes common to the seventh and eighth decades\ncan increase the risk of social isolation. Retirement and changes in social roles can affect\nsystems of contact and support, as can the loss of spouses and close friends.\nDepression, a frequent outcome of such changes, is of particular concern among older\nadults because of its impact on functional independence and its importance as a risk fac-\ntor for suicide. Men aged 65 through 74 have the highest suicide rate in the United\nStates.\n12\nDepression is treatable but often goes unsuspected by families and undiagnosed\nby physicians, perhaps because it is often only one of several health problems besetting\nan older adult. However, primary care providers who recognize the clinical signs and\nrisk factors for depression-bereavement, loneliness, and low self-esteem-can help\nreduce suicide among older adults. Illness and disrupted marital status have also been\nlinked to suicide in this age group.\nCommunity support networks that provide services to help older adults maintain inde-\npendence are also critical interventions for reducing social isolation. Primary care\nproviders can also play a critical role, not only in the identification of individuals at risk,\nbut also by supplying information and referral to available services.\nReferences\n1\n9\nAgency for Toxic Substances and Disease Registry.\nBureau of the Census. Educational Attainment in the\nThe Nature and Extent of Lead Poisoning in\nUnited States: March 1987 and 1986. Current\nChildren in the United States: A Report to\nPopulation Report, Series P-20, No. 428.\nCongress. Washington, DC: U.S. Department of\nWashington, DC: U.S. Department of Commerce,\nHealth and Human Services, 1988.\n1988.\n2\n10\nThe Alan Guttmacher Institute. Teenage\nCaspersen, C.J. Physical activity epidemiology:\nPregnancy: The Problem that Hasn't Gone\nConcepts, methods, and applications to exercise\nAway. New York: the Institute, 1981.\nscience. Exercise and Sport Sciences Reviews\n3\n17:423-473, 1989.\nAmerican Cancer Society. Cancer Facts and\n11\nFigures - 1989. New York: the Society, 1990.\nCenters for Disease Control. 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Journal of Health and Social Behavior\n29:92-112, 1988.\n14 Chasnoff, I.J. Drug use in women: Establishing a\n7\nstandard of care. Annals of New York Academy of\nBehavioral Risk Factor Surveillance System, Centers\nSciences 562:208, 1989.\nfor Disease Control, Public Health Service, U.S.\n15\nDepartment of Health and Human Services,\nChasnoff, I.J.; Landress, H.J.; and Barrett, M.E.\nAtlanta, GA.\nThe prevalence of illicit drug and alcohol use\n8\nduring pregnancy and discrepancies in mandatory\nBoyd, J.H and Moscicki, E.K. Firearms and youth\nreporting in Pinellas County, Florida. New\nsuicide. American Journal of Public Health\nEngland Journal of Medicine 322:1202-6, 1990.\n76:1240-1242, 1986.\n26\n2. The Nation's Health: Age Groups\n16\nClarfield, A.M. The reversible dementias: Do they\n33\nKleinman, J.C. and Madans, J.H. The effects of\nreverse? 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A decade of detectors: Measuring the\n41\nNational Health and Nutrition Examination Survey\neffect. Fire Journal 79:37-43, 1985.\n(NHANES), National Center for Health Statistics,\n25\nHollinshead, W.H. et al. Statewide prevalence of\nCenters for Disease Control, Public Health\nillicit drug use by pregnant women - Rhode\nService, U.S. Department of Health and Human\nIsland. Morbidity and Mortality Weekly Report\nServices, Hyattsville, MD.\n39(14):225-7, 1990.\n42\nNational Health Interview Survey, National Center\n26 Institute of Medicine. Disability in America: A\nfor Health Statistics, Centers for Disease Control,\nNational Agenda for Prevention. edited by Pope,\nPublic Health Service, U.S. Department of Health\nA. and Tarloff, A. Washington DC: National\nand Human Services, Hyattsville, MD.\nAcademy Press, in press.\n43 National Heart, Lung, and Blood Institute.\n27\nInstitute of Medicine. Preventing Low Birthweight.\nHypertension prevalence and the status of\nWashington, DC: National Academy Press, 1985.\nawareness, treatment, and control in the U.S.:\nFinal report of the subcommittee on definition\n28 Institute of Medicine. The Second Fifty Years:\nand prevalence of the 1984 joint national\nPromoting Health and Preventing Disability.\ncommittee. Hypertension 7(3): 457-468, 1985.\nWashington DC: National Academy Press, in\n44 National Heart, Lung, and Blood Institute. Report\npress.\nof the Expert Panel on Detection, Evaluation, and\n29 Jones, E.F. and Forrest, J.D. Contraceptive failure\nTreatment of High Blood Cholesterol in Adults.\nin the United States: Revised estimates from the\nNational Cholesterol Education Program.\n1982 National Survey of Family Growth. Family\nWashington, DC: U.S. Department of Health and\nPlanning Perspectives 21(3):103-9, 1989.\nHuman Services, 1988.\n30 Keith, L.G.; McGregor, S.N.; and Sciarra, J.J. Drug\n45\nNational Heart, Lung, and Blood Institute. The\nabuse in pregnancy. In: Chasnoff, I.J. ed. Drugs,\n1988 Report of the Joint National Committee on\nAlcohol, Pregnancy and Parenting. Hingham,\nDetection, Evaluation, and Treatment of High\nMA: Kluwer Academic Publishers, 1988.\nBlood Pressure. Washington, DC: U.S.\n31\nKleinman, J.C. and Kessel, S.S. Racial differences\nDepartment of Health and Human Services, 1988.\nin low birthweight: trends and risk factors, New\n46 National Heart, Lung, and Blood Institute, National\nEngland Journal of Medicine 317:749-753, 1987.\nInstitutes of Health, Public Health Service, U.S.\n32\nKleinman, J.C. and Kopstein, A. Smoking during\nDepartment of Health and Human Services,\npregnancy, 1967-1980. American Journal of\nBethesda, MD.\nPublic Health 77:823-25, 1987.\n27\nHealthy People 2000\n47\n62\nNational Highway Traffic Safety Administration.\nPresident's Committee on Mental Retardation.\nFatal Accident Reporting System, 1987.\nPreventing the New Morbidity: A Guide for State\nWashington, DC: U.S. Department of\nPlanning for the Prevention of Mental\nTransportation, 1988.\nRetardation and Related Disabilities Associated\n48 National Highway Traffic Safety Administration's\nwith Socioeconomic Conditions. Washington,\nDC: U.S. Deaprtment of Health and Human\n19 Cities Survey, U.S Department of\nServices, 1988.\nTransportation, Washington, DC.\n63\n49\nPublic Health Service. The Surgeon General's\nNational Institute on Drug Abuse, Monitoring the\nReport on Nutrition and Health. Washington, DC:\nFuture Study (High School Senior Survey);\nU.S. Department of Health and Human Services,\nAlcohol, Drug Abuse, and Mental Health\n1988.\nAdministration, Public Health Service, U.S.\n64\nDepartment of Health and Human Services,\nReport to Congress and the White House on the\nRockville, MD.\nNature and Effectiveness of Federal, State, and\n50 National Institute on Drug Abuse. National\nLocal Drug Prevention/Education Programs.\nWashington, DC: U.S. Department of Education,\nHousehold Survey on Drug Abuse: Population\n1987.\nEstimates, 1988. DHHS Pub. No.\n65\n(ADM)89-1636. Washington, DC: U.S.\nRouse, B.A. Epidemiology of smokeless tobacco\nDepartment of Health and Human Services, 1989.\nuse: national study. NCI Monograph 8:29-33,\n51 National Institute on Drug Abuse. National Survey\n1989.\n66\nResults from High School, College, and Young\nSchoenborn, C.A. Health promotion and disease\nAdult Populations, 1975-1988. DHHS Pub. No.\nprevention: United States, 1985. Vital and Health\n(ADM)89-1638. Washington, DC: U.S.\nStatistics, Series 10, No. 163. DHHS Pub. No.\nDepartment of Health and Human Services, 1989.\n(PHS)88-1591, Hyattsville, MD: U.S. Department\n52 National Institute of Health. Consensus\nof Health and Human Services, 1988.\n67\nDevelopment Conference Statement: Urinary\nShapiro, S.; Venet, W.; Strax, L.; and Roeser, R.\nIncontinence in Adults, October 3-5, 1988.\nSelection, follow-up, and analysis in the Health\n53\nInsurance Plan Study: A randomized trial with\nNational Research Council. Risking the Future:\nbreast cancer screening. NCI Monographs\nAdolescent Sexuality, Pregnancy, and\n67:65-74, 1985.\nChildbearing. Washington, DC: National\nAcademy Press, 1987.\n68 Shapiro S.; McCormick, M.C.; Starfield, B.H.;\n54\nKrischer, J.P.; and Bross, D. Relevance of\nNational School Boards Association. Smoke-free\ncorrelates of infant deaths for significant\nSchools: A Progress Report. Alexandria, VA: the\nmorbidity at one year of age. American Journal of\nAssociation, 1989.\nObstetrics and Gynecology 136:363-373, 1980.\n55\nNational Survey of Family Growth. National\n69 Sonnenstein, F.L.; Pleck, J.H.; and Ku, L.C. Sexual\nCenter for Health Statistics, Centers for Disease\nactivity, condom use, and AIDS awareness\nControl, Public Health Service, U.S. Department\namong adolescent males. Family Planning\nof Health and Human Services, Hyattsville, MD.\nPerspectives 21(4):152-8, 1989.\n56 Office of Disease Prevention and Health\n70\nPromotion. Mass Communications and Health.\nSurveillance, Epidemiology, and End Results\n(SEER) Program, National Cancer Institute,\nWashington, DC: U.S. Department of Health and\nNational Institutes of Health, Bethesda, MD.\nHuman Services, 1990.\n71\n57 Office on Smoking and Health. Reducing the\nTaffel, S.M. Maternal weight gain and the outcome\nof pregnancy. Vital and Health Statistics, Series\nHealth Consequences of Smoking: 25 Years of\n21, No. 44, DHHS Pub. No. (PHS)86-1922.\nProgress. A Report of the Surgeon General.\nWashington, DC: U.S. Department of Health and\nDHHS Publication No. (CDC)89-8411.\nHuman Services, 1986.\nWashington, DC: U.S. Department of Health and\n72\nHuman Services, 1989.\nU.S. Department of Health and Human Services.\n58 Office of Technology Assessment. Healthy\nNational children and youth fitness study II.\nJournal of Physical Education, Recreation, and\nChildren: Investing in the Future. Washington,\nDance 58:50-96, 1987.\nDC: U.S. Congress, 1988.\n59 Pamuk, E.R. and Mosher, W.D. Health aspects of\n73 U.S. Department of Health and Human Services.\nReport of the Secretary's Task Force on Black\npregnancy and childbirth: United States, 1982.\nand Minority Health. Washington, DC: the\nIn: Vital and Health Statistics. Series 23, No. 16.\nDepartment, 1985.\nHyattsville, MD: U.S. Department of Health and\n74\nHuman Services, 1988.\nU.S. Preventive Services Task Force. Guide to\nClinical Preventive Services: An Assessment of\n60 Pierce, J.P.; Fiore, M.C.; Novotny, T.E.;\nthe Effectiveness of 169 Interventions. Baltimore,\nHatziandreu, E.J.; and Davis, R.M. Trends in\nMD: Williams and Wilkins, 1989.\ncigarette smoking in the United States:\nProjections to the year 2000 JAMA 261:61-65,\n75 Westat, Inc. Study Findings: Study of National\n1989.\nIncidence of Child Abuse and Neglect.\n61 Pirie, P.L.; Murray, D.M.; and Luepker, R.V.\nWashington, DC: U.S. Department of Health and\nHuman Services, 1988.\nSmoking prevalence in a cohort of adolescents,\nincluding absentees, drop outs, and transfers.\nAmerican Journal of Public Health 78:176-78,\n1988.\n28\n3. The Nation's Health: Special Populations\nProgress toward a healthier America will depend substantially on improvements for cer-\ntain populations that are at especially high risk. For that reason, Healthy People 2000\nsets specific targets to narrow the gap between the total population and those population\ngroups that now experience above average incidences of death, disease, and disability.\nThese population groups include people with low incomes, people who are members of\nsome racial and ethnic minority groups, and people with disabilities. Likewise, it sets\nspecific targets for controlling some of the risk factors that contribute to the disease bur-\nden of groups at highest risk. Special population groups often need targeted preventive\nefforts, and such efforts require understanding the needs and the particular disparities ex-\nperienced by these groups. General solutions cannot always be used to solve specific\nproblems.\nThis section provides profiles of the at-risk population groups addressed by Healthy\nPeople 2000: low-income groups, minority groups, and people with disabilities. At the\noutset, it is necessary to point to two caveats that limit these profiles and pose major\nhealth challenges in themselves.\nFirst, data are limited; sometimes, and for some groups, the data may be severely limited.\nWithout data, targets cannot be set, even though professional consensus exists that a\npopulation group is at considerably higher risk than the total population. A challenge of\nthe coming years is to build better data systems, at national and State levels, in order that\nthe scope of health threats facing various groups within our society can be adequately\ndefined and appropriate preventive interventions can be effectively focused.\nSecond, the special populations themselves are extremely heterogenous. Whether the\ngroup is defined as low income, black, Hispanic, Asian and Pacific Islander Americans,\nAmerican Indians and Alaska Natives, or people with disabilities, the variations within\neach group are extensive. Generalizations, which characterize population profiles by\ndefinition, are dangerous because the exceptions are many. The challenge is to refine our\nknowledge and our understanding even further, especially as basic health policies are\ntranslated into community-based prevention programs and clinical preventive services.\nWith these two caveats in mind, profiles of special populations can be used, together with\nthose in the preceding section that address age groups, to provide the human context for\nthe health strategy laid out in this report.\nPeople with Low Income\nNearly 1 of every 8 Americans lives in a family with an income below the Federal pover-\nty level. Nearly a quarter of children younger than 6 are members of such families. 11\nLow income itself (or low socioeconomic status) is a shorthand label that encompasses\nfamily groups with individuals who have poorly paid jobs or are unemployed, families\nliving in substandard housing, and families more likely to have only a single parent in\nresidence. Health disparities between poor people and those with higher incomes are al-\nmost universal for all dimensions of health. Those disparities may be summarized by the\nfinding that people with low income have death rates that are twice the rates for people\nwith incomes above the poverty level. 1\nFor virtually all of the chronic diseases that lead the Nation's list of killers, low income is\na special risk factor. For example, the risk of death from heart disease is more than 25\npercent higher for low income people than for the overall population. 16 The incidence of\ncancer increases as family income decreases, and survival rates are lower for low-income\n29\nHealthy People 2000\ncancer patients. The association of cancer and low income varies by cancer site; lung,\nesophageal, oral, stomach, cervical, and prostate cancers are more frequent among the\npoor, while breast and colorectal cancers are not. 1,30 Infectious diseases, like HIV infec-\ntion and tuberculosis, are also often found disproportionately among the poor.\nSimilar vulnerability for low income people is found with some causes of traumatic\ninjury and death. These individuals, more than those with higher incomes, are the vic-\ntims of violent crime. Poverty appears to be a major predisposing factor associated\nwith a higher risk for murder of acquaintances and family members, as well as robbery-\nmotivated killings of strangers. Injuries and deaths among children from fires, drowning,\nand suffocation are strongly related to low socioeconomic status. 11\nNo single indicator of health status makes the connection between poverty and poor\nhealth more clear than does infant mortality. Poor pregnancy outcomes including\nprematurity, low birth weight, birth defects, and infant death are linked to low income,\nlow educational level, low occupational status, and other indicators of social and\neconomic disadvantage.⁸\nPoverty reduces a person's prospects for long life by increasing the chances of infant\ndeath, chronic disease, and traumatic death; poverty is also often associated with sig-\nnificant developmental limitations. For example, iron deficiency is more than twice as\ncommon in low income children, aged 1 and 2, as it is among the total population of that\nage.¹⁴ Growth retardation affects 16 percent of low income children younger than age 6.\nIn the mid-1980s, an estimated 3 million children, virtually all of them from low income\nfamilies, had blood lead levels that exceeded 15 µg/dL, sufficient to place them at risk for\nimpaired mental and physical development. The rate of mental retardation is reported to\nbe higher among children in poverty. Poor children experience more sickness from infec-\ntion and other debilitating conditions than the total population. Children in families with\nincomes below $5,000 per year had an average of 9.1 disability days in 1980 compared to\nonly 4 days for children in families with incomes of $25,000 or more.¹⁵\nThe pattern of increased vulnerability to injury, disease, and death continues into adult-\nhood. People in families with incomes of less than $13,000 a year are twice as likely as\nthe total population to be limited in major activities because of their health (Fig. 3.1).\nActivity limitations are four times more common among people with 8 years or less of\neducation than among those with 16 years or more. Bed disability days increase as in-\ncome decreases. 17\nJust as poor health is more likely among persons of low income, so are some, but not all,\nof the major risk factors for poor health. Higher-than-average rates of obesity and high\nIncome level\nAll persons\nFig. 3.1\nPercentage of\nLess than $13,000\npeople who\n$13,000-18,999\nexperience limitation\nof major activity, by\n$19,000-24,999\nincome level (1988,\nage-adjusted)\n$25,000-44,999\n$45,000 or more\n0\n5\n10\n15\n20\nSource: National Health\nPercent\nInterview Survey (CDC)\n30\n3. The Nation's Health: Special Populations\nblood pressure, which are major risks for heart disease and stroke, have been linked\ndirectly with low income status. 23 Tobacco use, which has declined dramatically in the\npast two decades for the population as a whole, has remained virtually constant since\n1966 for those who completed less than 12 years of schooling. Smoking levels among\n21\nblue-collar workers are about 20 percent higher than among others.\nWhereas in 1986 over 15 percent of people under age 65 had no health insurance either\nby private or public forms of coverage, lack of health insurance coverage was a problem\nfor 37 percent of families with incomes below $10,000 a year. 12\nIn 1987 only 22 percent of low-income women over age 40 had ever received a clinical\nbreast examination and a mammogram, as compared to 36 percent of women in the total\npopulation. 15 Relatively low survival rates for breast cancer among low-income women\npoint to the need for earlier diagnosis and treatment. While the benefits of prenatal care\nfor low-income women are well documented, with a savings-cost ratio on the order of 3-\nto-1, low utilization rates are characteristic of groups at high risk of low birth weight and\nother maternal and infant health problems. 8 Approximately 40 percent of children from\nlow-income families have untreated dental caries, another indicator of the lack of preven-\ntive and primary health care. 20\nFor the coming decade, perhaps no challenge is more compelling than that of equity. The\ndisparities experienced by people who are born and live their lives at the lowest income\nlevels define the dimensions of that challenge. The relationships between poverty and\nhealth are complex and cannot be reduced to a simple one-to-one relationship between\ndollars available and level of health. Low income may, in fact, be a product of poor\nhealth, just as poor health may be caused by environmental exposures, material deficien-\ncies, and lack of access to health services that adequate income might correct or improve.\nWhile, from a public health perspective, the leverage available to effect improvements is\nlimited largely to the availability and the quality of health services, improvements in\neducation, job training, and other social services are necessary to erase the health effects\nof current income disparities.\nPeople in Minority Groups\nThe United States has been called a \"melting pot\" of ethnic and racial groups. In recent\ndecades, it has become clearer that the image is no longer an appropriate one. Rather\nthan amalgamating into one single group, we have come to recognize and even celebrate\nour diversity as a basis for national strength. Nevertheless, our health care programs are\ncharacterized by unacceptable disparities linked to membership in certain racial and eth-\nnic groups.\nThe predominant minority populations of the United States can be categorized as blacks,\nHispanics, Asian and Pacific Islander Americans, and American Indians and Alaska Na-\ntives. From a total population perspective, the categories simplify the difficulties of as-\nsessing health status and making plans to improve health. But they are gross simplifica-\ntions. Within each racial or ethnic category, significant subgroup differences exist.\nDemarcations among minority populations are not absolute. For example, there are both\nblack and nonblack Hispanics. Many nonblack Hispanics share historic roots and genetic\nendowments that are closely related to those of many American Indian groups, while\nothers have European roots and do not share the genetic make-up which may predispose\nto adult-onset diabetes. Alaska Natives may have more in common with some Asians\nthan they do with American Indians in the lower 48 States. In short, differences within\nthe principal population groups must always temper generalizations about their health\nneeds.\n31\nHealthy People 2000\nThe extent of disparities suffered by minority groups in America was documented in the mid-\n1980s by the Report of the Secretary's Task Force on Black and Minority Health. 30 This\nreport found that black Americans suffered nearly 60,000 excess deaths per year in the period\n1979-1980, with \"excess deaths\" defined as the difference between the number of deaths ob-\nserved in that minority population and the number of deaths that would have been expected if\nthat population had the same age- and gender-specific death rate as the white population.\nA compelling disparity of most minority populations in the United States is socio-\neconomic. The discussion on low-income people describes a small portion of the white\nAmerican population. It applies to much larger portions of those from black, Hispanic,\nAsian and Pacific Islander, and American Indian and Alaska Native communities. Pover-\nty and near-poverty appear as underlying elements of many health problems experienced\nby these groups. But if the socioeconomic effects are set aside, disparities experienced\nby these population groups will still be observed. Simply put, some differences in sur-\nvival and health are not solely explained by poverty or other environmental factors.⁴ For\nthat reason, Healthy People 2000 assesses disparities not only in terms of income level\nand educational attainment, but also in terms of the Nation's racial and ethnic population\ngroups. Special population targets for improvements to be achieved by 2000 are set for\nthose groups with higher risks than the total population, where data are available to estab-\nlish such targets.\nBlack Americans\nAfrican Americans make up 12 percent of the United States population, thereby constitut-\ning the Nation's largest minority group. Members of this group live in all regions of the\ncountry and are represented in every socioeconomic group. One-third of blacks live in\npoverty, a rate three times that of the white population. Over half live in central cities, in\nareas often typified by poverty, poor schools, crowded housing, unemployment, exposure\nto a pervasive drug culture and periodic street violence, and generally high levels of\nstress. Life expectancy for blacks has lagged behind that for the total population through-\nout this century; since the mid-1980s the gap has actually widened, with the life expectan-\ncy rising to 75 years for the overall population while falling slightly for blacks, from a\nhigh of 69.7 years in 1984 to 69.4 years in 1987. 3 The leading chronic diseases as causes\nof death for black Americans are the same as those for the majority population (Fig. 3.2).\nHowever, black men die from strokes at almost twice the rate of men in the total popula-\ntion, and their risk of nonfatal stroke is also higher. Coronary heart disease death rates do\nnot show such disparate levels, although death rates are higher for black women than for\nwhite women. On the other hand, when heart disease rates are compared within income\nlevels, black rates are lower than those for whites.\nHeart disease\nCancer\nFig. 3.2\nStroke\nLeading causes\nInjuries\nof death for blacks\nHomicide\ncompared to whites\nPneumonia/influenza\n(1987, age-adjusted\nDiabetes\nrates)\nPerinatal conditions\nBlacks\nChronic lung disease\nWhites\nHIV infection\n0\n50\n100\n150\n200\n250\n300\nSource: National Center\nRate per 100,000\nfor Health Statistics (CDC)\n32\n3. The Nation's Health: Special Populations\nBlack men also experience a higher risk of cancer than nonblack men, with a 25-percent\nhigher risk of all cancers and a 45-percent higher incidence of lung cancer. Only 38 per-\ncent of blacks with cancer survive 5 years after diagnosis, compared to 50 percent of\nwhites.\n30\nDiabetes is 33 percent more common among blacks than whites. The highest rates are\namong black women, especially those who are overweight. The complications of\ndiabetes-heart disease, stroke, kidney failure, and blindness-all are more prevalent\namong blacks with diabetes than whites with diabetes. 30\nBlack babies are twice as likely as white babies to die before their first birthday. High\nrates of low birth weight among black babies account for many of these deaths, but even\nnormal-weight black babies have a greater risk of death. Black infant mortality rates are\nhigher not only for babies in the first month of life, but also for those between 1 month\nand 1 year of age. The major killer in this period is sudden infant death syndrome\n(SIDS). Other causes of death that are more prevalent for black infants than for the total\npopulation include respiratory distress syndrome, infections, and injuries. 19\nHomicide is the most frequent cause of death for black men between the ages of 15 and\n34. The homicide rate for those between ages 25 and 34 is 7 times that of whites. A\nblack man has a 1-in-21 lifetime chance of being murdered, and black women are more\nthan four times as likely to be homicide victims as white women. 30 Most young black\nmurder victims are killed with firearms in the course of an argument. It is estimated that\nabout half of all homicides in the United States are related to alcohol use and 10 percent\nor more to the use of illegal drugs.\nThe rate of AIDS among blacks is more than triple that of whites. Among women and\nchildren, the gaps are even wider. Black women face between 10 and 15 times the risk of\nAIDS as compared to white women. Black children account for more than 50 percent of\nall children with AIDS. The proportion of AIDS cases associated with intravenous drug\nabuse is greater for blacks than for other AIDS victims, and higher rates of heterosexual\ntransmission of the HIV virus and transmission of the virus from mother to infant occur\nas a consequence.²⁶\nDisparities in the experience of health risks mirror some of the most striking disparities\nin health outcomes. High blood pressure is much more common among blacks of both\ngenders than among the total population. Severe high blood pressure is present 4 times\nmore often among black men than among white men.²⁹ Overweight is a problem for 44\npercent of black women aged 20 and older, compared to 37 percent for low income\nwomen and 27 percent for all women. Poor nutrition, smoking, alcohol and drug abuse,\nand other risk factors appear more commonly among blacks with low incomes. 30\nAdolescent pregnancy is a major concern among the black population, for its social and\neconomic consequences as much as for its health effects. There are higher risks of infant\nmortality and low birth weight, especially for very young pregnant girls. But even\ngreater risks indirectly threaten the health of both mother and baby because of the pat-\nterns of poverty and low educational attainment that often become solidified as a result of\nearly childbearing. Actual rates of childbirth among black teenagers have dropped since\nthe 1960s, but because the number of girls in this population has risen by 20 percent, the\ntotal number of births has increased. In 1987, births among girls aged 15 through 17\nwere 3 times as likely among black girls as among white girls. Birth rates among black\ngirls younger than 15 were nearly 5 times higher, than the rate for white girls. 12\nStatistics demonstrate with sharp clarity that blacks do not receive enough early, routine,\nand preventive health care. Early prenatal care can reduce low birth weight and prevent\ninfant deaths. Early detection of cancers can increase survival rates. Appropriate medi-\ncal care can reduce the frequency and severity of the complications of diabetes, which\n33\nHealthy People 2000\nblacks experience at higher rates than others. Information about actual use of health care\nservices confirm these indications. Blacks make fewer annual visits to physicians than\nwhites, and black mothers are twice as likely as white mothers to receive no health care\nor care only in the last trimester of their pregnancies.³⁾ Hospital emergency rooms and\nclinics are a much more common source of medical care for blacks than for whites, and\n20 percent of blacks compared to 13 percent of whites report no usual source of medical\ncare.³⁰ Though recent statistics are not available to assess immunization coverage by\nrace, children in central cities-many of whom are black Americans-lagged as much as\n20 percent behind immunization rates for children living in other places. In 1986, about\n23 percent of blacks had no private or public medical insurance, compared to 14 percent\nof whites.¹²\nHispanic Americans\nThe Hispanic subgroups-Mexican Americans, Puerto Ricans, Cuban Americans,\nCentral and South American immigrants, and other Spanish-surname/Spanish-speaking\ncommunities-compose the second largest minority group in the United States. At the\nbeginning of the 1990s, they constitute about 8 percent of the total population and are the\nfastest growing minority group. Over 70 percent of Hispanics were born in this country.\nWithin the Hispanic populations, Mexican Americans are nearly two-thirds of the total,\nPuerto Ricans (excluding those who live in Puerto Rico) are 12 percent, Cuban Ameri-\ncans are 5 percent, people of Central and South American origin are 11 percent, and\nothers (including Spanish-speaking immigrants from Caribbean islands) make up 9 per-\ncent. Eighty-seven percent of Hispanics live in urban areas. The largest concentrations\nof Mexican Americans are in Western States, notably California and Texas. More Puerto\nRicans reside in East Coast States, led by New York. Cuban Americans more often\nreside in Florida. 13\nHispanics experience perhaps the most varied set of health issues facing a single minority\npopulation. Whereas Mexican Americans have low rates of cerebrovascular disease,\nstroke rates among New York Puerto Ricans are high. Cuban Americans have high\nutilization rates for prenatal care, but lower rates prevail among Mexican Americans and\nPuerto Ricans. Infant mortality rates vary substantially from group to group (Fig. 3.3).\nIn short, the Hispanic health profile is marked by diversity. This diversity is intertwined\nwith the ever-present effects of socioeconomic status, and with geographic and cultural\ndifferences.\nTwo related demographic facts are especially important for the health issues and\nprospects of the Hispanic population: its youthfulness and its high birth rate. The\nPuerto Rican\nFig. 3.3\nOther and unknown\nInfant mortality rates\nHispanic\nfor selected Hispanic\ngroups (1983-84)\nMexican\nCentral and South\nAmerican\nCuban\nSource: National Linked\n0\n2\n4\n6\n8\n10\n12\n14\n16\nBirth and Infant Death\nRate per 1,000 live births\nData Set (CDC)\n34\n3. The Nation's Health: Special Populations\nmedian Hispanic age is less than 26, compared to about 33 for the total population. Ap-\nproximately 38 percent of all Hispanics are aged 19 and younger. 3 The Hispanic birth\nrate was 22.3 births per 1,000 women in 1987, while that of the total population was 15.7\nbirths per 1,000 women. 19\nThe leading causes of death among Hispanic Americans document several differences be-\ntween their health experience and that of the total population (Fig. 3.4). Heart disease\nand cancer lead the list, as is the case for other Americans, but death rates from these 2\ncauses are actually lower than for non-Hispanics. Unintentional injuries, homicide,\nchronic liver disease and cirrhosis, and AIDS rank higher on the Hispanic list; suicide,\nstroke, and chronic obstructive pulmonary disease rank lower. 13 In the case of homicide,\nthe great majority of victims are young men. In the southwest, Hispanic men aged 20\nthrough 24 have 4 times the homicide rate of their non-Hispanic, white counterparts. 28 In\nthe case of AIDS, Hispanics' rate is nearly 3 times higher than for non-Hispanic whites,\nwith rates among Puerto Rican-born Hispanics as much as 7 times higher. 27 The cumula-\ntive incidence of AIDS among Hispanic women is about 8 times higher than among non-\nHispanic women, and the rate for HIV infection over 6 times higher for Hispanic children.\nAs with black Americans, HIV transmission among Hispanic women is primarily linked\nto intravenous drug abuse by these women or their sexual partners. 27 Diabetes is especial-\nly prevalent among Mexican Americans. 13\nHispanics\nRank\nWhite non-Hispanics\nFig. 3.4\nHeart disease\n25%\n1\nHeart disease\n37%\nCancer\n17%\n2\nCancer\n23%\nLeading causes of\nInjuries\n9%\n3\nStroke\n7%\ndeath for Hispanics\nStroke\n6%\n4\nChronic lung disease\n4%\nand white non-\nHomicide\n5%\n5\nInjuries\n4%\nHispanics in 18\nLiver disease\n3%\n6\nPneumonia/\n4%\nStates and the Dis-\ninfluenza\ntrict of Columbia, as\nPneumonia/\n3%\n7\nDiabetes\n2%\na percent of total\ninfluenza\ndeaths (1987)\nDiabetes\n3%\n8\nSuicide\n2%\nHIV infection\n3%\n9\nAtherosclerosis\n1%\nSource: Monthly Vital\nStatistics Report, Supple-\nPerinatal conditions\n3%\n10\nLiver disease\n1%\nment, September 26, 1989\nNote: National death rate data unavailable for Hispanics.\nAmong the risks to health, smoking continues among 43 percent of Hispanic men, and\nHispanic teenagers of both genders smoke more than do either non-Hispanic black or\nnon-Hispanic white teenagers. Likewise, Hispanic teenagers report heavy drinking of\nalcoholic beverages more frequently than do white or black teenagers. Puerto Ricans and\nCuban Americans aged 12 through 17 report higher rates of cocaine use than do either\nwhites or blacks, and Mexican Americans have higher rates of marijuana use. Cocaine-\nrelated deaths tripled between 1982 and 1984 among Hispanics, while they were dou-\nbling among non-Hispanic whites. 13\nOverweight is common among Hispanics, especially among Mexican American women.\nThis disparity cannot be accounted for completely by socioeconomic differences. Like-\nwise, Mexican Americans participating in a San Antonio Heart Study were found to have\nphysical activity rates lower than those in the total population, even after differences in\nsocioeconomic status, residential location, and gender were taken into account. 13\nLike black Americans, Hispanic Americans receive less preventive health care, including\nprenatal care, than the total population. In 1987, 39 percent of Hispanic mothers had no\nprenatal care during the first trimester of pregnancy compared to 21 percent of non-\nHispanic whites. 12 Barriers to care include language differences between Spanish-speak-\n35\nHealthy People 2000\ning patients and English-speaking health professionals, logistical barriers posed by rural\nresidence of some Hispanic families, and costs of services.\nMigrant farmworkers, a small but important subset of Hispanic Americans, deserve spe-\ncial attention. Migrant farmworkers may also belong to white, black, Haitian, or other\nethnic groups, but the largest group is Hispanic. Their infant mortality rate is about 25\npercent greater than that of the national average; their life expectancy is 49 years rather\nthan 75 years; the rate of parasitic infection among some sets of farm workers approaches\n50 times that of the total population. 18 The health care needs of these farmworkers are\nparticularly challenging, given their migratory patterns, low incomes, poor education, and\nlack of health insurance.\nAsian and Pacific Islander Americans\nThe diversity that characterizes the more than 11 million people who are Asian and\nPacific Islanders is striking. As a whole, they are the Nation's third largest minority\ngroup, but this single label is an oversimplification. They speak over 30 different lan-\nguages and bring with them a similar number of distinct cultures. Approximately three-\nquarters of them are immigrants, mostly from Southeast Asia, and many of them are\nrefugees. A small proportion are either immigrants from South Pacific islands or Native\nHawaiians\n3\nFrom the perspective of their health prospects, those born within the United States and\nestablished here for generations are virtually undistinguishable from the population as a\nwhole. Indeed, their median income is higher than that of the overall United States\npopulation, with Japanese families having annual incomes 38-percent higher than the\nnational median income. Yet, some groups, particularly recent immigrants, are extreme-\nly poor. For example, Laotian immigrants have one of the highest poverty rates of any\ngroup in the Nation. Even within subgroups, diversity characterizes both socioeconomic\nand health profiles. While Chinese Americans generally enjoy adequate incomes and\nrelatively good health, communities such as Chinatown in San Francisco have higher\npoverty levels. Elimination of the disparities between Asian and Pacific Islander Ameri-\ncans and the general population may parallel integration of the newer immigrants into\nboth the economy and the society of the United States.\nAn adequate depiction of the health of Asian and Pacific Islander Americans is con-\nstrained because data cannot be stratified by subgroups. Many national data systems are\nunable to make estimates of this minority population because of its relatively small size.\nThis prevents accurate assessment of the leading causes of death, disease, and disability\nthat it experiences. From local studies, however, it is possible to recognize certain dis-\neases as posing higher than normal risks for specific Asian and Pacific Islander Ameri-\ncans. Most of the studies are based in California, which has the largest Asian and Pacific\nIslander American population (Fig. 3.5). Generalizations from local studies may be inac-\ncurate and misleading due to the profound differences among Asian and Pacific Islander\nAmerican groups, for example the difference in perinatal mortality among the groups\n(Fig. 3.6).\nDisparities in rates of cancer exist for several subgroups and selected cancer sites. For\nexample, the breast cancer incidence rate among Native Hawaiians is 111 per 100,000\nwomen, as compared to 86 per 100,000 among whites.² The lung cancer rate is 18 per-\ncent higher among Southeast Asian men than for the white population. And the liver can-\ncer rate is more than 12 times higher among Southeast Asians than in the white popula-\ntion.\n2,25 Higher rates of high blood pressure have been found among Filipinos aged 50\nand older living in California (61 percent for men and 65 percent for women) than among\nthe total California population (47 percent). 30\n36\n3. The Nation's Health: Special Populations\nAsians and\nPacific Islanders\nRank Whites\nHeart disease\n28%\n1\nHeart disease\n35%\nFig. 3.5\nCancer\n24%\n2\nCancer\n23%\nStroke\n9%\n3\nStroke\n8%\nLeading causes of\nInjuries\n7%\n4\nChronic lung disease\n5%\ndeath for Asians and\nPneumonia/\n4%\n5\nPnuemonia/\n4%\nPacific Islanders and\ninfluenza\ninfluenza\nwhites in California,\nChronic lung disease\n3%\n6\nInjuries\n4%\nas a percent of total\nSuicide\n2%\n7\nSuicide\n2%\ndeaths (1987)\nDiabetes\n2%\n8\nLiver disease\n2%\nSource: California State\nPerinatal conditions\n2%\n9\nDiabetes\n1%\nDepartment of Health and\nLiver disease\n1%\n10\nAtherosclerosis\n1%\nAsian American Health\nForum\nNote: California's published data on the Asian and Pacific Islander popula-\ntion includes 93 percent Asians and 7 percent Other (Native Americans, Es-\nkimos, and Alaskan Aleuts.) National death rate data are unavailable for\nAsians and Pacific Islanders.\nLaotion\nAsian unspecified\nFig. 3.6\nCambodian\nOther Pacific Isl.\nPercent of deaths\nVietnamese\nattributed to condi-\nHawaiian\ntions originating in\nAsian Indian\nthe perinatal period,\nThai\nSamoan\nfor selected Asian\nKorean\ngroups\nFilipino\nChinese\nJapanese\nSource: California State\nGuamanian\nDepartment of Health and\n0\n2\n4\n6\n8\n10\nAsian American Health\nPercent\nForum\nThe two infectious diseases that have followed immigrant Asian and Pacific Islander\npopulation subgroups to this country are tuberculosis and hepatitis B. Tuberculosis is\nstill the leading cause of death in some Asian countries and has become a serious health\nproblem in some Asian communities in large American cities. Among Southeast Asian\nimmigrants, the incidence is 40 times higher than in the total population. Rates are par-\nticularly high among those over age 45.2 Higher rates of hepatitis B are also found\namong Asian immigrants. This infection is associated with chronic liver disease, cir-\nrhosis, and liver cancer. The overall carrier rate in the United States is estimated to be\n0.3 percent of the population; among immigrants from Southeast Asia the estimated rate\nis 4 percent. Infection is spread from mother to infant and from child to child. Refugee\ntransit camps now screen pregnant women and vaccinate infants of those who are carriers\nof hepatitis B and all children under age 6.⁵ Among the risk factors of greatest concern is\nsmoking. Among California immigrant groups, smoking rates among men are 92 percent\nfor Laotians, 71 percent for Cambodians, and 65 percent for Vietnamese, compared to 30\npercent for the overall American population.²\nFaced with western medicine and a health care system that is unfamiliar, Americans of\nAsian and Pacific Island heritage experience unique access barriers to primary care. In\n37\nHealthy People 2000\naddition to linguistic and cultural differences, financial problems beset many subgroups,\nespecially recent immigrants and refugees.\nAmerican Indians and Alaska Natives\nDescendants of the original residents of North America now number approximately 1.6\nmillion and compose the smallest of the defined minority groups. Diversity characterizes\nthis group, too, encompassing numerous tribes and over 400 federally recognized nations,\neach with its own traditions and cultural heritage. Eskimos, Aleuts, and Indians residing\nin Alaska are referred to as Alaska Natives; those residing in other States are referred to\nas American Indians. The Federal Government collects detailed data on American In-\ndians and Alaska Natives in 33 States that include reservations; health care services are\nprovided through the Indian Health Service to those living in these reservation States.\nThus, it is possible to derive a composite profile of this population group. However, only\nabout one-third of this group lives on reservations or historic trust lands, while about 50\npercent live in urban centers.\nIn general, the American Indian and Alaska Native population is youthful. The median\nage of those living in the reservation States is about 23, compared to over 32 for the\nUnited States population as a whole. Income and educational levels tend to be low, with\nmore than 1 in 4 living below the poverty level and fewer than 8 percent having college\ndegrees.⁶\nOne reason for the youthfulness of the population is the large proportion of the popula-\ntion who die before age 45. Most of the excess deaths-those that would not have oc-\ncurred if American Indian death rates were comparable to those of the total population-\ncan be traced to 6 causes: unintentional injuries, cirrhosis, homicide, suicide, pneumonia,\nand complications of diabetes (Fig. 3.7). Heart disease and cancer are not among the\nsources of excess deaths, perhaps because these are generally diseases of older age. Can-\ncer rates are lower overall, but are twice as high as the total population for lung cancer\namong Oklahoma Indians. Southwest Indians have high rates of gallbladder cancer, and\nAlaska Natives suffer high rates of liver cancer.³⁰\nHeart disease\nCancer\nFig. 3.7\nInjuries\nLeading causes of\nStroke\ndeath for American\nLiver disease\nIndians in Reserva-\ntion States\nDiabetes\ncompared to whites\nPneumonia/influenza\n(1987, age-adjusted\nSuicide\nAmerican Indians\nrates)\nHomicide\nWhites\nChronic lung disease\nSource: Indian Health\nService and National\n0\n50\n100\n150\n200\nCenter for Health Statis-\nRate per 100,000\ntics (CDC)\nThe second leading cause of death among American Indian men, and the first cause for\nthose younger than age 44, is unintentional injuries, accounting for over one-fifth of all\ntheir deaths each year. 19 An estimated 75 percent of these injuries are alcohol-related,\nand 54 percent involve motor vehicle crashes. Alcohol is also a factor in a homicide rate\nthat is 60 percent higher than that of the total population. Suicide, the third of the four\nalcohol-related causes of death among American Indians, occurs at an overall rate that is\n38\n3. The Nation's Health: Special Populations\n28 percent higher than the national rate, but among some tribes the suicide rate is 10\ntimes higher than the total population rate.⁶\nCirrhosis and diabetes are the two chronic diseases that afflict American Indians more fre-\nquently than other groups. Cirrhosis deaths occur at about three times the total popula-\ntion rate, and cirrhosis is the fourth alcohol-related health effect contributing significantly\nto death and disability among American Indians. 24 Diabetes is now so prevalent that in\nmany tribes more than 20 percent of the members have this disease. 6 Among two tribes\nin Arizona, the rate is 40 percent of adults. Obesity contributes to the high incidence of\ndiabetes experienced by many American Indian communities, and it is also linked to hy-\npertension and cardiovascular disease. The increase in obesity among American Indians\nin the last 50 years has paralleled the increasing rates of diabetes.\nAlcohol and obesity are risk factors that stand out as problems for the American Indian\npopulation. One estimate is that 95 percent of American Indian families are affected\neither directly or indirectly by a family member's alcohol abuse. 24 While American In-\ndians living on reservations and tribal members with access to reservation health facilities\nare served by the Indian Health Service, access to health care is still a problem for many.\nMany live in rural areas where the availability of physicians is about half that of the na-\ntional average and where the Indian Health Service may not provide health care services.\nHealth problems may appear especially intractable, but gains achieved among a number\nof tribes in reducing infant mortality rates to levels below those of the population as a\nwhole provide testimony to the possibility of major improvement in the coming decade.\nPeople With Disabilities\nThroughout this document, the preventive actions implicit in targets to be achieved by\n2000 seek not only to reduce unnecessary deaths and the immediate suffering and costs\nof infectious and chronic diseases; they also seek to prevent the longer-term consequen-\nces of functional impairments that can severely affect the quality of one's life. As a\nprevention plan for the 1990s, Healthy People 2000 addresses not only the prevention of\npremature death and disease, but also the prevention of disabilities. Even when data are\nunavailable to define health outcomes except in terms of death, the thrust of objectives\nfor the year 2000 is aimed at the living consequences of unhealthy behaviors, unsafe en-\nvironments, and illness-causing infections. Disabilities may be defined, as distinct from\nillness or disease, in terms of limited ability to function. Disabilities may be physical or\nmental; and they may include motor or sensory limitations. The focus is on effects,\nrather than causes, since a similar functional limitation, such as a limitation in ability to\nwalk, may be caused by a congenital birth defect, an injury, or a leg amputation resulting\nfrom complications of diabetes.\nWhen the focus is on prevention of disabilities, another group of Americans who face spe-\ncial health risks becomes evident: those who already experience serious and chronic dis-\nability. The health promotion and disease prevention needs of people with disabilities are\nnot nullified because they were born with an impairing condition or have experienced a\ndisease or injury that has long-term consequences. In fact, those needs for health promo-\ntion are accentuated. People with disabilities are at higher risk of future problems that\ncan only increase the limitations that they experience. For that reason, Healthy People\n2000 addresses people with disabilities as a special population, and where data are avail-\nable, sets specific targets to address their needs and enhance their health.\nSecondary conditions-health problems that arise from, or are related to, the main cause\nof disability-are common among people with disabilities and are the principal targets of\nhealth promotion and disease prevention efforts for this special population. Some, such\nas decubitus ulcers (pressure sores) and genitourinary disorders, are associated with\n39\nHealthy People 2000\nliving conditions linked to the disability, i.e., confinement to a wheel chair or bed. Immo-\nbility or inactivity also increases the risk of metabolic, circulatory, respiratory, and mus-\nculoskeletal problems. Other secondary health problems can be seen as a progression of\nthe original disabling condition. Diabetes, for example, can lead to serious foot problems\nand vision impairment.\nMany secondary health problems are preventable. For others, the risks can be reduced.\nFor example, pressure sores are a major health risk for all people with spinal cord injuries\nyet can be prevented through improved health care, properly designed seating, and per-\nsonal hygiene. Remediable genitourinary tract disorders are also a problem for people\nwhose major motor function is severely restricted. Inadequate health care is implicated in\nthe development of these disorders. Other factors include nutritional disorders, alcohol\nand drug abuse, inadequate personal hygiene, and acute and chronic illness. Cardiovas-\ncular disorders and stroke, brought on by hypertension, nutritional problems, smoking,\nand lack of physical activity, may be particular problems for people with disabilities.\nMusculoskeletal disorders caused by a lack of physical activity and injuries are especially\nprevalent among people with disabilities. Many respiratory problems for people with dis-\nabilities are thought to be preventable. They can result from tobacco use, lack of physi-\ncal activity, and inadequate immunization.\nAlcohol and other drug abuse often are associated with emotional problems. For some\npeople with disabilities, special risks may stem from negative family and cultural at-\ntitudes.\nAs with minority populations, the elements of this report that explicitly call for improve-\nments for people with disabilities are limited by the availability of data with which to set\ntargets. Disabilities vary in their type and their intensity; those with disabilities include\nall age, racial, and ethnic groups. One of the major challenges of the coming years is to\nimprove our understanding of the needs of the full range of people with disabilities by im-\nproving the effectiveness of data systems.\nEstimates of the number of people with chronic, significant disabilities vary from 34 mil-\nlion to 43 million. These estimates include the almost 4 percent of the total population of\nthe Nation who are unable to perform their major activity (play, school, work, self-care);\nabout 6 percent whose ability to perform major activities is limited in some fashion; and\nover 4 percent who are limited in nonmajor activities. 9 Many more people, of course,\nhave impairments that are not yet, but could become, disabling; and still more have\nchronic conditions, such as hypertension or alcoholism, that can lead to impairment and\ndisability. Many people have several disabling conditions. About 27 percent of people\nwith disabilities report more than one cause of their limited function and over 7 percent\nreport three or more.⁹\nActivity limitations are most common among older people, the poor, and those Ameri-\ncans who are less educated. In comparison to the total population, about twice as many\npeople in families with incomes of less than $10,000 a year report major activity limita-\ntion. Education too is clearly linked to disability; about 40 percent of people with 8 years\nor less of education have activity limitations compared to under 11 percent of those with\n16 years or more.⁹\nThe prevalence of disability increases with age, as one would expect (Fig. 3.8). More\nthan one out of every five people aged 65 and older is limited in one or more of his or her\nmajor activities, and nearly half of those aged 85 and older need assistance in activities of\ndaily living. On the other hand, people who are under age 65 and living in the commu-\nnity, i.e., not institutionalized, make up about 40 percent of those who need assistance in\nactivities of daily living. 9\n40\n3. The Nation's Health: Special Populations\nPercent\n30\nFig. 3.8\n25\nPercentage of\n20\npeople experiencing\nlimitation of major\n15\nactivity, by age\n(1987)\n10\n5\n0\nSource: Health, United\nUnder 5\n5-14\n15-44\n45-64\n65-74\n75+\nStates, 1989 and Preven-\nAge group\ntion Profile\nThe major causes of activity limitation vary with age. People under age 18 are most like-\nly to have disabilities associated with mental impairment, asthma, mental illness, deaf-\nness and other ear disorders, and speech impairments. Among young adults, orthopedic\nimpairments, such as spinal curvature and other back impairments, are most common,\nwhile at older ages degenerative diseases, led by arthritis and heart disease, predominate.⁹\nAmong ethnic groups, American Indians have the highest rates of activity limitation and\nAsian and Pacific Islander Americans the lowest. 17 Activity limitations are slightly\nhigher among blacks than among non-Hispanic whites, and both have higher rates of dis-\nability than Hispanics.\nIt is evident from this list that people with disabilities face many of the same risks as\nother people-nutritional problems, physical inactivity, alcohol and other drug abuse,\nand stress. But for people with disabilities reducing risks may be a particular challenge.\nPhysical activity, considered especially important in preventing secondary health prob-\nlems, offers a compelling example. To establish fitness regimens, people with disabilities\noften need to learn new skills, have access to special equipment, and be part of a support\nnetwork that enables participation.⁷\nLack of adequate rehabilitation, maintenance therapies, and personal assistance increases\nthe risk of secondary health problems among people with disabilities. Inadequate health\ninsurance, especially among those without access to work-related group insurance, also\nposes a significant problem for this group.\nA clear opportunity exists for health promotion and disease prevention efforts to improve\nthe health prospects and functional independence of people with disabilities. Efforts to\nadapt existing preventive services and programs are underway. For example, exercise\nvideotapes have been developed for people with paraplegia, quadriplegia, amputation,\ncerebral palsy, and other physical impairments. Some fitness centers offer modified\naerobics, mild exercise in warm water, and other exercises designed to meet the needs of\nindividuals with disabilities. But fitness services are just one of many that are needed.\nPreventing the occurrence of secondary health problems depends on the availability of a\nvariety of health and social services. Gaps, overlaps, inconsistencies, and inequities in ex-\nisting programs require the effective coordination of existing services if the health of\npeople with disabilities is to be promoted.⁷\n41\nHealthy People 2000\nReferences\n1\n17\nAmler, R.W. and Dull, H.B., Closing the Gap: The\nNational Institute on Disability and Rehabilitation\nBurden of Unnecessary Illness. New York:\nResearch, Chartbook on Disability in the United\nOxford University Press, 1987.\nStates, Washington, DC: the Institute 1989.\n2\n18\nAsian American Health Forum. Year 2000 Strategic\nNational Migrant Resource Program and the\nHealth Development Program for Asian and\nMigrant Clinicians Network. Migrant and\nPacific Islander Americans. April 1989.\nSeasonal Farmworker, Health Objectives for the\n3\nYear 2000: Document in Progress, April 1990.\nBureau of the Census. U.S. Census of Population:\nAustin, TX: National Migrant Resource Program,\n1980. Washington DC: U.S. Department of\nInc., 1990.\nCommerce.\n19\n4\nCouncil on Ethical and Judicial Affairs. Black-white\nNational Vital Statistics System, National Center\nfor Health Statistics, Centers for Disease Control,\ndisparities in health care. JAMA 263:2344-2346,\nPublic Health Service, U.S. Department of Health\n1990.\nand Human Services, Hyattsville, MD.\n5\nFranks, A.L.; Berg, C.J.; Kane. M.A.; Browne, B.B.;\n20\nNorth Carolina Oral Health School Survey. North\net al. Hepatitis B virus infection among children\nCarolina Division of Dental Health, Raleigh,\nborn in the United States to Southeast Asian\nNorth Carolina and the University of North\nrefugees, New England Journal of Medicine\nCarolina School of Public Health, Chapel Hill,\n321(9):1301-5, 1989.\nNorth Carolina.\n6\nIndian Health Service, Indian Health Service Chart\n21\nOffice on Smoking and Health. Unpublished data\nSeries Book, Washington, DC: U.S. Department\nfrom the 1987 National Health Interview Survey.\nof Health and Human Services, 1988.\n22\n7\nOffice of Substance Abuse Prevention (OSAP).\nInstitute of Medicine. Disability in America: A\nCommunicating about alcohol and other drugs:\nNational Agenda. edited by Pope, A. and Tarloff,\nStrategies for reaching populations at risk. OSAP\nA. Washington, DC: National Academy Press, in\nPrevention Monograph 4. Washington, DC: U.S.\npress.\nDepartment of Health and Human Services, in\n8\nInstitute of Medicine. Preventing Low Birthweight.\npress.\nWashington, DC: National Academy Press, 1985.\n23\nPublic Health Service. The Surgeon General's\n9\nLaPlante, M.P., Data on Disability from the\nReport on Nutrition and Health. Washington, DC:\nNational Health Interview Survey, 1983-1985,\nU.S. Department of Health and Human Services,\nWashington, D.C.: National Institute on\n1988.\nDisability and Rehabilitation Research, 1988.\n24\nRhoades, E.R.; Hammond, J.; Welty, T.K.;\n10\nNational Cancer Institute and National Center for\nHandler, A.O.; and Amler, R.W. The Indian\nHealth Statistics. Unpublished data from the\nburden of illness and future health interventions.\nCancer Control Supplement to the 1987 National\nPublic Health Reports 102(4):361-8, 1987.\nHealth Interview Survey.\n25\nSchwartz, S.M. and Thomas, D.B. \"Estimates of\n11\nNational Center for Children in Poverty. A\nCancer Incidence Among Southeast Asian\nStatistical Profile of Our Poorest Young Citizens.\nRefugees in the United States.\" Paper presented at\nNew York: the Center, 1990.\nthe Annual Meeting of the American Public\n12\nHealth Association, New Orleans, LA October\nNational Center for Health Statistics. Health,\n1987.\nUnited States, 1989 and Prevention Profile.\n26\nHyattsville, MD: U.S. Department of Health and\nSelik, R.M.; Castro, K.G.; and Papaionnou, M.\nHuman Services, 1990.\nRacial/ethnic differences in the risk of AIDS in\n13\nthe United States. American Journal of Public\nNational Coalition of Hispanic Health and Human\nHealth 78(12):1539-1544, 1988.\nServices Organizations. Delivering Preventive\n27\nHealth Care to Hispanics: A Manual for\nSelik, R.M.; Castro, K.G.; Papaionnou, M.; and\nProviders, Washington, DC: the Coaltion, 1988.\nRuehler, J.W. Birthplace and the risk of AIDS\n14\namong Hispanics in the United States. American\nNational Health and Nutrition Examination Survey\nJournal of Public Health 79(7):836-9, 1989.\n(NHANES) II, National Center for Health\n28\nStatistics, Centers for Disease Control, Public\nSmith, J.C.; Mercy, J.A.; and Rosenberg, M.L.\nHealth Service, U.S. Department of Health and\nSuicide and homicide among Hispanics in the\nHuman Services, Hyattsville, MD.\nSouthwest. Public Health Reports\n15 National Health Interview Survey, National Center\n101(3):265-270, 1986.\nfor Health Statistics, Centers for Disease Control,\n29\nSubcommittee on Definition and Prevalence, Joint\nPublic Health Service, U.S. Department of Health\nNational Committee on Detection, Evaluation,\nand Human Service, Hyattsville, MD.\nand Treatment of High Blood Pressure.\n16\nHypertension prevalance and the status of\nNational Heart, Lung, and Blood Institute, National\nawareness, treatment and control. Hypertension\nCholesterol Education Program. Report of the\n7(3):460, 1985.\nExpert Panel on Population Strategies for Blood\n30\nCholesterol Reduction. Washington, DC: U.S.\nU.S. Department of Health and Human Services.\nDepartment of Health and Human Services, 1990.\nReport of the Secretary's Task Force on Black\nand Minority Health. Washington, DC: the\nDepartment, 1985.\n42\n4. Goals for the Nation\nThe promise embodied in Healthy People 2000 involves people in all their variety: age,\ngender, family relationships, racial and ethnic identity, income level, education, and occu-\npation. It involves birth and death, two sentinel health events. Birth frames the potential\nfor a healthy lifetime; death often summarizes how that potential was used. It involves\nthe values of family, neighborhood, community, and Nation, enabling or undermining the\nhealth course that a life takes. It involves an array of risks-some posing apparent, imme-\ndiate danger and others invisible and delayed in their effects. Finally, it involves medical\nscience and medical care, with their ability to thwart infections, reverse the course of\nsome chronic diseases, and enhance ability to function where limitations exist.\nThree overarching goals emerge from the complexity of the health challenge of the\n1990s. They permeate the structure and the content of this report. They further define\nthe challenge, especially for health planners, policy-makers, and providers (Fig. 4.1).\nIncrease the span of healthy life for Americans\nFig. 4.1\nReduce health disparities among Americans\nHealthy People 2000\nGoals\nAchieve access to preventive services for all\nAmericans\nGoal I\nIncrease the Span of Healthy Life for Americans\nA central purpose of Healthy People 2000 is to increase the proportion of Americans who\nlive long and healthy lives. The first goal underlying our strategy for the coming decade\nclearly states this intention. It encompasses the essential elements of health promotion\nand disease prevention: prevention of premature death, disability, and disease, and enhan-\ncement of the quality of life.\nFrom an individual perspective, healthy life extends into the final quarter of a full century,\nfree from chronic, disabling diseases and conditions, from preventable infections, and\nfrom serious injury. It means a full range of functional capacity at each life stage, from\ninfancy through old age, allowing one the ability to enter into satisfying relationships\nwith others, to work, and to play. From a national perspective, healthy life means a vital,\ncreative, and productive citizenry contributing to thriving communities and a thriving Na-\ntion.\nIn the course of this century, average life expectancy at birth has increased by almost 60\npercent, from 47 years in 1900 to 75 years in 1987 (Fig. 4.2). This progress has been lar-\ngely due to the advances of science and public health in conquering life-threatening com-\nmunicable diseases. The aging of the population and the evolution from communicable\ndiseases to chronic diseases and injuries as the leading causes of death and disability\ndirect our attention to quality of life issues. Both chronic diseases and injuries can be\nmeasured by the death certificates that they generate; but the numbers reflecting human\nsuffering and costs associated with heart disease, cancer, nonfatal strokes, diabetes, and\nlung diseases far outstrip mortality statistics. The results of injury caused both by unin-\ntentional trauma and by interpersonal violence are not limited to lives cut short; they also\ninclude lives that must overcome brain damage, motor limitations, and other permanent\nimpairments.\n43\nHealthy People 2000\nLife years\n85\nFig. 4.2\n80\nLife expectancy at\nbirth, U.S. population\n75.0\n75\n70\n65\n1970\n1975\n1980\n1985\n1990\n1995\n2000\nSource: Health, United\nYear\nStates, 1989 and Preven-\ntion Profile\nWe can measure our progress in increasing the span of healthy life in several ways. One\nmeasure offered here indicates the rate of deaths per 100,000 people before age 75, the\napproximate average life expectancy at birth in 1990 (Fig. 4.3). Infant mortality, a tradi-\ntional tool for judging the effectiveness and compassion of health systems, can indicate\nnational progress at the early end of the age spectrum (Fig. 4.4).\nRate per 100,000\n1000\nFig. 4.3\n800\nDeath rates for\npeople aged 74 and\n600\nyounger, U.S.\n392\npopulation (age-ad-\n400\njusted)\n200\n0\n1970\n1975\n1980\n1985\n1990\n1995\n2000\nYear\nSource: National Vital\nStatistics System (CDC)\nDeaths per 1,000 live births\n35\nFig. 4.4\n30\nInfant mortality rate,\n25\nU.S. population\n20\n15\n10.1\n10\n5\n0\n1970\n1975\n1980\n1985\n1990\n1995\n2000\nYear\nSource: National Vital\nStatistics System (CDC)\n44\n4. Goals for the Nation\nAnother measure uses a formula that combines death rates with acute and chronic illnes-\nses, impairments, and handicaps to define average years of healthy life. Using this meas-\nure, time spent in a healthy state or years of healthy life can be compared to the average\nlife expectancy at birth. (Fig. 4.5) The difference between these two estimates indicates\nthe average amount of time spent in a dysfunctional state due to either chronic or acute\nlimitation. One major indicator of dysfunction is limitation of major activity due to\nchronic conditions. (Fig. 4.6) Years of healthy life uses a life expectancy model in which\nstandard life table data are adjusted for level of well-being of a population. Measures of\nwell-being represent individual functioning and include measures of mental, physical,\nand social functioning. For example, social functioning may be measured in terms of an\nindividual's limitation in performing his or her usual social role, whether this be work,\nschool, or housework; physical functioning may be measured in terms of being confined\nto bed, chair, or couch due to health reasons, or in terms of health-related limitation in\nmobility. Because years of healthy life is a relatively new type of measure, the baseline\nestimates may change. Nonetheless it should prove an informative indicator as we track\nthe Nation's health progress.\nOver the course of the decade, we will be able to use each of these measures as indicators\nof our overall progress in increasing the span of healthy life. To explain the basis for\nthat progress, it is necessary to move beyond the broad goals that are proposed here and\nlook to the priorities for preventive action. Healthy life will be expanded to more years\nand more Americans as a result of efforts to address the priorities defined in the next\nchapter.\nHealthy life\n62 years\nFig. 4.5\nYears of healthy life\nas a proportion of life\nexpectancy, U.S.\npopulation (1980)\nDysfunctional life\n11.7 years\nSource: National Vital\nStatistics System and Na-\nLife expectancy\ntional Health Interview\n73.7 years\nSurvey (CDC)\nPercent\n20\nFig. 4.6\n15\nPercentage of\npeople experiencing\nlimitation of major\n9.4\n10\nactivity, U.S. popula-\ntion (crude rates)\n5\n0\n1970\n1975\n1980\n1985\n1990\n1995\n2000\nYear\nSource: National Health\nInterview Survey (CDC)\n45\nHealthy People 2000\nGoal II\nReduce Health Disparities Among Americans\nAchieving a healthier America depends on significant improvements in the health of\npopulation groups that now are at highest risk of premature death, disease, and disability.\nThe particular health problems of those high risk groups were presented in the previous\ntwo chapters. In some instances and for some health risks, they are age groups. In most\ncases and for virtually all health risks, they are members of certain racial and ethnic groups,\npeople with low income, and people with disabilities. Special attention is needed to close\nthe gap that exists between the majority of the population and the various minority popu-\nlations. Whether the issue is chronic diseases, infectious diseases, unintentional injuries,\nor violence-related injuries, the services and protection that might most effectively bring\nabout improvements in their circumstances must be made available.\nAlthough health statistics that take race and ethnicity into account are sparse, the ones\nthat do exist leave no doubt about disparities. The greatest opportunities for improve-\nment and the greatest threats to the future health status of the Nation reside in population\ngroups that have historically been disadvantaged economically, educationally, and politi-\ncally. These must be our first priority.\nEven as average life expectancy at birth edged into the upper 70s, the expected life span\nfor black American male babies born in 1986, 1987, and 1988 actually shrank. 1 The\ndisparities appear across the spectrum of health concerns, not just in average life expec-\ntancy. (Fig. 4.7) One perspective on these differences is death rates before age 75 (Fig.\n4.8). A particularly sensitive and compelling measure of disparity is infant mortality. Al-\nthough America's infant mortality rate is at an all-time low, a persistent racial gap\nremains. Black babies continue to die at twice the rate of white babies (Fig. 4.9).\nAnother is potential years of life lost before age 65 among white and black men from\nchronic diseases, calculated as years lost per 1,000 population. In 1987, rates for black\nmen are 55 percent higher for heart disease, 26 percent higher for cancer, 180 percent\nhigher for stroke, and 100 percent higher for lung disease. For homicide, years of poten-\ntial life lost were 630 percent higher for black men than for white men. Among women\nof both races, death rates for all causes were lower, but comparisons of premature death\nof white and black women are equally startling. Lost years of life before age 65 were\n134 percent higher among black women for heart disease, 166 percent higher for stroke,\nand 360 percent higher for homicide. 1 Statistics to compute years of potential life lost are\nscarce for other racial and ethnic populations, for low-income groups, and for people\nwith disabilities, but analyses of local data from small area studies confirm disparities\namong these groups as well.\nLife years\n80\nFig. 4.7\n75.6\nWhites\n75\nLife expectancy at\nbirth, blacks and\nwhites\n69.4\n70\nBlacks\n65\n60\n1970\n1975\n1980\n1985\n1990\n1995\n2000\nSource: Health, United\nYear\nStates, 1989 and Preven-\ntion Profile\n46\n4. Goals for the Nation\nDeaths per 1,000 live births\n35\nBlacks\nFig. 4.8\n30\nInfant mortality rates,\n25\nblacks and whites\n20\n17.9\n15\nWhites\n8.6\n10\n5\nSource: National Vital\n0\n1970\n1975\n1980\n1985\n1990\n1995\n2000\nStatistics System and Na-\ntional Linked Birth and\nYear\nInfant Death Data Set\n(CDC)\nRate per 100,000\n1000\nBlacks\nFig. 4.9\n800\nDeath rates for\n628\npeople aged 74 and\n600\nyounger, blacks and\n367\nwhites (1987)\n400\nWhites\n200\n0\n1970\n1975\n1980\n1985\n1990\n1995\n2000\nYear\nSource: National Vital\nStatistics System (CDC)\nContrasting death rates are mirrored by statistics that depict disability outcome, as well as\ndeath. Statistics on years of healthy life reflect the gap between our racial and ethnic\ngroups in the United States (Fig. 4.10). Similarly, rates of disability, measured in terms\nof limitation of major activity, confirm the fact of inequity in health. The most striking\naspect of these comparative rates is the great gap between low-income people and all\nother groups (Fig. 4.11).\nHealthy People 2000 thus calls for special attention to reducing-and finally eliminat-\ning-disparities among population groups of Americans. In the priorities for preventive\naction, this report sets separate, challenging targets when baseline data are available.\nUsually the targets are sufficient to narrow the gap between the death, disease, or disabil-\nity rates for population groups and the total population; where trends have been worsen-\ning for population groups, targets may appear less challenging but may, in fact, be dif-\nficult to achieve because of recent setbacks. In many instances, targets cannot be set in\n1990 because measurement tools are not available to provide baselines from which to set\nrealistic, achievable targets for 2000. For this reason, the health status of black Ameri-\ncans, for whom data are most readily available, is used to provide proxy measures of our\nprogress in moving toward the basic goal of equity in health for all our Nation's people.\n47\nHealthy People 2000\nYears\n100\n80\n74.4\n75\nFig. 4.10\n68\n63\n62\nLife expectancy and\n60\n56\nyears of healthy life,\nwhites, blacks, and\n40\nHispanics (1980)\n20\nSource: Analysis based\n0\non data from the National\nWhites\nBlacks\nHispanics\nVital Statistics System\n(CDC), National Health In-\nLife expectancy\nYears of healthy life\nterview Survey (CDC),\n(preliminary estimates)\nand the U.S. Census\nBureau\nPercent\n25\nFig. 4.11\n20\nLow income\n18.9\nPercentage of\npeople experiencing\n15\nAmerican Indians\n13.4\nlimitation of major ac-\nBlacks\n11.2\ntivity, by race and\n10\nWhites\n9.3\nethnicity (crude rates)\nHispanics\n5\n6.6\n0\n1970\n1975\n1980\n1985\n1990\n1995\n2000\nYear\nSource: National Health\nInterview Survey (CDC)\n48\n4. Goals for the Nation\nGoal III\nAchieve Access to Preventive Services for All Americans\nHealthy People 2000 calls for a comprehensive strategy to support the improvements in\nhealth that are possible through prevention. This report defines the major parts of that\nstrategy as Health Promotion, Health Protection, and Preventive Services. The priorities\nfor prevention are grouped under these three categories. They are not precise or mutually\nexclusive categories, but they serve to underscore an important point. Major improve-\nments depend on all three approaches to prevention, not just one. We cannot rely solely\non success in persuading people to change their health-related behaviors through health\npromotion efforts, any more than we can rely solely on environmental improvements or\nexpanded and enhanced clinical interventions.\nA health strategy for the 1990s, however, must put particular emphasis on the arena\nwhere health professionals in both the private and public sectors have most responsi-\nbility, namely the arena of preventive services. Those services, made available to all\nAmericans, can provide the foundation for achievement of other parts of our health\nstrategy. An example, which we will use to track our effectiveness in moving toward\nthis goal, relates to the birth of healthy babies. Prenatal health care is a vital, fundamen-\ntal ingredient in attaining this sentinel health event (Fig. 4.12). Early and regular prenatal\nvisits to qualified health care providers can ensure greater likelihood that low birth weight\nand other perinatal complications will be prevented. Prenatal health care services can\nalso serve as a resource and a reinforcer for health promotion efforts that are equally im-\nportant to healthy pregnancies. The role of prenatal services in education and counseling\nabout parental behaviors, including nutrition, abstinence from tobacco, alcohol, and other\ndrugs, and, even before conception, behaviors that involve risks of sexually transmitted\ndiseases, including HIV infection, is crucial. Likewise, preventive services for pregnant\nwomen can serve as the means of monitoring protection against toxic exposures, such as\nlead, dangerous prescription medications, and radiation.\nPercent of live births\n100\nFig. 4.12\n90\nPercentage of\nWhites\n79\n80\npregnant women\nreceiving first\n70\ntrimester prenatal\n61\nBlacks\ncare, blacks and\n60\nwhites\n50\n40\n1970\n1975\n1980\n1985\n1990\n1995\n2000\nYear\nSource: National Vital\nStatistics System (CDC)\n49\nHealthy People 2000\nOther preventive services are equally fundamental to our national prevention plan. Basic\nmonitoring of child growth and development; immunization against childhood diseases\n(Fig. 4.13); appropriate immunization for vulnerable adults against pneumonia and in-\nfluenza; screening to detect high blood pressure and high blood cholesterol and breast,\ncervical, oropharyngeal, and colorectal cancers; counseling on nutrition, smoking cessa-\ntion, and injury prevention; all these services are indispensable parts of prevention.\nAchievement of this goal clearly requires that health care providers offer, and patients\nreceive, these services. Objectives throughout this report focus on increasing the propor-\ntion of primary care providers who routinely offer preventive services to their patients.\nPercent vaccinated\n100\nFig. 4.13\n80\nPercentage of\nchildren immunized\n60\nby time of school\nentry\n40\n20\n0\n1970\n1975\n1980\n1985\n1990\n1995\n2000\nYear\nSource: Center for\nPrevention Services, CDC\nAccess to preventive services involves more than just availability of services. Preventive\nservices cannot, and should not, be separated from basic primary health care. Approxi-\nmately 18 percent of all Americans and 31 percent of those without either private or\npublic health insurance have no source of primary health care. (Fig. 4.14) Thus, tracking\nof progress to achieve access to preventive services over the coming decade must focus\non increases in the number of people who have a primary source of health care and those\nwho have adequate insurance coverage (Fig. 4.15), with particular attention to the exten-\nsion of health insurance and managed health care systems to cover preventive services\nsuch as immunizations, screening, and patient education and counseling.\nPercent\n35\n30\nFig. 4.14\nPercentage of\n25\npeople who lack a\n20\nsource of primary\ncare (1986)\n15\n10\n5\n0\nAll\nPeople\nSource: Robert Wood\nHispanics\nBlacks\nLow-income\nw/o insurance\nJohnson Foundation\n50\n4. Goals for the Nation\nPrivate insurance\nFig. 4.15\n77%\nHealth insurance\ncoverage for people\naged 64 and younger,\nOther/unknown\nby type of coverage\n2%\n(1986)\nMedicaid\n6%\nNot covered\n15%\nSource: Based on Health,\nUnited States, 1989 and\nPrevention Profile\nNote: Percent distribution approximate due to overlap among categories.\nThese three goals-healthy lives for more Americans, elimination of disparities among\npopulation groups, access to necessary preventive services for everyone-are our broad\nnational aspirations for health improvements. They can serve as a shared set of values\nthat underpin all of our health promotion and disease prevention work. They can inform\nour public policy, whether at the Federal, State, or local levels. But taken alone, they do\nnot provide us with adequate direction to guide actual decisions about programs, resource\nallocation, or professional and personal commitments. The goals are insufficient, unless\nthey are buttressed by a framework of specific and substantive preventive actions that\nwill move us steadily in the direction of their achievement. The next chapter lays out the\nspecifics of the Healthy People 2000 plan and gives substance to the goals for the Nation.\nReference\n1\nNational Center for Health Statistics. Health,\nUnited States, 1989 and Prevention Profile.\nDHHS Pub. No. (PHS)90-1232. Hyattsville,\nMD: U.S. Department of Health and Human\nServices, 1990.\n51\n5. Priorities for Health Promotion and\nDisease Prevention\nHealthy People 2000 is a platform for action. The information it contains may be interest-\ning; the statistical data on which it is based may be analytically useful; and the objectives-\noriented structure that it employs may serve as a practical model for other planning\nendeavors. But its value must finally be judged by how well it helps to shape what we\ndo to improve the health of the Nation in the coming decade.\nThis chapter summarizes the priorities for preventive action. Organized in three basic\ncategories-Health Promotion, Health Protection, and Preventive Services-it outlines\nspecific behavioral risks, disease conditions, and health outcomes that must be effectively\naddressed in the coming years if we are to take advantage of our opportunities for better\nhealth. In addition, a cross-cutting priority that supports each of the others is improve-\nment of our surveillance and data systems to foster more effective decision-making.\nEach specific priority is summarized in the following pages, together with representative\nhealth objectives drawn from Part II of Healthy People 2000. These representative objec-\ntives serve as abbreviated examples of the measurable targets that are more fully stated\nand discussed in greater detail in Part II. While they cannot completely summarize all\naspects of the health improvements, risk reductions, and service enhancements that are\ncontained in the chapters of Part II, these examples demonstrate the magnitude and impor-\ntance of the change envisioned in Healthy People 2000.\n53\nHealthy People 2000\nHealth Promotion\nPhysical Activity and Fitness\nNutrition\nTobacco\nAlcohol and Other Drugs\nFamily Planning\nMental Health and Mental Disorders\nViolent and Abusive Behavior\nEducational and Community-Based Programs\n54\n5. Priorities for Health Promotion and Disease Prevention\nPhysical Activity and Fitness\nRegular physical activity increases life expectancy, 74 can help older adults maintain func-\ntional independence, and enhances quality of life at each stage of life. 33 The beneficial\nimpact of physical activity touches widely on various diseases and conditions. Regular\nphysical activity can help to prevent and manage coronary heart disease, hypertension,\ndiabetes, osteoporosis, and depression. 26 It has also been associated with a lower rate of\ncolon cancer⁷⁷ and stroke⁸³ and may be linked to reduced back injury. 8 It is an essential\ncomponent of weight loss programs.\nPhysical activity is a complex behavior and its relationship with health is multifaceted.\nRegular vigorous physical activity promotes cardiorespiratory fitness and helps prevent\ncoronary heart disease. 5,75 Activity that builds muscular strength, endurance, and flexi-\nbility may protect against injury and disability. And any activity that expends energy is\nimportant in weight control. Physical activity can also produce changes in blood pres-\nsure, blood lipids, clotting factors, and glucose tolerance, that may help prevent and con-\ntrol high blood pressure, coronary heart disease and diabetes, 38\nWhile activity should be habitual, it need not be unduly strenuous. People who engage\ndaily in light to moderate exercise, equivalent to sustained walking for about 30 minutes\na day, can achieve substantial health gains. Increasing evidence suggests that even small\nincreases in light to moderate activity by those who are least active will produce meas-\nurable health benefits. 39,82\nOf particular importance is the role of physical activity in preventing coronary heart dis-\nease, the leading cause of death in the United States. A sedentary lifestyle appears to be\nan independent risk factor for coronary heart disease, nearly doubling a person's risk. 78\nIts effect on coronary heart disease risk is almost as great as the better known risk factors,\nsuch as cigarette smoking and high blood pressure. Because more people are at risk of\ncoronary heart disease due to physical inactivity than to any other single risk factor, it has\nan especially great public health impact.\nFew Americans engage in regular physical activity despite the potential benefits. Current-\nly, only 22 percent of adults engage in at least 30 minutes of light to moderate physical\nactivity 5 or more times per week, and only 12 percent report that they are this active 7\nor more times a week. Less than 10 percent of the population exercises 3 or more times\na week at the more vigorous level necessary to improve cardiorespiratory fitness. Nearly\n25 percent of adults report no leisure-time physical activity, and the prevalence of seden-\ntary behavior increases with advancing age.\nTo increase physical activity and fitness, by the year 2000\n1.3\nIncrease moderate daily physical activity to at least 30% of people\n(a 36% increase)\n1.5 Reduce sedentary lifestyles to no more than 15% of people\n(a 38% decrease)\nOther objectives target sustained combined changes in diet and activity patterns for\nthose who are overweight; physical education in schools; sponsorship by employers\nof worksite physical activity programs; increasing accessibility of community\nresources like trails and pools; and a stronger focus by primary care providers on the\nphysical activity patterns of their patients.\n55\nHealthy People 2000\nNutrition\nIn ways often interrelated with patterns of physical inactivity, dietary factors are associ-\nated with 5 of the 10 leading causes of death in the United States: coronary heart disease,\nsome types of cancer, stroke, noninsulin-dependent diabetes mellitus, and atherosclerosis.\nThe 1988 Surgeon General's Report on Nutrition and Health⁷⁹ found that for the 2 out of\n3 Americans who neither smoke nor drink, eating patterns may shape their long-term\nhealth prospects more than any other personal choice. In general, excesses and imbalan-\nces of some food components in the diet have replaced once-prevalent nutrient deficien-\ncies as the principal concern.\nWhile many dietary components are involved in diet and health relationships, chief\namong them is the disproportionate consumption of foods high in fats (especially\nsaturated fats), often at the expense of foods high in complex carbohydrates and dietary\nfiber that may be more conducive to health. 79 To help promote health and prevent\nchronic disease, the Dietary Guidelines for Americans,⁹¹ issued by the United States\nDepartments of Health and Human Services and Agriculture, recommend one should eat\na variety of foods; maintain healthy weight; choose a diet low in fat, saturated fat, and\ncholesterol; choose a diet with plenty of vegetables, fruits, and grain products; use sugars\nonly in moderation; use salt and sodium only in moderation; and, if alcoholic beverages\nare consumed, do so in moderation.\nOverweight affects about 26 percent of the population. It is a particular problem for poor\nand minority populations, affecting 44 percent of black women over age 20 and 37 per-\ncent of all women below the poverty level. Obesity has been linked to increased risk for\ndiabetes mellitus, high blood pressure and stroke, coronary heart disease, some types of\ncancer, and gallbladder disease. 79\nDietary fat contributes more than twice as many calories per unit of weight as carbo-\nhydrate or protein, and currently constitutes 36 percent of the calories in the average\nAmerican diet. Considerable evidence associates diets high in fat with increased risk of\nobesity, some types of cancer, and possibly gallbladder disease. 79 Strong and consistent\nevidence relates saturated fat intake to high blood cholesterol and increased risk for\ncoronary heart disease. Moreover, Americans eat only about half of the dietary fiber\nrecommended by the National Cancer Institute to help reduce the risk for some types of\ncancer. Dietary fiber is readily available from a variety of foods such as vegetables,\nfruits, and grains, which are also low in fat.\nTo improve nutrition, by the year 2000\n2.3\nReduce overweight to a prevalence of no more than 20% of people\n(a 23% decrease)\n2.5\nReduce dietary fat intake to an average of 30% of calories\n(a 17% decrease)\nOther objectives target increasing consumption of vegetables, fruits, and grain\nproducts; decreasing sodium consumption; increasing calcium intake, in particular for\nyoung people and pregnant or lactating women; increasing breastfeeding; reducing\niron deficiency and growth retardation in children; useful and informative nutrition\nlabeling for all food products; increasing availability of low-fat products; better\nidentification of low-fat, low-calorie food choices in restaurants; more attention to\nnutrition education and food choices in schools; better use of worksites for nutrition\neducation and services; and a stronger focus by primary care providers on the\nnutritional practices of their patients.\n56\n5. Priorities for Health Promotion and Disease Prevention\nTobacco\nTobacco use is the most important single preventable cause of death in the United States,\naccounting for one of every six deaths, or some 390,000 deaths annually. 73 It is a major\nrisk factor for diseases of the heart and blood vessels; chronic bronchitis and emphysema;\ncancers of the lung, larynx, pharynx, oral cavity, esophagus, pancreas, and bladder; and\nother problems such as respiratory infections and stomach ulcers. 73 Cigarette smoking is\nresponsible for an estimated 21 percent of all coronary heart disease deaths (40 percent of\nthose under age 65), 30 percent of all cancer deaths, and 87 percent of lung cancer deaths\nin the United States. The risk of dying from lung cancer is 22 times higher for men and\n12 times higher for women who smoke than for lifetime nonsmokers. Passive or involun-\ntary smoking causes lung cancer and other diseases in healthy nonsmokers and severe\nrespiratory problems in children. Middle ear infections in children have been linked to\npassive smoking.\nCigarette smoking during pregnancy is a risk factor for low birth weight, prematurity,\nmiscarriage, sudden infant death syndrome, and other maternal and infant health prob-\nlems. Between 20 and 30 percent of the incidence of low birth weight, 36 up to 14 percent\nof preterm deliveries, and about 10 percent of all infant deaths are attributable to mater-\nnal cigarette smoking. 73 Yet 25 percent of pregnant women smoke throughout their preg-\n50\nnancy.\nCigarette smoking has declined dramatically since 1964, when the first Surgeon General's\nreport on smoking appeared. In 1987, 29 percent of adults smoked compared to 40 per-\ncent in 1965. Nearly half of all living adults who ever smoked have quit. Nevertheless,\nsmoking rates remain high in certain populations, including blacks, blue collar workers,\nand people with fewer years of education. In 1987, 34 percent of blacks smoked. 73\nSmoking is a special problem for workers with exposure to hazardous substances that\nmay compound the risk.\nAmong youth, more than half of 8th graders and nearly two-thirds of 10th graders report\nhaving tried cigarettes. 4 More than one-fourth of 10th graders report having smoked a\ncigarette during the preceding month and nearly one in five reports smoking a pack or\nmore in the previous month.\nTo reduce use of tobacco, by the year 2000\n3.4\nReduce cigarette smoking prevalence to no more than 15% of adults\n(a 48% decrease)\n3.5\nReduce initiation of smoking to no more than 15% by age 20\n(a 50% decrease)\nOther objectives target reducing lung cancer and chronic obstructive lung disease\ndeaths; increasing smoking cessation during pregnancy; reducing use of smokeless\ntobacco; prevention education and tobacco-free environments in schools; restrictions\non smoking in the workplace and other public places; enforcement of prohibition of\nsales of tobacco products to youth; restrictions on tobacco advertising and promotion\ntargeting youth; State plans to reduce tobacco use; and more smoking cessation\nassistance to patients by primary care providers.\n57\nHealthy People 2000\nAlcohol and Other Drugs\nApproximately two-thirds of American adults drink alcohol at least occasionally. Of\nthese, it is estimated that about 18 million currently experience problems as a result of\nalcohol use, and about 7 percent of drinkers experience moderate levels of dependence\nsymptoms. 65 Alcohol is a factor in approximately half of all homicides, suicides, and\nmotor vehicle fatalities 76 With fetal alcohol syndrome affecting as many as 3 infants\nper 1,000 live births in some hospital reports, it is the leading preventable cause of birth\ndefects. 65 Alcohol is also responsible for numerous deaths due to liver disease. Of spe-\ncial concern are the problems for young people. Nine out of ten high school seniors\nreport using alcohol at least once.\nDrug use is also a dominant societal concern. Surveys in 1988 found that 21 million\nAmericans had used cocaine at least once, and 21 million also had used marijuana in the\nlast year. 63 Among high school seniors, almost 44 percent report having tried marijuana,\nand 10 percent report ever using cocaine. 45 It has been estimated that one in four Ameri-\ncan adolescents is at very high risk of alcohol and other drug problems and their conse-\nquences.\n20 The data may underestimate the problem because existing surveys fail to\ncount high risk youth who have dropped out of school. Drug abuse is linked to high rates\nof violent crime in the Nation, to transmission of the HIV virus, and to developmental\nproblems in infants.\nThese are the immediate health problems posed by alcohol and other drugs. Their abuse,\nhowever, is closely related to a host of other social and health problems, such as early un-\nwanted pregnancy, delinquency, and school failure. The economic cost of problems at-\ntendant to alcohol abuse was estimated in 1990 to be $70 billion, and another $44 billion\nfor drug problems. 27,80 Alcohol and other drug abuse appears to be declining across the\ntotal population. Use of crack cocaine, however, is on the rise, especially in some urban\ncenters. Homeless people are at special risk of alcohol abuse. 64\nIn the past decade, public awareness of this problem grew, uniting diverse groups in the\ncommon goal. Businesses, schools, parent groups, and minority organizations have devel-\noped ways to fight the pervasive dangers of alcohol and other drugs. A changing social\nclimate has been accompanied by legislative and policy actions, particularly concerning\ndrinking and driving.\nTo reduce alcohol and other drug abuse, by the year 2000\n4.1\nReduce alcohol-related motor vehicle crash deaths to no more than 8.5 per\n100,000 people (age adjusted)\n(a 12% decrease)\n4.6\nReduce alcohol use by school children aged 12 to 17 to less than 13%;\nmarijuana use by youth aged 18 to 25 to less than 8% ; and cocaine use\nby youth aged 18 to 25 to less than 3%\n(50% decreases)\nOther objectives target increasing the average age of first use of addictive substances;\nreducing occasions of heavy drinking by young people; reducing aggregate per capita\nalcohol consumption nationally; increasing awareness of the harmful effects of\naddictive substances; better access to treatment programs; stronger and better\nenforced laws related to driving under the influence of intoxicants; better access of\nworkers to assistance for problems; policies to reduce minors' access to alcohol; and\ngreater involvement of primary care providers in dealing with these problems.\n58\n5. Priorities for Health Promotion and Disease Prevention\nFamily Planning\nFamilies are the bedrock of our society. Decisions about forming a family are of critical\nimportance. Decisions made today may have long-term consequences. Safe and health-\nful childbearing both contributes to, and is a result of, effective family planning. Miscar-\nriage, stillbirth, and infant mortality are tragic examples of problems that occur more\nfrequently as a result of family planning failures. Family planning is defined here as the\nprocess of establishing the preferred number and spacing of children in one's family and\nselecting the means by which these preferences are achieved. It presupposes the impor-\ntance of family and the importance of planning. It requires that fundamental questions be\naddressed concerning an individual's relationship to the lives, health, and well-being of\nothers.\nSuccessful implementation of family planning choices requires mature, thoughtful deci-\nsions accompanied by motivation to carry out those decisions. It requires the exercise\nof personal responsibility. There are many effective means by which family planning\nchoices can be implemented. Childbearing, adoption, abstinence from sexual activity\noutside of a monogamous relationship, use of contraception methods, natural family plan-\nning, and treatment of infertility are all means of reaching desired family planning goals.\nDespite the fundamental importance of these decisions to each individual and to society\nas a whole, problems attendant to poor family planning exert a tremendous toll on our\nNation. In 1988, nearly half of American women surveyed reported that their pregnan-\ncies in the last 5 years had been mistimed or unwanted-56 percent if adjustment is made\nfor unreported abortions. 69\nThe problem is most pressing among young people. More than three out of four young\nwomen and 85 percent of young men have had sexual intercourse by age 20.69,87 Each\nyear, one out of ten young women in this age group becomes pregnant. By age 20, ap-\nproximately 40 percent of all women have been pregnant while 63 percent of black\nwomen have been pregnant. 90 An estimated 84 percent of these pregnancies were unin-\ntended, 32 and abortion rates among American teenagers are considerably higher than for\nmany other countries.\nTo improve family planning, by the year 2000\n5.1\nReduce teenage pregnancies to no more than 50 per 1,000 girls aged 17 and\nyounger\n(a 30% decrease)\n5.2 Reduce unintended pregnances to no more than 30% of pregnancies\n(a 46% decrease)\nOther objectives target reducing sexual intercourse among teenagers; reducing\nnonuse of contraceptives among those who are unmarried and sexually active;\nincreasing effectiveness with which contraceptives are used; improving\ncommunication between adolescents and parents on human sexuality; increasing\navailability of appropriate preconception counseling; increasing referral rates to\nappropriate services; increasing availability of information on adoption for unmarried\npregnant patients; and reducing rates of infertility.\n59\nHealthy People 2000\nMental Health and Mental Disorders\nMental health refers to an individual's ability to negotiate the daily challenges and social\ninteractions of life, without experiencing undue emotional or behavioral incapacity. It\ncan be affected by numerous factors ranging from exogenous stresses presenting in ways\nthat may be difficult to manage to organic disease or genetic defects that impair brain\nfunction. An estimated 23 million noninstitutionalized adults in the United States have\ncognitive, emotional, or behavioral disorders, not including alcohol and other drug abuse.\nSchizophrenic disorders most often result in functional disabilities, but depression is the\nmost common of the major disorders, affecting about 5 percent of the population at any\none time.\nSuicide is clearly the most serious of the potential outcomes of these disorders and it\nclaims more than 30,000 lives each year. 70 Injuries from firearms are directly responsible\nfor a majority of suicidal deaths, and much of the increase in suicide that has taken place\nsince the 1950s is specific to firearm deaths 6,46 There has been a steady increase in\ndeaths from suicide among youth aged 15 to 19, and by the mid-1980s suicide was the\nsecond leading cause of death in this age group.\nA variety of approaches have been proposed to reduce the impact of mental health prob-\nlems. Stress, whether stemming from life events, chronic strain, or environmental pres-\nsures, is associated with biological changes linked to cognitive, emotional, and behav-\nioral dysfunctions. Healthful habits, such as good nutrition and adequate amounts of ex-\nercise, and relaxation techniques may be useful in helping to relieve stress. Because\npeople with low levels of control over their environment (actual or perceived) appear to\nbe at greater risk, interventions have also been directed at increasing individuals' resour-\nces and coping skills through education and social support. For those needing more ag-\ngressive attention, medical interventions are available that include antidepression drugs,\npsychotherapeutic agents, and biofeedback.\nChildhood developmental delays and specific skill disorders have also been linked to\nlearning and adjustment problems in adolescence and early adulthood. Early interven-\ntions with parents and children that address prenatal care, parental skills, and remedial\nhelp in early school programs may help prevent developmental problems and their\nprogression to mental health problems.\nTo improve mental health and prevent mental disorders, by the year 2000\n6.1\nReduce suicides to no more than 10.5 per 100,000 people\n(a 10% decrease)\n6.5\nReduce adverse effects of stress to less than 35% of people\n(an 18% decrease)\nOther objectives target reducing prevalence of mental disorders; increasing utilization\nof community support programs; increasing treatment for those with major depressive\ndisorders; increasing use of broad social support mechanisms for those with trouble\ncoping; more attention by employers to services related to managing employee stress;\nbetter access to mutual-help clearinghouses; and more attention by primary care\nproviders to the cognitive, emotional, and behavioral needs of their patients.\n60\n5. Priorities for Health Promotion and Disease Prevention\nViolent and Abusive Behavior\nViolent and abusive behavior (intentional injury) exacts a large toll on the physical and\nmental health of Americans. Child abuse, spouse abuse, and other forms of intrafamilial\nviolence continue to threaten the health of thousands of American families. Homicide\nand suicide account for over one-third of the more than 145,000 injury deaths that occur\nin the United States each year. Because of its growing prominence as a source of the\nleading health problems experienced by Americans, violent and abusive behavior has\nbeen increasingly recognized as an important public health problem.\nHomicide is the 11th leading cause of death in the United States, accounting for nearly\n21,000 deaths in 1987. 51 Men, teenagers, young adults, and minority group members,\nparticularly blacks and Hispanics, are most likely to be murder victims. It is the leading\ncause of death for blacks between the ages of 15 and 34. 13 Overall homicide rates for\nblacks have declined since 1970, while the rates for whites have increased. 13 Most\nhomicides are committed with a firearm, occur during an argument, and occur among\npeople who are acquainted with one another. Homicide rates in the United States far ex-\nceed those of any other developed country.\nAssault injuries are another consequence of interpersonal violence. Each year between\n1979 and 1986 more than 2.2 million people suffered nonfatal injuries from violent and\nabusive behavior. Of these injured victims, 1 million received medical care and 500,000\nwere treated by emergency medical facilities. 25 More than 25 percent of the Nation's\n10,000 to 15,000 spinal cord injuries each year are the result of assaultive violence.\nFirearms account for 60 percent of all homicides and suicides, and a substantial propor-\ntion of all traumatic spinal cord injuries. 44\nIntrafamilial violence is more prevalent than often recognized. In 1986 an estimated 1.6\nmillion children nationwide experienced some form of abuse or neglect. 95 Physical abuse\naccounted for the greatest portion of abuse incidents, followed by emotional and then\nsexual abuse. Studies also suggest that between 2 and 4 million women are physically\nbattered each year by partners including husbands, former husbands, boyfriends, and\nlovers. Between 21 and 30 percent of all women in the United States are estimated to\nhave been beaten by a partner at least once. More than 1 million women seek medical\nassistance for injuries caused by battering each year, and the vast majority of domestic\nhomicides are preceded by episodes of violence. 56\nTo reduce violent and abusive behavior, by the year 2000\n7.1\nReduce homicides to no more than 7.2 per 100,000 people\n(a 15% decrease)\n7.6\nReduce assault injuries to no more than 10 per 1,000 people\n(a 10% decrease)\nOther objectives target reducing weapon-related injury deaths; reducing child and\nspouse abuse, reducing rape; reducing weapon-carrying by adolescents; reducing\ninappropriate storage of weapons; improving emergency treatment, housing, and\nreferral services for battered women, children, and older people; improving school\nprograms for conflict resolution; and strengthening State-based efforts in violence\nprevention.\n61\nHealthy People 2000\nEducational and Community-Based Programs\nA supportive social environment may be the most important factor in changing behaviors\nthat contribute to many of today's leading health threats. Consequently activity and\nleadership at the community level is fundamental to progress. Educational and com-\nmunity-based programs, developed to reach people outside of traditional health care set-\ntings, may address one risk factor in one setting, but increasingly they use multiple\ninterventions in a variety of settings.\nMany involve various sectors and levels of society. Changes in the social and physical\nenvironment call for the involvement of social institutions, businesses, legislative and\njudicial bodies, the media, and other parts of the community. Because comprehensive,\ncommunitywide programs aim to draw upon and become involved in as many aspects of\ncommunity life as possible, they require a high degree of cooperation and coordination\nbetween groups that are often not traditional partners: environmental citizen groups and\nmanufacturers, health professionals and churches, employers and hospitals. Important to\nthe success of these partnerships are information networks and coordinating mechanisms,\nboth of which can help streamline services and interventions.\nSchools offer a natural locus for the provision of crosscutting educational interventions in\nhealth, and studies have shown that school health education is an effective means of help-\ning children improve their health knowledge and develop attitudes that facilitate healthier\nbehaviors. Yet only 25 States currently mandate comprehensive school health education\nprograms, and implementation is spotty in even these States.\nSimilarly, the workplace can be an excellent site for health promotion programs. More\nthan 85 percent of adult Americans spend much of their day at their workplace.\nNumerous studies have shown the benefits of worksite health promotion programs in im-\nproving employee health, reducing insurance claims, improving morale, reducing absen-\nteeism, and reducing employee turnover. Among workplaces with more than 50 employ-\nees, about two-thirds report offering at least one health promotion activity. 71 A much\nsmaller share offers a comprehensive package to employees, and even fewer include spe-\ncial activities for family members or retirees.\nTo enhance educational and community-based programs, by the year 2000\n8.4\nProvide quality K-12 school health education in at least 75% of schools\n8.6\nProvide employee health promotion activities in at least 85% of work-\nplaces with 50 or more employees\n(a 31% increase)\nOther objectives target increasing reading levels and high school graduation rates;\nincreasing preschool programs for disadvantaged children; strengthening the public\nhealth system; increasing accessibility of health promotion programs for older people;\ndevelopment of broad State-based strategies for health promotion; and stronger focus\non the health promotion needs of minorities.\n62\n5. Priorities for Health Promotion and Disease Prevention\nHealth Protection\nUnintentional Injuries\nOccupational Safety and Health\nEnvironmental Health\nFood and Drug Safety\nOral Health\n63\nHealthy People 2000\nUnintentional Injuries\nUnintentional injuries are the fourth leading cause of death in the United States, killing\nabout 100,000 people a year, and are a major cause of disability. 51 Nonfatal injuries are\nresponsible for one of every six hospital days and one of every 10 hospital discharges.⁸¹\nNearly two-thirds of all injury deaths and 84 percent of all injuries resulting in hospital-\nization involve unintentional injuries. Motor vehicle crashes account for approximately\none-half of the deaths from unintentional injuries. Deaths from falls rank second, fol-\nlowed by deaths from poisoning, drowning, and residential fires. 17\nAt highest risk are the young and older adults. During the first four decades of life inju-\nries account for more deaths than either chronic or infectious diseases, taking more than 2\nmillion potential years of life from Americans every year. Males are more than twice as\nlikely to die from unintentional injuries than females, and blacks have higher death rates\nthan\nwhites. 51 American Indian and Alaska Natives have disproportionately higher in-\njury death rates. 30\nInjuries have been estimated to cost the United States more than $100 billion annually\ndue to lost productivity and medical care, with a third of these costs attributable to falls\nand 28 percent to motor vehicle crashes. 81\nAbout 46,000 people die and 3,500,000 people are injured annually in motor vehicle\ncrashes. By themselves, motor vehicle crashes rank as the fifth leading cause of death in\nthe United States, and approximately half of these are alcohol-related. Alcohol-related\ntraffic crashes are the leading cause of death and spinal cord injury for young\nAmericans. 60\nAlthough use of automobile safety restraints has increased in recent years, only 42 per-\ncent of people currently report using them. Increasing this share to 85 percent could save\nabout 10,000 lives per year. Given the fact that almost 30 percent of motor vehicle fatal-\nities are related to motorcycle, pedestrian, and bicycle casualities, increasing helmet use\ncould also prove of substantial benefit. 61,62\nMany injuries are multifactorial in nature. Alcohol use is a factor in numerous uninten-\ntional injuries, including about half of all motor vehicle fatalities and a sizable share of\ndrownings. Of the 33,000 firearm-related deaths in 1987, nearly 3,400 were children\naged 1 through 19. 14 Of these, about 15 percent were unintentional and often due to im-\nproper handling, accessibility to children, and lack of safety mechanisms. 14 Progress in\nreducing unintentional injuries will require full participation of the fields of education,\ntransportation, law, engineering, architecture, and safety sciences.\nTo reduce unintentional injuries, by the year 2000\n9.1\nReduce unintentional injury deaths to no more than 29.3 per 100,000\npeople\n(a 15% decrease)\n9.12 Increase automobile safety restraint use to at least 85% of occupants\n(a 102% increase)\nOther objectives target death from motor vehicle crashes, falls, drownings, and\nresidential fires; occurrence of hip fractures, poisonings, head injuries, and spinal\ncord injuries; use of protective helmets; extension of safety belt and motorcycle\nhelmet use laws; handgun design; expanded installation of fire sprinklers and smoke\ndetectors; better roadway design and markers; injury prevention instruction in\nschools; and involvement of primary care providers in counseling on safety.\n64\n5. Priorities for Health Promotion and Disease Prevention\nOccupational Safety and Health\nApproximately 110 million people make up the American workforce, with most spending\nmajor portions of their days in their work environments. Of the estimated 10 million in-\njuries that occur annually among workers, about 3 million are severe and include some\n3,400 to 11,000 deaths. Although the number of fatal occupational injuries has gradually\ndeclined in recent years, work-related illnesses and nonfatal injuries appear to be increas-\ning. During 1987, permanent impairments suffered on the job grew from 60,000 to\n70,000, total disabling injuries numbered 1.8 million, and combined occupational ill-\nnesses and injuries in the manufacturing industries increased by 12 percent.⁷\nApproximately 40 percent of work-related fatalities involved people between 25 and 44\nyears old. More than 20 percent of fatal occupational injuries in the mid-1980s involved\nhighway vehicles, which were the leading cause of death in seven of eight industry\ndivisions. Other causes included falls (13 percent), nonhighway industrial vehicular in-\njuries (11 percent), blows other than by vehicles or equipment (8 percent), and electrocu-\ntions (7 percent). Other leading work-related problems include occupational lung\ndiseases, musculoskeletal injuries, and occupational cancers.⁷\nThose occupations with relatively higher rates of injury include mining, agriculture, con-\nstruction, manufacturing, trucking, and warehousing. The largest numbers (as opposed to\nrates) of injuries occur in industries with large total workforces such as eating and drink-\ning establishments, grocery stores, hospitals, trucking companies, nursing homes, depart-\nment stores, and hotels/motels. While employees in occupations related to these enter-\nprises comprise about one-fifth of the total workforce, they report one-fourth of the inju-\nries.⁷\nPrevention of occupational health hazards rests on the basic principles of control technol-\nogy: engineering controls, work practices, personal protective equipment, and monitor-\ning of the workplace for emerging hazards. Despite the number of occupational injuries,\neffective prevention is practiced in many workplaces, and approximately 48 percent of all\nestablishments report no injuries in a given year.\nTo improve occupational safety and health, by the year 2000\n10.1 Reduce work-related injury deaths to no more than 4 per 100,000 workers\n(a 33% decrease)\n10.2 Reduce work-related injuries to no more than 6 per 100 workers\n(a 22% decrease)\nOther objectives target reductions in cumulative trauma disorders (e.g., from\nrepetitive motion, pressure, or noise), occupational skin disorders, and, among health\nworkers, hepatitis B infection; use of occupant protection systems by workers;\nreducing workplace exposure to lead; State implementation of plans for identification\nand control of major work-related illnesses and injuries; State standards to prevent\nwork-related lung disease; increasing worksites with formal plans for worker health\nand safety, including back injury prevention programs; expanded State assistance to\nsmall businesses in implementation of worker health and safety programs; and greater\nattention by primary health care providers to occupational health exposures.\n65\nHealthy People 2000\nEnvironmental Health\nEnvironmental measures have long been a mainstay of public health. State and local ef-\nforts to assure safe supplies of food and water, to manage sewage and municipal wastes,\nand to control or eliminate vector-borne illnesses have contributed substantially to public\nhealth improvements in the United States. The most difficult challenges for environmen-\ntal health today come from uncertainties about the toxic and ecologic effects of the use of\nfossil fuels and synthetic chemicals in modern society. An estimated 82 percent of major\nindustrial chemicals have not been tested for their toxic properties and links to specific\ndiseases, and only a small proportion of chemicals have been adequately tested for their\nability to cause or promote cancer. 68 Still, enough is known to target improvement in\nseveral areas.\nExposure to lead, air pollutants, and radon are good examples. Exposure to high levels of\nlead is toxic to the central nervous system and can be fatal. Even low levels of exposure\ncan result in persistent impairments in central nervous system function, especially in\nchildren, including delayed learning, impaired hearing, and growth deficits. Yet an es-\ntimated 2 out of 3 poor inner-city black children aged 6 months through 5 years have\nblood lead levels above 15 µg/dL and 1 out of 10 has levels above 25 µg/dL. For the\nNation as a whole, nearly 3 million children are at some risk from elevated lead levels. 1\nDecreased levels of lead in gasoline, air, and food and releases from industrial sources\nhave resulted in lower mean blood lead levels. However, lead in paint, dust, and soil in\ninner-city urban areas has been lowered only to a limited extent. A strong national effort\nis needed to reduce lead in the home environment.\nAirborne pollutants have been shown to contribute to lung diseases, bronchial asthma,\ncancer, neural disorders, and eye irritation. 21 Standards have been set by the Environmen-\ntal Protection Agency for ozone, carbon monoxide, particulates, sulfur dioxide, nitrogen\ndioxide, and lead. Air quality has improved greatly since 1970, but in 1988 less than 50\npercent of Americans lived in counties that met all the EPA standards for air quality for\nthe previous 12 months. 22 Additional measures are necessary to reduce contamination\nfrom motor vehicles and other sources.\nRadon comes from rock and soil, enters buildings through cracks in foundations or base-\nments, and when inhaled releases ionizing radiation that can damage lung tissue and lead\nto lung cancer. Along with tobacco smoke, it is a leading indoor air hazard, and as many\nas an estimated 8 million homes may have radon at a level requiring correction. 21 Low-\ncost test kits are available to identify exposures, but only about 5 percent of homes have\nbeen tested. 72\nTo improve environmental health, by the year 2000\n11.4 Eliminate blood lead levels above 25 µg/dL in children under age 5\n11.5 Increase protection from air pollutants so that at least 85% of people live\nin counties that meet EPA standards\n(a 71% increase)\n11.6 Increase protection from radon so that at least 40% of people live in homes\ntested by homeowners and found to be/made safe\n(a 700% increase)\nOther objectives target reducing infectious agent and chemical contamination of\ndrinking water supplies and surface water; reducing human exposure to toxic agents\nreleased into the air, water, and soil; reducing environmental burden of solid waste\ncontamination; eliminating immediate risks from hazardous waste sites; improving\nhousehold management of recyclable materials and toxic waste materials; and better\nState-based systems to track environmental exposures and diseases.\n66\n5. Priorities for Health Promotion and Disease Prevention\nFood and Drug Safety\nAmerican consumers currently benefit from extensive food and drug safety assurance sys-\ntems. Microbial contamination of food in the production process is rare. Inspections of\nfoods for pesticide residues consistently find that between 96 and 98 percent of foods\ntested do not contain pesticides in excess of legal limits-and those limits are typically\nset with a wide margin for error, 100 to 1,000 times lower than a level causing toxic ef-\nfects in animals. 23 Similarly, careful procedures are established to test new drugs, and\neach year FDA officials inspect one-third of 18,000 drug and biologics establishments in\nthe United States to ensure proper manufacture and handling. 24\nNevertheless, outbreaks of foodborne disease and incidents involving drugs continue to\noccur and cause illness or death. Some problems are caused by failures in the protective\nsystems established at the Federal, State, and local levels. In many cases, problems are\ncaused by foods improperly handled by consumers, the misuse of a prescribed drug, and\ndrug interactions that occur when different health care providers unknowingly prescribe\ndifferent drugs for the same patient.\nBased on the number and severity of cases that occur, Salmonella, Campylobacter, Es-\ncherichia coli, and Listeria are four of the most important foodborne pathogens in the\nUnited States-largely related to time and temperature abuse of foods. One problem that\nhas increased markedly over the decade of the 1980s is illness due to infection with Sal-\nmonella enteritidis. This foodborne disease is often traced to contaminated eggs and\nresults in severe diarrhea, fever, vomiting, and can even cause death. The 77 outbreaks\noccurring in 1989 involved nearly 2,400 cases and 14 deaths. 14 Expanded efforts are\nneeded both to reduce source exposure (e.g., sale of contaminated eggs) and to improve\nfood preparation and handling techniques that can protect against this problem.\nThe principal drug safety issue of the coming years is related to polypharmacy, the use of\nmultiple prescription and over-the-counter medications, especially by older people with\nchronic health problems. This problem calls for a coordinated prevention approach, in-\nvolving care on the part of those who prescribe medications to ensure that they will not\nadversely interact with previously prescribed drug regimens still in use; attentiveness on\nthe part of pharmacists to spot potential medication problems as their customers purchase\nnew prescription drugs; and education for consumers to help them comply with\nprescribed pharmacologic therapies.\nTo ensure food and drug safety, by the year 2000\n12.2 Reduce salmonella infection outbreaks to fewer than 25 yearly\n(a 68% decrease)\nOther objectives target reductions in the incidences of foodborne diseases; improving\nfood handling techniques on the part of consumers; better pharmacy-based systems to\nprovide alerts to customers of potential adverse drug interactions; and more regular\nreview by primary care providers of all medications used by their older patients.\n67\nHealthy People 2000\nOral Health\nAlthough the prevalence of dental caries or cavities among children has declined steadily\nsince the 1940s, oral diseases remain a prevalent health problem in the United States. On\naverage, among adults 40 through 44, about 1 out of 4 tooth surfaces have been affected\nby decay. 66 Currently 53 percent of children aged 6 to 8 and 78 percent of 15 year olds\nhave caries. 67 Tooth loss is a major problem among people aged 65 and older, with near-\nly 40 percent of those aged 65 and older having no natural teeth in 1986. 53 Periodontal\ndiseases, especially gingivitis, also affect many adults. The total cost of dental care to the\nNation was more than $27 billion in 1988. 28\nRegular care is a factor in maintaining oral health. However, nearly half the population\nin the United States does not obtain regular oral health care, and among low-income\npeople the proportion not receiving care is higher. 53 The proportions of black and His-\npanic adolescents with untreated decay are approximately 65 percent higher than for the\ntotal population. 57,67 One out of every four American Indian and Alaska Native adults\naged 35 through 44, and nearly three out of four aged 55 and older, has fewer than 20\nnatural teeth.\nAmong preventive measures, community water fluoridation is the single most effective\nand efficient means of preventing dental caries in children and adults, regardless of race\nor income level. Yet more than one-third of people with community water systems do\nnot have adequate fluoride, and only about half of those without fluoridated water receive\nfluoride from other sources. 10 Improvements are needed. Other factors that can improve\noral health include regular self-care, avoiding foods that promote caries, and not using\ntobacco. Excessive alcohol consumption also affects oral health.\nOral cancer is also a serious problem, with 30,000 new cases and 8,600 deaths a year. 88\nIn fact, oral cancer deaths are more numerous than deaths from cervical cancer. Because\n75 percent of oral cancers can be attributed to tobacco and alcohol use, they are prevent-\nable. Moreover, because early treatment can reduce mortality, attention is needed for its\nearly detection.\nTo improve oral health, by the year 2000\n13.1 Reduce the prevalence of dental caries to no more than 35% of children by\nage 8\n(a 34% decrease)\n13.4 Reduce edentulism to no more than 20 percent in people aged 65 and older\n(a 44% decrease)\nOther objectives target expanding treatment of dental caries; reducing periodontal\ndisease and tooth loss; increasing use of protective sealants on permanent teeth in\nchildren; improving parental practices that prevent baby bottle tooth decay; and\nimproving use of oral health screening and follow-up services for all age groups.\n68\n5. Priorities for Health Promotion and Disease Prevention\nPreventive Services\nMaternal and Infant Health\nHeart Disease and Stroke\nCancer\nDiabetes and Chronic Disabling Conditions\nHIV Infection\nSexually Transmitted Diseases\nImmunization and Infectious Diseases\nClinical Preventive Services\n69\nHealthy People 2000\nMaternal and Infant Health\nOf every 1,000 babies born in the United States each year, about 10 die before they reach\ntheir first birthday. 70 Although the infant mortality rate in the United States is declining\nand has reached an all-time low, the pace of progress has slowed. Mortality is also higher for\nblack infants, who die at twice the rate of white infants, and data from the National Birth\nCohort Study of 1983 indicate that other minorities may have higher rates than had been\nestimated previously. Leading causes of deaths among infants are congenital anomalies,\nsudden infant death syndrome (SIDS), respiratory distress syndrome, and disorders relat-\ning to short gestation. 49\nThe most prominent risk factor for infant death, low birth weight (less than 2,500 grams),\noccurred among nearly 7 percent of all births in 1987 and was associated with more than\nhalf of all infant deaths. Black babies have twice the risk of having low birth weight.\nLow birth weight is also linked to a variety of nonfatal disorders, including neurodevelop-\nmental conditions, learning and behavior problems, and lower respiratory tract infections.\nIn 1985, approximately 11,000 low-birth-weight infants were born with moderate to\nsevere disabilities. 55 From 1970 to 1981 low birth weight declined about 1.3 percent per\nyear, but has since been stagnant. 70 A number of risk factors have been identified for low\nbirth weight, including: younger and older maternal age, high parity, poor reproductive\nhistory (especially history of low birth weight), low socioeconomic status, low level of\neducation, late entry into prenatal care, low pregnancy weight gain, smoking, and other\nsubstance abuse. 35 Smoking is estimated to be associated with from 20 to 30 percent of\nall low-birth-weight births in this country. 36 Illicit drug use as a contributor to low birth\nweight has increased in some urban areas.\nAn expectant mother with no prenatal care is three times more likely to have a low-birth-\nweight baby. Despite the importance of early prenatal care in protecting against low\nbirth weight and infant deaths, nearly one of every four pregnant women in the United\nStates receives no care in the first trimester of her pregnancy. 70 A disproportionate share\nof these mothers has low income, less than a high school education, or is very young. 86\nBetween 1970 and 1980 there was a significant trend toward increasing early entry into\nprenatal care, but that trend has since plateaued. 70 Contributing to this problem is the fact\nthat an estimated 14 million women of reproductive age have no insurance to cover\nmaternity care. 2\nTo improve maternal and infant health, by the year 2000\n14.1 Reduce infant mortality to no more than 7 deaths per 1,000 births\n(a 31% decrease)\n14.5 Reduce low birth weight to no more than 5% of live births\n(a 28% decrease)\n14.11 Increase first trimester prenatal care to at least 90% of live births\n(an 18% increase)\nOther objectives target reducing rates of fetal death, maternal mortality, and fetal\nalcohol syndrome; increasing abstinence from tobacco, alcohol, cocaine, and\nmarijuana during pregnancy; increasing the proportion of mothers who gain enough\nweight during their pregnancies, as well as increasing the number who breastfeed\ntheir babies; reducing severe complications of pregnancy and cesarean delivery rates;\nincreasing the availability of preconception care and counseling, as well as of genetic\nservices and counseling; improving the management of high risk cases; and\nincreasing the proportion of babies who receive recommended primary care services.\n70\n5. Priorities for Health Promotion and Disease Prevention\nHeart Disease and Stroke\nDespite dramatic declines in mortality from heart disease and stroke in the past two\ndecades, about 7 million Americans are affected by coronary artery disease, and cardio-\nvascular diseases still cause more deaths in the United States than all other diseases com-\nbined. 51 Reductions in major risk factors-high blood pressure, high blood cholesterol,\nand smoking-are having a significant impact on cardiovascular mortality.\nApproximately 30 percent of adults in America have high blood pressure. 58 People with\nuncontrolled high blood pressure are at 3 to 4 times the risk of developing coronary heart\ndisease and as much as 7 times the risk of developing a stroke as do those with normal\nblood pressures. 18 Overall, blacks have a higher prevalence of high blood pressure than\nwhites (38 percent versus 29 percent). 58 Although surveys indicate that most adults with\nhigh blood pressure are aware of their condition, only about one-quarter to a third have\ntheir blood pressure under control. 57 This remains a problem despite the fact that many\ncan reduce their blood pressure to normal through programs of physical activity and\nweight loss, reduced sodium and alcohol intake, and stress management; and medications\nare available for those who cannot.\nThe National Heart, Lung, and Blood Institute regards a blood cholesterol level below\n200 mg/dL as desirable. 58 Yet the mean cholesterol level for Americans is 213 mg/dL, 54\nand about 60 million adults in this country are estimated to have blood cholesterol levels\nthat place them at high risk for coronary heart disease. 84 The Coronary Primary Preven-\ntion Trial showed that men at high risk were able to reduce coronary heart disease by\nabout 2 percent for every 1 percent lower blood cholesterol level. 40 Most people can\nlower their high blood cholesterol by reducing their intake of saturated fat, total fat, and\ndietary cholesterol, and by normalizing their weight and increasing physical activity.\nMedications are available for those whose blood cholesterol levels remain significantly\nelevated despite diet modification.\nTobacco use, which may account for as much as 40 percent of heart disease deaths among\npeople under age 65, is discussed elsewhere. Other contributors to cardiovascular disease\ninclude obesity, physical inactivity, and diabetes mellitus.\nTo reduce heart disease and stroke, by the year 2000\n15.1 Reduce coronary heart disease deaths to no more than 100 per 100,000\npeople\n(a 26% decrease)\n15.2 Reduce stroke deaths to no more than 20 per 100,000 people\n(a 34% decrease)\n15.4 Increase control of high blood pressure to at least 50% of people with HBP\n(a 108% increase)\n15.6 Reduce blood cholesterol to an average of no more than 200 mg/dL\n(a 6% decrease)\nOther objectives target appropriate management behaviors by those with high blood\ncholesterol and high blood pressure; reducing dietary fat intake; reducing overweight\nand increasing physical activity; reducing tobacco use; increasing numbers of adults\nwho have recently been screened for high blood pressure or high blood cholesterol;\nbetter use of worksites for detection and followup programs; and improving\nadherence to recommended protocols and standards for primary care providers and\nlaboratories involved in cholesterol testing and management.\n71\nHealthy People 2000\nCancer\nCancer accounts for about one of every five deaths in the United States each year. 3\nAbout 75 million Americans now living, nearly one in three, will eventually have cancer.\nWhile the incidence of cancer has increased in the past two decades, death rates for those\nunder 55 have fallen. 47 More people are surviving cancer now than several decades ago.\nNot everyone, however, has benefitted equally from this trend. Blacks are less likely\nthan whites to survive 5 years from the time of diagnosis. The five-year survival rate for\nall cancer sites combined is 50 percent for white patients and 37 percent for black\npatients.\nOnce surrounded by fear and fatalism, cancer has been the focus of nationwide educa-\ntional campaigns to inform the public that the risk of cancer can be significantly reduced\nwhen adequate preventive measures are taken. Tobacco has been estimated to account\nfor 30 percent of cancers, and dietary factors roughly another 35 percent. 48 For example,\nmost cases of lung cancer, the leading cause of cancer mortality, can be prevented by not\nsmoking, and epidemiological research suggests that diets relatively low in fat and higher\nin foods containing fiber may help prevent colon, rectal, breast, prostate, and other can-\ncers. High levels of alcohol use have been linked to esophageal and oral cancers. Limit-\ning sun exposure, use of sunscreens and protective clothing when exposed to sunlight,\nand avoidance of sun lamps and tanning booths can reduce the risk of skin cancer.\nEarly detection also can have an important impact on cancer death rates. Procedures\nsuch as mammography and clinical breast examination, the Pap test, fecal occult blood\ntests, proctosigmoidoscopy, and oral, skin, and digital rectal examinations make it pos-\nsible to treat cancers before they spread. For example, research suggests than breast can-\ncer deaths could be reduced by 30 percent among women aged 50 and older through the\nuse of mammography and clinical breast examination. 85,89,93 Yet in 1987, only 25 per-\ncent of such women had these tests within the preceding 2 years. A Pap test could reduce\ncervical cancer deaths by an estimated 75 percent, but one out of every five women with\nfamily incomes less than $10,000 has never had a Pap test. 53 Despite the fact that fecal\noccult blood testing and sigmoidoscopy are important to facilitate early diagnosis of\ncolorectal cancer, especially among those at high risk, only 27 percent of people aged 50\nand older report receiving a fecal occult blood test within the preceding 2 years.\nTo prevent and control cancer, by the year 2000\n16.1 Reverse the rise in cancer deaths to no more than 130 per 100,000 people\n16.11 Increase clinical breast exams and mammography every 2 years to at\nleast 60% of women aged 50 and older\n(a 140% increase)\n16.12 Increase Pap tests every 1-3 years to at least 85% of women aged 18 and\nolder\n(a 13% increase)\n16.13 Increase fecal occult blood testing every 1-2 years to at least 50% of\npeople aged 50 and older\n(an 85% increase)\nOther objectives target reducing dietary fat intake; increasing consumption of\nvegetables, fruits, and grain products; reducing tobacco use; decreasing sun exposure;\nmore counseling by primary care providers on diet and tobacco use and offering of\nscreening procedures according to established protocols; and improving the quality of\nPap tests and mammograms.\n72\n5. Priorities for Health Promotion and Disease Prevention\nDiabetes and Chronic Disabling Conditions\nAs the population of the United States grows older, the problems posed by chronic and\ndisabling conditions increasingly demand the Nation's attention. Chronic conditions\nsuch as heart disease, cancer, stroke, and lung and liver disease are joined in importance\nby other chronic and disabling conditions, affecting people in all age groups, such as\ndiabetes, arthritis, deformities or orthopedic impairments, hearing and speech impair-\nments, and mental retardation.\nChronic and disabling conditions have a profound effect not only on mortality rates but\nalso on quality of life. Disability, defined by its impact on major activities one is able to\nperform, affected more than 9 percent of Americans in 1988 50 About 33 million people\nhave functional limitations that interfere with their daily activities, and more than 9 mil-\nlion have limitations that prevent them from working, attending school, or maintaining a\nhousehold. The underlying impairments most often responsible for these conditions are\narthritis, heart disease, back conditions (including spinal curvature), lower extremity im-\npairments, and intervertebral disk disorders.³⁷ For those under age 18 the most frequent\ncauses of activity limitation are asthma, mental retardation, mental illness, and hearing\nand speech impairments.\nDiabetes is one of the most prevalent chronic conditions among Americans. Approxi-\nmately 7 million people in the United States have been diagnosed with diabetes and each\nyear some 650,000 new cases are identified. In 1987, diabetes was the underlying cause\nof death for more than 37,000 Americans and contributed to over 100,000 additional\ndeaths. According to the American Diabetes Association, in addition to death, diabetes is\naccountable for 30 percent of kidney failure cases, is the second leading cause of blind-\nness in people aged 45 through 74, causes half of all nontraumatic amputations, and\ncauses a threefold increase in risk for congenital malformations and perinatal mortality\namong babies of diabetic mothers. Insulin-dependent diabetes mellitus (IDDM or Type\nI) is the most severe form, but comprises no more than 10 percent of all cases of diabetes.\nNoninsulin-dependent diabetes mellitus (NIDDM or Type II), while serious, has less\nsevere consequences, usually appears after age 40, is often associated with obesity, and\nmay often be controlled by diet and exercise, sometimes in combination with oral hypo-\nglycemic agents. Careful control of diabetes is critical to prevention of its complications.\nDiet and physical activity are important to the management of both types of diabetes, and\nNIDDM can often be prevented through these measures.\nTo reduce diabetes and chronic disabling conditions, by the year 2000\n17.2 Reduce disability from chronic conditions to no more than 8% of people\n(a 15% decrease)\n17.9 Reduce diabetes-related deaths to no more than 34 per 100,000 people\n(an 11% decrease)\nOther objectives target reducing reducing complications of diabetes; reducing\ndisability from asthma, chronic back conditions, osteoporosis, hearing impairment,\nvision impairment, and mental retardation; increasing physical activity; reducing\noverweight; improving early diagnosis and referral for disabling conditions among\nthe very young and older people; improving community and self-help resources for\npeople with chronic and disabling conditions; and improving employer policies\nrelated to the needs of people with disabilities.\n73\nHealthy People 2000\nHIV Infection\nThe human immunodeficiency virus (HIV) epidemic is a multifaceted national and inter-\nnational problem. People with HIV infection can develop acquired immunodeficiency\nsyndrome (AIDS), including severe opportunistic infections, Kaposi's sarcoma, and\nmultiple-system medical complications. Without treatment about 50 percent of people\ndevelop AIDS within 10 years of becoming infected with HIV, and another 40 percent or\nmore develop other clinical illnesses associated with HIV infection. 29 By the end of\n1989, reported cases of AIDS had reached 115,000, 12 but the projected figure is expected\nto more than triple or quadruple by the end of 1993. It has become the seventh leading\ncause of potential years of life lost in the United States. By the end of 1993, a projected\ntotal of 390,000 to 480,000 cases of AIDS will have been diagnosed in the United States\nand 285,000 to 340,000 people will have died from the disease. 14 Annual costs of AIDS\nare projected to climb as high as $5 to $13 billion by 1992. 14,43\nAn estimated 1 million people in the United States are infected with HIV and of these ap-\nproximately 40,000 became infected in 1989. Groups at special risk have been identified\nand include: intravenous drug abusers and their sex partners; people with large numbers\nof sex partners; men who have sex with men, and their female partners; and people who\nexchange sex for money or drugs. Of current AIDS patients, more than three-fourths are\nmale, and two-thirds are male homosexuals and bisexuals; but the most rapid increases\nare occurring among intravenous drug-abusers, women, and babies born to women in\nhigh risk groups. An estimated 20 to 35 percent of infants of infected mothers develop\nHIV infection. Approximately 60 percent of AIDS patients are white, 25 percent are\nblack, and 15 percent are Hispanic. 12\nAlthough some therapeutic agents may extend survival, there is currently no available\ntreatment to prevent death among people with AIDS. The survival rate in the early 1980s\nwas only about 15 percent, before the licensure of antiviral drugs, such as zidovudine\n(AZT). AZT has been shown to slow replication of the virus and improve survival\nprospects, as have selected other agents now under study.\nThe development of a safe and effective HIV vaccine is a high priority for the coming\ndecade, although the prospects for the availability of such a vaccine are uncertain. Other\nprevention and control strategies are vital to stopping the spread of HIV infection. Most\nHIV-infected people in the United States do not know they harbor the virus, and in-\ncreased counseling, testing, and follow-up services are needed. Public education efforts\non risks and precautions are essential to slowing the spread of the disease.\nTo prevent and control HIV infection, by the year 2000\n18.2 Confine HIV infection to no more than 800 per 100,000 people\nOther objectives target reducing experience with sexual intercourse among\nadolescents; increasing use of condoms among sexually active, unmarried people;\nincreasing outreach and access to treatment programs for intravenous drug abusers;\nexpanding testing and counseling for people at risk of HIV infection, including\nimproved skills among primary care providers; increasing education in schools and\ncolleges about HIV infection and its prevention; and extension of regulations to\nprotect workers at risk for occupational transmission of HIV.\n74\n5. Priorities for Health Promotion and Disease Prevention\nSexually Transmitted Diseases\nSexually transmitted diseases affect almost 12 million Americans each year, 86 percent\nof whom are aged 15 through 29. 11 About one-fifth of all young people, by the time they\nreach 21, have needed treatment for a sexually transmitted disease. 94 Because only some\nteenagers are sexually active, this amounts to an effective rate of at least 25 percent among\nthose who are. The sexually transmitted diseases encompass more than 50 recognized\norganisms and syndromes, including, in addition to syphilis and gonorrhea, chlamydia\ntrachomatis infections, genital herpes, hepatitis B, chancroid, cytomegalovirus, and\nhuman immunodeficiency virus (HIV). After AIDS, the most serious complications of\nsexually transmitted diseases are pelvic inflammatory disease (PID), sterility, ectopic\npregnancy, blindness, cancer associated with human papillomavirus, fetal and infant\ndeath, birth defects, and mental retardation. The total societal cost of sexually trans-\nmitted diseases exceeds $3.5 billion annually, with the cost of PID and PID-associated\nectopic pregnancy and infertility alone exceeding $2.6 billion. 94\nGonorrhea is the most frequently reported communicable disease in the United States. In\n1989, some 733,000 cases were reported and the incidence was an estimated 300 per\n100,000 people. Youth, low-income, and minority populations are at particular risk. In\n1989, adolescents aged 15 through 19 had an infection rate of 1,125 per 100,000 and\nblacks a rate of 1,990 per 100,000. Despite the fact that since 1981, cases of gonorrhea in\nmales have declined 29 percent and declined 24 percent in females, the rates have not\ndeclined among racial and ethnic minorities or among teenagers. Furthermore, the per-\ncent of all gonorrhea organisms that are antibiotic-resistant grew from less than 1 percent\nin 1985 to 7 percent in 1989. 10\nIn 1989, nearly 45,000 cases of syphilis were also reported. Syphilis is the first sexually\ntransmitted disease for which control measures were developed and tested. Since the in-\nitiation of Federal assistance for syphilis control in the 1940s, reported cases of all stages\nof syphilis declined from an all-time high of 575,600 cases in 1943 to fewer than 68,000\ncases in 1985. In recent years, however, the number of syphilis cases has increased dra-\nmatically, due in part to an increase in the exchange of sex for drugs, to an increased num-\nber of crack cocaine users, and to increased sexual activity among adolescents. Between\n1986 and 1989, the number of reported syphilis cases increased over 55 percent, to the\nhighest level in the United States since the early 1950s. 10\nTo reduce sexually transmitted diseases, by the year 2000\n19.1 Reduce gonorrhea infections to no more than 225 per 100,000 people\n(a 25% decrease)\n19.3 Reduce syphilis infections to no more than 10 per 100,000 people\n(a 45% decrease)\nOther objectives target reducing infections with chlamydia trachomatis, genital\nherpes and genital warts, and hepatitis B; reducing occurrence of pelvic inflammatory\ndisease; increasing use of condoms among sexually active, unmarried people; fuller\navailability of comprehensive sexually transmitted disease-related services in clinics\nand centers that provide family planning, maternal and child health care, drug\ntreatment, and primary care to low income families; increasing partner tracing and\nnotification; improving primary care provider management of STD cases; and\ninclusion of instruction on STD transmission and prevention as part of school health\neducation for middle and secondary school students.\n75\nHealthy People 2000\nImmunization and Infectious Diseases\nThe reduction in incidence of infectious diseases is the most significant public health\nachievement of the past 100 years. This success is most notably embodied in the global\neradication of smallpox, achieved in 1977. Other gains in control of infectious diseases\nare nearly as striking, including the virtual elimination of diphtheria and poliomyelitis in\nthe United States. Much of the progress made has been a result of improvements in basic\nhygiene, food production and food handling, and water treatment. The development and\nuse of antimicrobial drugs have reduced the morbidity and mortality associated with a\nnumber of infectious diseases. The other major factor in reducing the toll from infectious\ndiseases has been the development and widespread use of vaccines, which are among the\nsafest and most effective measures for the prevention of infectious diseases.\nNevertheless, infectious diseases still cause many preventable illnesses and deaths. Influ-\nenza and pneumonia, for example, shorten the lives of many older adults despite the avail-\nability of vaccines. Approximately 80 to 90 percent of all influenza-associated deaths in\nthe United States occur in people 65 years or older.⁹ The childhood vaccine-preventable\ndiseases, although they have declined dramatically, remain problems among certain high-\nrisk, under-immunized groups. Moreover, newly recognized diseases, such as Legion-\nnaire's disease, toxic shock syndrome, Lyme disease, and the wide spectrum of diseases\nassociated with human immunodeficiency virus infection, have emerged as threats to\npublic health.\nThe occurrence of measles in the United States is an example of an infectious disease\nproblem that should be readily controlled in that a vaccine has been available since 1963.\nUse of that vaccine helped to reduce the number of reported measles cases in this country\nto an all-time-low of under 1,500 in 1983. However, due to inadequate immunization of\nlow-income preschool children, as well as of young people, the disease has demonstrated\na resurgence in susceptible populations, with over 16,000 cases reported in 1989, includ-\ning\n41\ndeaths. 42 In response, the measles immunization protocol recommended by the\nImmunization Practices Advisory Committee now calls for a two-dose schedule of meas-\nles vaccine, but effective control will also require better outreach in low-income com-\nmunities, continued strong enforcement of school entry laws, and efficient identification\nand intervention in disease outbreaks.\nTo increase immunization and prevent infectious diseases, by the year 2000\n20.1 Eliminate measles\n20.2 Reduce epidemic-related pneumonia and influenza deaths to no more than\n7.3 per 100,000 people aged 65 and older\n(a 20% decrease)\n20.11 Increase childhood immunization levels to at least 90% of 2 year-olds\n(a 20% increase)\nOther objectives target eliminating indigenous cases of diphtheria, tetanus, polio, and\nrubella; reducing viral hepatitis, tuberculosis, bacterial meningitis; reducing\ninfectious diarrhea among children in licensed child care centers; reducing middle ear\ninfections; increasing immunization levels for pneumococcal pneumonia and\nhepatitis B; expanding immunization laws for schools, preschools, and child care\nsettings; eliminating financial barriers to immunizations; fully involving primary care\nproviders in meeting the immunization needs of their patients; and expanding\nlaboratory capabilities for rapid viral diagnosis of influenza.\n76\n5. Priorities for Health Promotion and Disease Prevention\nClinical Preventive Services\nClinical preventive services refer to those disease prevention and health promotion ser-\nvices-immunizations, screening, and counseling-delivered to individuals in a health\ncare setting. The effectiveness of preventive services in reducing disease, disability, and\npremature death is now well documented. The dramatic declines observed for childhood\ninfectious diseases and early death from strokes and cervical cancer are largely attributed\nto the widespread application of three preventive services: childhood immunizations,\nhigh blood pressure detection and control, and Pap tests. Several other preventive ser-\nvices, such as screening mammography, have also been shown to be effective. In 1989,\nthe U.S. Preventive Services Task Force reported on its review of the scientific evidence\non 169 clinical preventive services for 60 target conditions. Based on well-established\ncriteria, it published in the Guide to Clinical Preventive Services⁹² its recommendations\non the basic services that should be provided.\nDespite their proven effectiveness, clinical preventive services are rarely covered under\nhealth insurance or delivered as recommended. The few studies that have examined the\nreceipt of clinical preventive services have found the delivery to be less than optimal.\nFor example, although 93 percent of newborns studied had received at least one well-\nchild examination, less than half had received three or more doses of diphtheria-pertussis-\ntetanus (DPT) vaccine and three or more doses of polio vaccine by age 18 months. 41 The\nNational Health Interview Survey found an increase in the use of eight routine preventive\nservices among adults and children between 1973 and 1982, but low-income people,\npeople with low levels of education, and people of Hispanic origin were among the least\nlikely to have ever received all eight procedures. 19 A related study found that only 42\npercent of women had adequately received a blood pressure check, clinical breast ex-\namination, Pap test, and glaucoma screening.⁹⁶ Screening was less adequate among the\npoor, the less educated, and those living in rural areas, with only 33, 34, and 38 percent,\nrespectively, screened for all four conditions.\nBarriers specific to the delivery or use of preventive services include uncertainty among\nhealth care providers about which services to offer, practice organization characteristics\nthat are not conducive to delivery of preventive services (e.g., lack of time, too few allied\nhealth professionals, and limited access to medical record systems organized for preven-\ntion), and inadequate knowledge among consumers to create the necessary demand.\nAnother important barrier is the lack of reimbursement or financing. In addition to the\nfact that few insurance plans cover preventive services, a substantial proportion of\nAmericans-some 30 to 37 million-are without any form of health insurance. And\nmany more are underinsured or are covered by insurance programs with requirements\nand payments that providers are increasingly reluctant to accept.\nTo expand access and use of clinical preventive services, by the year 2000\n21.4 Eliminate financial barriers to clinical preventive services\nOther objectives target increasing the proportion of people with a specific source of\nongoing primary care; increasing primary care providers' delivery of recommended\npreventive services; increasing the number of people who receive recommended\nclinical preventive services; increasing delivery of preventive services to patients of\npublicly funded providers of primary care; and increasing representation of minorities\namong primary care providers.\n77\nHealthy People 2000\nSurveillance and Data Systems\n78\n5. Priorities for Health Promotion and Disease Prevention\nSurveillance and Data Systems\nSystematically collecting, analyzing, interpreting, disseminating, and using health data is\nessential to understanding the health status of a population and to planning effective pre-\nvention programs. Public health surveillance and data systems collect information on\nmorbidity, mortality, disability, injuries, risk factors, services, and costs. Systems used in\nthe United States include vital statistics and disease reporting systems as well as sample\nsurveys, such as the continuous National Health Interview Survey (NHIS).\nAlthough the United States Public Health Service takes the lead role in national public\nhealth data collection, it is only one partner within the larger structure necessary to col-\nlect national public health data. Surveillance often requires active cooperation among\nFederal, State, and local agencies. For example, the National Vital Statistics System ob-\ntains information on births, deaths, marriages, and divorces from all 50 States, New York\nCity, the District of Columbia, Puerto Rico, the United States Virgin Islands, and Guam.\nPrograms in each State collect vital information from many sources in local communities,\nincluding funeral directors, medical examiners, coroners, hospitals, religious authorities,\nand justices of the peace. Other surveys, like the National Health Interview Survey, are\nbased on interviews with thousands of individual citizens nationwide. Still others, like\nthe Centers for Disease Control's Behavioral Risk Factor Surveillance System, are based\non State reports of telephone interviews with individual citizens.\nThe Institute of Medicine's report, The Future of Public Health, recognized the impor-\ntance of surveillance and data systems for guiding public health into the 21st century, in\nrecommending the creation and use of methods for the collection of national data that\nwill permit comparison of local and State health data with those of the Nation and of\nother States and localities and that will facilitate progress towards the national health ob-\njectives. ,,31 The development and dissemination of comparable procedures for data col-\nlection would facilitate comparability of data on health status within and among State and\nlocal areas and would permit the valid comparison of local and State health data with na-\ntional data. In addition, the development of a small set of common health indicators, ar-\nrived at through a consensus process, would facilitate communication among public\nhealth officials and with others involved in programs and activities that affect the\nNation's health (e.g., employers and school administrators). Though complete com-\nparability across data systems is not possible given the differences in purposes and ap-\nproaches (e.g., direct interviews V. telephone V. mail), differences can be minimized.\nTo improve surveillance and data systems, by the year 2000\n22.1 Develop and implement common health status indicators for use by\nFederal/State/local health agencies\nOther objectives target creation of data sources to track the year 2000 objectives;\nexpanded State-based activity to track the progress of the population toward the year\n2000 objectives; improvement of related data for blacks, Hispanics, American Indians\nand Alaska Natives, Asian Americans, and people with disabilities; improvement of\ninformation transfer capabilities among Federal, State, and local agencies; and more\nspeedy processing of survey and surveillance data.\n79\nHealthy People 2000\nReferences\n1\n15\nAgency for Toxic Substances and Disease\nCenters for Disease Control In: U.S Preventive\nRegistry. 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Presented at\nHealth and Human Services, 1989.\nAIDS/Frontline Health Care Conference,\n31\n1989.\nInstitute of Medicine, National Academy of\nSciences. The Future of Public Health.\n44\nMercy, J.A., and Houk, V.N. Firearm injuries:\nWashington, DC: National Academy Press,\nA call for science. New England Journal of\n1988.\nMedicine 319:1283-85, 1988.\n32\nJones, E.F.; Forrest, J.D.; Goldman, N; Hen-\n45 Monitoring the Future Study (High School\nshaw, S.; Lincoln, R.; Rosoff, J.I.; Westoff,\nSenior Survey), Alcohol, Drug Abuse, and\nC.F.; and Wulf, D. Teenage Pregnancy in In-\nMental Health Administration, Public Health\ndustrialized Countries: A Study Sponsored by\nService, U.S. Department of Health and\nthe Alan Guttmacher Institute New Haven,\nHuman Services, Rockville, MD.\nCT: Yale University Press, 1986.\n46 Moscicki, E.K., and Boyd, J.H. Epidemiologic\n33 Katz, S.; Branch, L.G.; Branson, M.H.; Pap-\ntrends in firearm suicides among adoles-\nsidero, J.A.; Beck, J.C.; and Greer, D.S. Active\ncents. Pediatrician 12:52-62, 1985.\nlife expectancy. New England Journal of\n47 National Cancer Institute. 1987 Annual Cancer\nMedicine 309:1218-1224, 1983.\nStatistics Review. DHHS Pub.No. (NIH)88-\n34\nKleinman, J.C.; and Kopstein, A. Smoking\n2789. Bethesda, MD: U.S. Department of\nduring pregnancy 1967-1980. American Jour-\nHealth and Human Services, 1988.\nnal of Public Health 77:823-825, 1987.\n48 National Cancer Institute. Cancer control ob-\n35 Kleinman, J.C., and Kessel, S.S. Racial differen-\njectives for the nation: 1985-2000. National\nces in low birthweight: Trends and risk fac-\nCancer Institute Monographs 2 (1986). DHHS\ntors. New England Journal of Medicine 317:749-\nPub. No. (NIH)86-2880. Bethesda, MD: U.S.\n753, 1987.\nDepartment of Health and Human Services,\n1986.\n36 Kleinman, J.C., and Madans, J.H. The effects of\nmaternal smoking, physical stature, and\n49 National Center for Health Statistics. Advance\neducational attainment on the incidence of\nReport of Final Mortality Statistics, 1987.\nlow birthweight. American Journal of\nMonthly Vital Statistics Report. Vol. 38 No. 5\nEpidemiology 121(6):843-855, 1985.\n(Supp.) Hyattsville, MD: U.S. Department of\n37\nHealth and Human Services, 1989.\nLaPlante, M.P. Data on Disability from the Na-\ntional Health Interview Survey, 1983-85. An\n50 National Center for Health Statistics. Current\nInfoUse Report. Washington, D.C.: National\nEstimates from the National Health Inter-\nInstitute on Disability and Rehabilitation Re-\nview Survey, United States, 1988. Vital and\nsearch, 1988.\nHealth Statistics. Series 10, No. 173, DHHS\n38\nPub. No. (PHS)89-1501. Hyattsville, MD: U.S.\nLeon, A.S. Effects of physical activity and fit-\nDepartment of Health and Human Services,\nness on health. In: National Center for\n1989.\nHealth Statistics. Assessing Physical Fitness and\nPhysical Activity in Population-Based Surveys.\n51 National Center for Health Statistics. Health,\nDHHS Pub. No. (PHS)89-1253. Hyattsville,\nUnited States, 1989 and Prevention Profile.\nMD: U.S. Department of Health and Human\nDHHS Pub. No. (PHS)90-1232. Washington,\nServices, 1989.\nDC: U.S. Department of Health and Human\n39 Leon, A.S.; Connett, J.; Jacobs, D.R.; and\nServices, 1990.\nRaurama, R. Leisure-time physical activity\n52 National Center for Health Statistics. Hispanic\nlevels and risk of coronary heart disease and\nHealth and Nutrition Examination Survey, 1983-\ndeath: The multiple risk factor intervention\n84. Hyattsville, MD: U.S. Department of\ntrial. JAMA 258:2388-2395, 1987.\nHealth and Human Services.\n40\nLipid Research Clinics Program. The lipid re-\n53\nNational Center for Health Statistics. National\nsearch clinics coronary primary prevention\nHealth Interview Survey, 1986. Hyattsville,\ntrial results: I. Reduction in the incidence of\nMD: U.S. Department of Health and Human\ncoronary heart disease. JAMA 251:351-364,\nServices.\n1984.\n81\nHealthy People 2000\n54\nNational Center for Health Statistics. \"Total\n65\nNational Institute on Alcohol Abuse and Al-\nSerum Cholesterol Levels of Adults 20-74\ncoholism. Sixth Special Report to the U.S. Con-\nYears of Age, United States, 1976-80.\" Data\ngress on Alcohol and Health. Washington, DC:\nfrom the National Health Survey, Series II,\nU.S. Department of Health and Human Ser-\nNo. 236. Hyattsville, MD: U.S. Department of\nvices, 1987.\nHealth and Human Services, 1986.\n66 National Institute of Dental Research. The\n55\nNational Commission to Prevent Infant Mor-\nOral Health of United States Adults. The Nation-\ntality. Indirect Costs of Infant Mortality and Low\nal Survey of Oral Health in U.S. Employed\nBirth Weight. Washington, DC: the Commis-\nAdults and Seniors: 1985-1986. DHHS Pub.\nsion, 1988.\nNo. (PHS)87-2868. Bethesda, MD: U.S.\n56\nDepartment of Health and Human Services,\nNational Family Violence Survey 1985, Nation-\n1987.\nal Institute of Mental Health, Alcohol, Drug\n67\nAbuse, and Mental Health Administration,\nNational Institute of Dental Research. Oral\nPublic Health Service, U.S. Department of\nHealth of United States Children. The National\nHealth and Human Services, Rockville, MD.\nSurvey of Dental Caries in U.S. School Children,\n57\n1986-1987. DHHS Pub. No. (PHS)89-2247.\nNational Health and Nutrition Examination\nBethesda, MD: U.S. Department of Health\nSurvey, National Center for Health Statistics,\nand Human Services, 1989.\nCenters for Disease Control, Public Health\nService, U.S. Department of Health and\n68\nNational Research Council. Toxicity Testing:\nHuman Services, Hyattsville, MD.\nStrategies to Determine Needs and Priorities.\n58\nWashington, DC: National Academy Press,\nNational Heart, Lung and Blood Institute. Hy-\n1984.\npertension prevalence and the status of\nawareness, treatment, and control in the\n69 National Survey of Family Growth. National\nUnited States: Final report of the subcommit-\nCenter for Health Statistics, Centers for Dis-\ntee on definition and prevalence of the 1984\nease Control, Public Health Service, U.S.\njoint national committee. Hypertension\nDepartment of Health and Human Services,\n7(3):457-468, 1985.\n1988.\n59\nNational Heart, Lung, and Blood Institute.\n70 National Vital Statistics System, National Cen-\nReport of the Expert Panel on Detection, Evalua-\nter for Health Statistics, Centers for Disease\ntion, and Treatment of High Blood Cholesterol\nControl, Public Health Service, U.S. Depart-\nAdults. National Cholesterol Education Pro-\nment of Health and Human Services, Hyat-\ngram. Bethesda, MD: U.S. Department of\ntsville, Maryland.\nHealth and Human Services, 1988.\n71\nOffice of Disease Prevention and Health\n60 National Highway Traffic Safety Administra-\nPromotion. National Survey of Worksite Health\ntion. The Economic Cost to Society of Motor\nPromotion Activities: A Summary.\nVehicle Accidents. Technical Report DOT HS\nWashington, DC: U.S. Department of Health\n809-195, p. 1. Washington, DC: U.S. Depart-\nand Human Services, 1987.\nment of Transportation, 1987.\n72 Office of Radiation Programs, U.S. Environ-\n61 National Highway Traffic Administration. The\nmental Protection Agency, Washington, DC.\nEffectiveness of Motorcycle Helmets in Prevent-\ning Fatalities. Technical Report DOT HS 807-\n73 Office on Smoking and Health. Reducing the\n416. Washington, DC: U.S. Department of\nHealth Consequences of Smoking: 25 Years of\nTransportation, 1989.\nProgress. A Report of the Surgeon General.\nDHHS Publication No. (CDC)89-8411.\n62 National Highway Traffic Safety Administra-\nWashington, DC: U.S. Department of Health\ntion. Motorcycle Accident Cause Factors and\nand Human Services, 1989.\nIdentification of Countermeasures. Technical\nReport DOT HS 805-862. Washington, DC:\n74 Paffenbarger, R.S.; Hyde, R.T.; Wing, A.L.; and\nU.S. Department of Transportation, 1981.\nHsieh, C.C. Physical activity, all-cause mor-\ntality, and longevity of college alumni. New\n63 National Household Survey of Drug Abuse,\nEngland Journal of Medicine 314:605-613, 1986.\nNational Institute on Drug abuse, Alcohol,\nDrug Abuse, and Mental Health Administra-\n75 Paffenbarger, R.S.; Wing, A.L.; and Hyde, R.T.\ntion, Public Health Service, U.S. Department\nPhysical activity as an index of heart attack\nof Health and Human Services, Rockville,\nrisk in college alumni. American Journal of\nMD..\nEpidemiology 108:161-175, 1978.\n64\nNational Institute on Alcohol Abuse and Al-\n76 Perrine, M.; Peck, R.; and Fell, J.\ncoholism. Seventh Special Report to the U.S.\nEpidemiologic perspectives on drunk driv-\nCongress on Alcohol and Health. Washington,\ning. In: Surgeon General's Workshop on Drunk\nDC: U.S. Department of Health and Human\nDriving: Background Papers. Washington,\nServices, 1988.\nDC: U.S. Department of Health and Human\nServices, 1988.\n82\n5. Priorities for Health Promotion and Disease Prevention\n77\n87\nPowell, K.E.; Caspersen, C.J.; Koplan, J.P.; and\nSonnenstein, F.L.; Pleck, J.H.; Ku, L.C. Sexual\nFord, E.S. Physical activity and chronic dis-\nactivity, condom use, and AIDS awareness\nease. American Journal of Clinical Nutrition\namong adolescent males. Family Planning\n49:999-1006, 1989.\nPerspectives 21(4):152-158, 1989.\n78 Powell, K.E.; Thompson, P.D.; Caspersen, C.J.;\n88\nSurveillance, Epidemiology, and End Results\nand Kendrick, J.S. Physical activity and the\nProgram, 1987. National Cancer Institute,\nincidence of coronary heart disease. Annual\nNational Institutes of Health, Public Health\nReview of Public Health 8:253-287, 1987.\nService, U.S. Department of Health and\nHuman Services, Bethesda, MD.\n79 Public Health Service. The Surgeon General's\n89\nReport on Nutrition and Health. DHHS Pub.\nTabar, L.; Gad, A.; Holmberg L.H.; Ljungquist,\nNo. (PHS)88-50210. Washington, DC: U.S.\nV.; Eklund, G.; Fagorberg, C.J.G.; Baldetorp,\nDepartment of Health and Human Services,\nL.; Grontoft, O.; Lundstrom, B.; Manson, J.C.;\n1988.\nDay, N.E.; and Pehersson, F. Reduction in\nmortality from breast cancer after mass\n80 Rice, D.P.; Kelman, L.S.; Dunmeyer, S. The\nscreening with mammography. Lancet 1:829-\nEconomic Costs of Alcohol and Drug Abuse and\n832, 1985.\nMental Illness. San Francisco, CA: Institute\n90\nfor Health and Aging, University of Califor-\nTanfer, K., and Horn, M.C. Contraceptive use,\nnia-San Francisco, 1990.\npregnancy, and fertility patterns among\nsingle American women in their 20s. Family\n81 Rice, D.P.; MacKenzie, E.J.; Jones, A.S.; Kauf-\nPlanning Perspectives 17(1):10-19, 1985.\nman, S.R.; deLissovoy, G.V.; Max, W.; Mc-\n91\nLoughlin, E.; Miller, T.R.; Robertson, L.S.;\nU.S. Department of Agriculture and U.S.\nSalkever, D.S.; and Smith, G.S. Cost of Injury\nDepartment of Health and Human Services.\nin the United States: A Report to Congress,\nDietary Guidelines for Americans. Washington,\n1989. San Francisco, CA: Institute for Health\nDC: the Departments, 1990.\nand Aging, University of California and In-\n92 U.S. Preventive Services Task Force. Guide to\njury Prevention Center, The Johns Hopkins\nClinical Preventive Services: An Assessment of\nUniversity, 1989.\nthe Effectiveness of 169 Interventions, Report of\n82 Sallis, J.F.; Haskell, W.L.; Fortmann, S.P.;\nthe U.S. Preventive Services Task Force. Bal-\nWood, P.D.; and Vranizan, K.M. Moderate-\ntimore, MD: Williams and Wilkins, 1989.\nintensity physical activity and cardiovascular\n93 Verbeek, A.L.M.; Hendricks, J.H.C.L.; Holland,\nrisk factors: The Stanford five-city project.\nR.; Mravunac, M.; Sturmans, F.; and Day,\nPreventive Medicine 15:561-568, 1986.\nN.E. Reduction of breast cancer mortality\n83 Salonen, J.T.; Puska, P.; and Tuomilehto, J.\nthrough mass screening with modern mam-\nPhysical activity and risk of myocardial in-\nmography: First results of the Nijmegan\nfarction, cerebral stroke and death: A lon-\nProject, 1975-1981. Lancet 1:1222-1224, 1984.\ngitudinal study in Eastern Finland. American\nJournal of Epidemiology 115:526-537, 1982.\n94 Washington, A.E.; Arno, P.S.; and Brooks,\nM.A. The economic costs of pelvic inflam-\n84 Sempos, C.; Fulwood, R.; Haines, C.; Carroll,\nmatory disease. JAMA 255:1735-1738, 1986.\nM.; Anda, R.; Williamson, B.F.; Remmington,\nP.; and Cleeman, J. The Prevalence of High\n95 Westat, Inc. Study of the National Incidence of\nBlood Cholesterol Levels Among Adults in\nChild Abuse and Neglect. Washington, DC:\nthe United States. JAMA 262:45-52, 1989.\nU.S. Department of Health and Human Ser-\nvices, 1988.\n85 Shapiro, S.; Venet, W.; Strax, L.; and Roeser; R.\n96 Woolhandler, S., and Himmelstein, D.U.\nSelection, Followup, and Analysis in the\nHealth Insurance Plan Study: A Randomized\nReverse targeting of preventive care due to\nTrial With Breast Cancer Screening. National\nlack of health insurance. JAMA 259:2872-\n2874, 1988.\nCancer Institute Monographs 67:65-74, 1985.\n86\nSingh, S.; Torres, D.; and Forrest, J.D. The need\nfor prenatal care in the United States:\nEvidence from the 1980 national natality sur-\nvey. Family Planning Perspectives 17:118-124,\n1985.\n83\n6. Shared Responsibilities\nThe challenge set out through Healthy People 2000 is one directed to people throughout\nthe Nation. Each of us, whether acting as an individual, an employee or employer, a member\nof a family, community group, professional organization, or government agency, has\nboth an opportunity and an obligation to contribute to the effort to improve the Nation's\nhealth profile. To arrive at the established goals and objectives, we must chart a common\ncourse that depends upon commitment and action from every level of our society. Then\nthe challenge can be met.\nPersonal Responsibility\nThe individual is both the starting point and the ultimate target of the campaign towards\nHealthy People 2000. Through the many roles that each of us fulfills in our daily lives,\nwe are afforded numerous opportunities for promoting health and preventing disease.\nWith these opportunities, though, comes responsibility, and the first role we must all un-\ndertake is responsibility for our own personal health habits. Improving personal health\nbehavior can count among the most potent means to prevent disease and promote health.\nMeasurable decreases in risks to health can result from changes in diet, exercise, tobacco\nuse, alcohol and other drug use, injury prevention behavior, and sexual habits, but each of\nus must choose to make these changes a personal priority.\nOur worksites can provide a smoking cessation program and a fitness center, for example,\nbut we have to enroll. Fast food chains can offer salads, but we have to choose them.\nLegislators can mandate food labeling, but we must care enough to read the labels. Our\nhealth care providers can provide the necessary screening tests and immunizations, but\nwe must take the initiative to obtain them.\nWhile the responsibility for change lies with each of us, it also lies with all of us, and\nindividuals cannot be expected to act alone.\nThe Family\nThe family is the primary context in which health promoting activities occur and is there-\nfore potentially the most immediate source of health-related support and education for the\nindividual. It is in the context of the family that attitudes and behaviors regarding diet,\nphysical activity, hygiene, smoking, and alcohol and other drug use are often learned and\nmaintained. Therefore, the family offers the primary opportunity for change in these\nareas. Parents can teach children healthy habits and offer the supportive environment\nnecessary to sustain them. In addition, parents can ensure that their children receive\nneeded preventive services-immunizations, screening tests, as well as counseling and\neducation about health risks and behaviors.\nAlthough the family plays a key role in meeting the challenge of Healthy People 2000,\nthe family also should not be expected to assume these responsibilities in isolation. Families\nneed and deserve the support of their communities in achieving and maintaining stand-\nards of good health. When families experience stresses that can result in self-destruction\nthrough abuse, neglect, and addiction, the community's responsibility becomes increas-\ningly urgent. Single-parent homes, children in poverty, and an aging society are all fac-\ntors that threaten the family's viability. As the burdens of a family increase, its very\nspirit is threatened and the need for community support becomes still more crucial, not\nonly to the well-being of its members but also to its survival.\n85\nHealthy People 2000\nCommunity\nIn today's society, a supportive community can make a vital difference in the well-being\nof its members. Accordingly, there is evidence that community-based health programs\ncan play a strong role in improving the health status of their citizens. Multiple oppor-\ntunities exist for community health promotion efforts on the part of government, volun-\ntary and self-help groups, businesses, and schools. Such local community programs are\noften more efficient than centralized programs managed far from the point of delivery.\nFurthermore, indigenous programs maintain the sensitivity to family and neighborhood\nvalues that is vital to encourage change successfully towards healthier lifestyles within\nthe community.\nLocal health officials can contribute to the challenge of Healthy People 2000 by work-\ning to ensure that health department clinics provide appropriate preventive and health pro-\nmotion services for the people they serve-in addition to their historic roles of providing\nand monitoring traditional community health services related to public sanitation, clean\nwater, and water fluoridation. Local governments can form partnerships with grassroots\norganizations, such as neighborhood associations and tenant councils, in a cooperative\neffort to reach specific populations on topics of special local concern.\nVoluntary organizations have long worked to improve health through research, public\neducation, and other program activities. In fact, the spirit of volunteerism is one of our\nstrongest national traditions. Groups that have not traditionally been involved in reduc-\ning health risks should now begin to define their role in community health education.\nFor example, local organizations serving youth can collaborate on alcohol and other drug\nabuse-reduction programs or on discouraging the use of tobacco. Groups representing\nspecial populations-people with disabilities, racial and ethnic minorities, older people-\ncan work together to achieve needed changes both within their memberships and in the\ncommunity at large.\nBusiness, community leaders, and labor can work together for mutual benefit to enhance\nthe well-being of employees and the community. Management, unions, and employee\ngroups can sponsor wellness and employee assistance programs; coverage for effective\npreventive services can be sought in contract negotiations; and employees can work to\nmake community health promotion services available at the worksite for themselves,\ntheir dependents, and retirees. Many important disease prevention and health promotion\nactivities, such as smoking cessation, diet modification, and physical conditioning, can be\naccomplished at the worksite in an effective and efficient manner. Company policies can\nhelp create a healthy work and living environment and contribute to the ecology of the\ncommunities in which they are based. From enforcing safety procedures, to mandating\nsmoke-free workplaces, to ensuring that healthful food choices are available in employee\ncafeterias, employers have multiple opportunities to improve the health prospects of their\nemployees. Companies also have a responsibility to contribute to the community leader-\nship in maintaining a healthy environment through responsible waste disposal policies.\nSchools have a special role in enhancing and maintaining the health of their community's\nchildren, since roughly one-quarter of a young person's time is spent in this environment.\nSchool health education can foster healthful behaviors and help prevent hazardous ones,\nparticularly in the areas of physical fitness, smoking, and nutrition. Standard course cur-\nricula can be modified to include health promotion, as, for example, through the addition\nof environmental health components to science classes. Provision of healthy meals, safe\nwork and play areas, and physical education courses that stress the acquisition of lifetime\nexercise habits can be instituted as well to foster the long-term health of our youth. In\npartnership with parents and other community groups, schools can help to create health\npromotion programs and enhance health education curricula. Schools can, in addition,\n86\n6. Shared Responsibilities\nopen their facilities and health curricula to the adults of the community, thereby serving\nas an even greater local resource.\nChurches and other religious institutions may also offer important resources for enhanc-\ning access to health promotion and disease prevention services, especially for populations\nthat may otherwise be difficult to reach. Churches are often strong in the same communities\nwhere the health care system is weak and overburdened. In poor black communities, for\nexample, the church has met not only the spiritual but also the educational, physical, and\nsocial needs of its members and their families and friends. Increasingly, religious institu-\ntions are sponsoring health fairs and establishing blood pressure education, screening,\nand control programs. They offer individual and family counseling and are often in-\nvolved in adolescent pregnancy prevention efforts. These are important contributions.\nHealth Professionals\nResponsibility also falls to physicians and other health care providers, who are for many\nAmericans the primary sources of health information. Their professional training gives\nthem the skill to translate science into practice. Practice can take the form of partnerships\nwith nonprofessionals in the pursuit of individual, family, and community health care.\nThe effectiveness and efficiency of preventive services-screening tests, immunizations,\nand counseling-will be enhanced by such partnerships.\nHealth education and counseling, in particular, provide opportunities for interdisciplinary\nconsulting among educators, administrators, social workers, health and other professionals in\norder to integrate healthy practices into the daily lives of individuals, their families, and\ncommunities. Professional associations can facilitate dissemination of the health promo-\ntion and disease prevention knowledge base through their established information ex-\nchange and professional education networks. A special opportunity and responsibility\nexists for the teachers of health professionals to design curricula and allocate educational\nresources which will equip health-related professions with prevention expertise and with\nthe skills to share their knowledge with the public.\nAmerica's physicians, dentists, nurses, pharmacists, medical technicians and other health\nprofessionals must be not only knowledgeable in the basic and clinical sciences; they also\nmust be life-long learners, excellent communicators, good team players, managers of\nscarce resources, health care visionaries, and community leaders. The day of the solo\npractitioner, dealing with the patient in isolation from other professionals is past.\nMedia\nThe day of the print and electronic media is, however, very much here, and these media\ncan contribute to the exchange of health information between health professionals and\nthe public, as well as among health professionals themselves. The average American is\nexposed to many different kinds of health-related messages, some explicit in news, public\naffairs, and documentaries, and some buried in the plots and characters seen in entertain-\nment programs through the mass media. In partnerships with the media, voluntary and\nprofessional organizations can expand the reach of their programs while performing an\nimportant service to the community.\nPartnerships can also be created between community groups and the increasing number\nof cable television stations, radio stations, and regional magazines that are aimed at\nvery specific audiences and therefore have a unique opportunity to tailor their messages\ndirectly to the target audience. New opportunities will also unfold through the evolving\nintegration of telecommunications media-telephone, television, computer-to make\ncustomized health information more accessible than ever before.\n87\nHealthy People 2000\nGovernment\nPolicy decisions are made regularly that can assist health professionals and the public in\nreaching our national health goals. These decisions range from health care legislation to\nlegislation that bears on the environment, business, farming, production, energy, housing,\ninformation dissemination, education, and the economy. The health interests of Ameri-\ncans are directly and indirectly shaped by such policy decisions. Local, State, and Fed-\neral governments can ensure that health promotion and disease prevention activities\nreceive adequate attention and support. The accomplishment of this task can be effec-\ntively bridged through partnerships with each other and with the private sector.\nWith the increasing decentralization of government health services, the States have taken\non new roles as conveners, fostering alliances and common interests among many poten-\ntial participants in disease prevention and health promotion activities. These alliances\ncan occur both horizontally, among statewide organizations, and vertically, among com-\nmunity, State, and national groups. Particularly important is their role in maintaining\nsurveillance systems on the occurrence of disease, exposure to risks, and delivery of\nservices. They are in this respect the keepers of the tools most important to charting our\nprogress.\nThe Federal Government supports basic biomedical research on disease prevention and\nsponsors demonstration projects to help identify effective health promotion strategies.\nIt provides financial support for many State and local government initiatives in health\npromotion and disease prevention, and directly serves some of the population groups\nmost in need. On issues of particular prominence, it sponsors the development of nation-\nal educational campaigns and the formation of coalitions for action. In order to address\npublic health issues that are in flux with changing social, behavioral, and economic envi-\nronments, sustained Federal leadership is necessary to improve the health of the\nAmerican people.\nHealthy People: The Vision\nClearly, to meet the challenge of the Healthy People 2000 goals and objectives, we must\nwork both individually and collectively. Alone, no one person, family, business, organi-\nzation, or government has the resources to bring about the changes needed to implement\nthis broad program, and yet the program cannot succeed unless each of us contributes in-\ndividually. In essence, Healthy People 2000 offers hope that through cooperative efforts\nall Americans can live longer, healthier lives.\nThere are existing examples of cooperative programs which, if replicated, could propel\nus toward our health goals for the year 2000. Promising efforts are emerging in programs\nthat have taken deep roots in neighborhoods across America and focus upon the early\ndevelopmental needs of children. In many areas, these programs are the chief, if not the\nonly, agents of family and community. Through these efforts, parents can both receive\nsupport and become active participants and leaders within the community. Where such\nprograms are successful, they demonstrate that by working together-by mobilizing\nfamilies, neighborhoods, schools, businesses, churches, the media, and government-we\ncan make great strides toward helping Americans become healthier, more productive, and\nmore fulfilled.\nThus, the final message of this report is one of shared responsibility-among the many\npartners in prevention. It is what we do collectively and personally that will move us as\nindividuals and as a Nation towards a healthier future.\n88\nAppendices\nContents\nA.\nSummary List of\nObjectives\nB.\nContributors to Healthy\nPeople 2000\nC.\nPriority Area Lead\nAgencies\nA. Summary List of Objectives\nDuplicate objectives, which appear in two or more priority areas, are marked with an asterisk (*).\nExcept as otherwise noted, all rates in the following objectives are annual. Where the baseline rate is age adjusted, it is age\nadjusted to the 1940 U.S. population, and the target is age adjusted also.\n1.\nPhysical Activity And Fitness\nHealth Status Objectives\n1.1*\nReduce coronary heart disease deaths to no more than 100 per 100,000 people. (Age-adjusted baseline: 135 per\n100,000 in 1987)\nSpecial Population Target\nCoronary Deaths (per 100,000)\n1987 Baseline\n2000 Target\n1.1a\nBlacks\n163\n115\n1.2*\nReduce overweight to a prevalence of no more than 20 percent among people aged 20 and older and no more than 15\npercent among adolescents aged 12 through 19. (Baseline: 26 percent for people aged 20 through 74 in 1976-80,\n24 percent for men and 27 percent for women; 15 percent for adolescents aged 12 through 19 in 1976-80)\nSpecial Population Targets\nOverweight Prevalence\n1976-80 Baseline\n2000 Target\n1.2a\nLow-income women aged 20 and older\n37%\n25%\n1.2b\nBlack women aged 20 and older\n44%\n30%\n1.2c\nHispanic women aged 20 and older\n25%\nMexican-American women\n39%\nCuban women\n34%\nPuerto Rican women\n37%+\n1.2d\nAmerican Indians/Alaska Natives\n29-75%\n30%\n1.2e\nPeople with disabilities\n36%+\n25%\n1.2f\nWomen with high blood pressure\n50%\n41%\n1.2g\nMen with high blood pressure\n39%\n35%\n+ Baseline for people aged 20-74 + 1982-84 baseline for Hispanics aged 20-74\n§ 1984-88 estimates for different tribes +1985 baseline for people aged 20-74 who report any limitation in\nactivity due to chronic conditions\nNote: For people aged 20 and older, overweight is defined as body mass index (BMI) equal to or greater than 27.8\nfor men and 27.3 for women. For adolescents, overweight is defined as BMI equal to or greater than 23.0 for\nmales aged 12 through 14, 24.3 for males aged 15 through 17, 25.8 for males aged 18 through 19, 23.4 for\nfemales aged 12 through 14, 24.8 for females aged 15 through 17, and 25.7 for females aged 18 through 19. The\nvalues for adolescents are the age- and gender-specific 85th percentile values of the 1976-80 National Health and\nNutrition Examination Survey (NHANES II), corrected for sample variation. BMI is calculated by dividing weight\nin kilograms by the square of height in meters. The cut points used to define overweight approximate the 120 per-\ncent of desirable body weight definition used in the 1990 objectives.\nRisk Reduction Objectives\n1.3*\nIncrease to at least 30 percent the proportion of people aged 6 and older who engage regularly, preferably daily, in\nlight to moderate physical activity for at least 30 minutes per day. (Baseline: 22 percent of people aged 18 and\nolder were active for at least 30 minutes 5 or more times per week and 12 percent were active 7 or more times per\nweek in 1985)\nNote: Light to moderate physical activity requires sustained, rhythmic muscular movements, is at least equivalent\nto sustained walking, and is performed at less than 60 percent of maximum heart rate for age. Maximum heart rate\nequals roughly 220 beats per minute minus age. Examples may include walking, swimming, cycling, dancing, gar-\ndening and yardwork, various domestic and occupational activities, and games and other childhood pursuits.\n91\nHealthy People 2000\n1.4\nIncrease to at least 20 percent the proportion of people aged 18 and older and to at least 75 percent the proportion of\nchildren and adolescents aged 6 through 17 who engage in vigorous physical activity that promotes the\ndevelopment and maintenance of cardiorespiratory fitness 3 or more days per week for 20 or more minutes per\noccasion. (Baseline: 12 percent for people aged 18 and older in 1985; 66 percent for youth aged 10 through 17 in\n1984)\nSpecial Population Target\nVigorous Physical Activity\n1985 Baseline\n2000 Target\n1.4a\nLower-income people aged 18 and older (annual family\nincome <$20,000)\n7%\n12%\nNote: Vigorous physical activities are rhythmic, repetitive physical activities that use large muscle groups at 60\npercent or more of maximum heart rate for age. An exercise heart rate of 60 percent of maximum heart rate for age\nis about 50 percent of maximal cardiorespiratory capacity and is sufficient for cardiorespiratory conditioning.\nMaximum heart rate equals roughly 220 beats per minute minus age.\n1.5\nReduce to no more than 15 percent the proportion of people aged 6 and older who engage in no leisure-time physical\nactivity. (Baseline: 24 percent for people aged 18 and older in 1985)\nSpecial Population Targets\nNo Leisure-Time Physical Activity\n1985 Baseline\n2000 Target\n1.5a\nPeople aged 65 and older\n43%\n22%\n1.5b\nPeople with disabilities\n35%¹\n20%\n1.5c\nLower-income people (annual family income <$20,000)\n32%⁺\n17%\nBaseline for people aged 18 and older\nNote: For this objective, people with disabilities are people who report any limitation in activity due to chronic con-\nditions.\n1.6\nIncrease to at least 40 percent the proportion of people aged 6 and older who regularly perform physical activities that\nenhance and maintain muscular strength, muscular endurance, and flexibility. (Baseline data available in 1991)\n1.7*\nIncrease to at least 50 percent the proportion of overweight people aged 12 and older who have adopted sound dietary\npractices combined with regular physical activity to attain an appropriate body weight. (Baseline: 30 percent of\noverweight women and 25 percent of overweight men for people aged 18 and older in 1985)\nServices and Protection Objectives\n1.8\nIncrease to at least 50 percent the proportion of children and adolescents in 1st through 12th grade who participate in\ndaily school physical education. (Baseline: 36 percent in 1984-86)\n1.9\nIncrease to at least 50 percent the proportion of school physical education class time that students spend being\nphysically active, preferably engaged in lifetime physical activities. (Baseline: Students spent an estimated 27\npercent of class time being physically active in 1983)\nNote: Lifetime activities are activities that may be readily carried into adulthood because they generally need only\none or two people. Examples include swimming, bicycling, jogging, and racquet sports. Also counted as lifetime\nactivities are vigorous social activities such as dancing. Competitive group sports and activities typically played\nonly by young children such as group games are excluded.\n1.10\nIncrease the proportion of worksites offering employer-sponsored physical activity and fitness programs as follows:\nWorksite Size\n1985 Baseline\n2000 Target\n50-99 employees\n14%\n20%\n100-249 employees\n23%\n35%\n250-749 employees\n32%\n50%\n≥750 employees\n54%\n80%\n1.11\nIncrease community availability and accessibility of physical activity and fitness facilities as follows:\nFacility\n1986 Baseline\n2000 Target\nHiking, biking, and fitness trail miles\n1 per 71,000 people\n1 per 10,000 people\nPublic swimming pools\n1 per 53,000 people\n1 per 25,000 people\nAcres of park and recreation open space\n1.8 per 1,000 people\n4 per 1,000 people\n(553 people per\n(250 people per\nmanaged acre)\nmanaged acre)\n1.12 Increase to at least 50 percent the proportion of primary care providers who routinely assess and counsel their patients\nregarding the frequency, duration, type, and intensity of each patient's physical activity practices. (Baseline:\nPhysicians provided exercise counseling for about 30 percent of sedentary patients in 1988)\n92\nA. Summary List of Objectives\n2.\nNutrition\nHealth Status Objectives\n2.1*\nReduce coronary heart disease deaths to no more than 100 per 100,000 people. (Age-adjusted baseline: 135 per\n100,000 in 1987)\nSpecial Population Target\nCoronary Deaths (per 100,000)\n1987 Baseline\n2000 Target\n2.1a\nBlacks\n163\n115\n2.2*\nReverse the rise in cancer deaths to achieve a rate of no more than 130 per 100,000 people. (Age-adjusted baseline:\n133 per 100,000 in 1987)\nNote: In its publications, the National Cancer Institute age adjusts cancer death rates to the 1970 U.S. population.\nUsing the 1970 standard, the equivalent baseline and target values for this objective would be 171 and 175 per\n100,000, respectively.\n2.3*\nReduce overweight to a prevalence of no more than 20 percent among people aged 20 and older and no more than 15\npercent among adolescents aged 12 through 19. (Baseline: 26 percent for people aged 20 through 74 in 1976-80,\n24 percent for men and 27 percent for women; 15 percent for adolescents aged 12 through 19 in 1976-80)\nSpecial Population Targets\nOverweight Prevalence\n1976-80 Baseline¹ 2000 Target\n2.3a\nLow-income women aged 20 and older\n37%\n25%\n2.3b\nBlack women aged 20 and older\n44%\n30%\n2.3c\nHispanic women aged 20 and older\n25%\nMexican-American women\n39%\nCuban women\n34%\nPuerto Rican women\n37%\n2.3d\nAmerican Indians/Alaska Natives\n29-75%\n30%\n2.3e\nPeople with disabilities\n36%+\n25%\n2.3f\nWomen with high blood pressure\n50%\n41%\n2.3g\nMen with high blood pressure\n39%\n35%\nBaseline for people aged 20-74 + 1982-84 baseline for Hispanics aged 20-74\n§ 1984-88 estimates for different tribes 1985 baseline for people aged 20-74 who report any limitation in\nactivity due to chronic conditions\nNote: For people aged 20 and older, overweight is defined as body mass index (BMI) equal to or greater than 27.8\nfor men and 27.3 for women. For adolescents, overweight is defined as BMI equal to or greater than 23.0 for\nmales aged 12 through 14, 24.3 for males aged 15 through 17, 25.8 for males aged 18 through 19, 23.4 for females\naged 12 through 14, 24.8 for females aged 15 through 17, and 25.7 for females aged 18 through 19. The values for\nadolescents are the age- and gender-specific 85th percentile values of the 1976-80 National Health and Nutrition\nExamination Survey (NHANES II), corrected for sample variation. BMI is calculated by dividing weight in\nkilograms by the square of height in meters. The cut points used to define overweight approximate the 120 percent\nof desirable body weight definition used in the 1990 objectives.\n2.4\nReduce growth retardation among low-income children aged 5 and younger to less than 10 percent. (Baseline: Up to\n16 percent among low-income children in 1988, depending on age and race/ethnicity)\nSpecial Population Targets\nPrevalence of Short Stature\n1988 Baseline\n2000 Target\n2.4a\nLow-income black children <age 1\n15%\n10%\n2.4b\nLow-inçome Hispanic children <age 1\n13%\n10%\n2.4c\nLow-income Hispanic children aged 1\n16%\n10%\n2.4d\nLow-income Asian/Pacific Islander children aged 1\n14%\n10%\n2.4e\nLow-income Asian/Pacific Islander children aged 2-4\n16%\n10%\nNote: Growth retardation is defined as height-for-age below the fifth percentile of children in the National Center\nfor Health Statistics' reference population.\nRisk Reduction Objectives\n2.5*\nReduce dietary fat intake to an average of 30 percent of calories or less and average saturated fat intake to less than 10\npercent of calories among people aged 2 and older. (Baseline: 36 percent of calories from total fat and 13 percent\nfrom saturated fat for people aged 20 through 74 in 1976-80; 36 percent and 13 percent for women aged 19\nthrough 50 in 1985)\n2.6*\nIncrease complex carbohydrate and fiber-containing foods in the diets of adults to 5 or more daily servings for\nvegetables (including legumes) and fruits, and to 6 or more daily servings for grain products. (Baseline: 2½\nservings of vegetables and fruits and 3 servings of grain products for women aged 19 through 50 in 1985)\n2.7*\nIncrease to at least 50 percent the proportion of overweight people aged 12 and older who have adopted sound dietary\npractices combined with regular physical activity to attain an appropriate body weight. (Baseline: 30 percent of\noverweight women and 25 percent of overweight men for people aged 18 and older in 1985)\n93\nHealthy People 2000\n2.8\nIncrease calcium intake so at least 50 percent of youth aged 12 through 24 and 50 percent of pregnant and lactating\nwomen consume 3 or more servings daily of foods rich in calcium, and at least 50 percent of people aged 25 and\nolder consume 2 or more servings daily. (Baseline: 7 percent of women and 14 percent of men aged 19 though 24\nand 24 percent of pregnant and lactating women consumed 3 or more servings, and 15 percent of women and 23\npercent of men aged 25 through 50 consumed 2 or more servings in 1985-86)\nNote: The number of servings of foods rich in calcium is based on milk and milk products. A serving is considered\nto be 1 cup of skim milk or its equivalent in calcium (302 mg). The number of servings in this objective will general-\nly provide approximately three-fourths of the 1989 Recommended Dietary Allowance (RDA) of calcium. The RDA\nis 1200 mg for people aged 12 through 24, 800 mg for people aged 25 and older, and 1200 mg for pregnant and lac-\ntating women.\n2.9\nDecrease salt and sodium intake so at least 65 percent of home meal preparers prepare foods without adding salt, at\nleast 80 percent of people avoid using salt at the table, and at least 40 percent of adults regularly purchase foods\nmodified or lower in sodium. (Baseline: 54 percent of women aged 19 through 50 who served as the main meal\npreparer did not use salt in food preparation, and 68 percent of women aged 19 through 50 did not use salt at the\ntable in 1985; 20 percent of all people aged 18 and older regularly purchased foods with reduced salt and sodium\ncontent in 1988)\n2.10 Reduce iron deficiency to less than 3 percent among children aged 1 through 4 and among women of childbearing\nage. (Baseline: 9 percent for children aged 1 through 2, 4 percent for children aged 3 through 4, and 5 percent for\nwomen aged 20 through 44 in 1976-80)\nSpecial Population Targets\nIron Deficiency Prevalence\n1976-80 Baseline\n2000 Target\n2.10a Low-income children aged 1-2\n21%\n10%\n2.10b Low-income children aged 3-4\n10%\n5%\n2.10c Low-income women of childbearing age\n8%⁺\n4%\nAnemia Prevalence\n1983-85 Baseline\n2000 Target\n2.10d Alaska Native children aged 1-5\n22-28%\n10%\n2.10e Black, low-income pregnant women (third trimester)\n41%\n20%\nBaseline for women aged 20-44 +1988 baseline for women aged 15-44\nNote: Iron deficiency is defined as having abnormal results for 2 or more of the following tests: mean corpuscular\nvolume, erythrocyte protoporphyrin, and transferrin saturation. Anemia is used as an index of iron deficiency.\nAnemia among Alaska Native children was defined as hemoglobin <11 gm/dL or hematocrit <34 percent. For preg-\nnant women in the third trimester, anemia was defined according to CDC criteria. The above prevalences of iron\ndeficiency and anemia may be due to inadequate dietary iron intakes or to inflammatory conditions and infections.\nFor anemia, genetics may also be a factor.\n2.11* Increase to at least 75 percent the proportion of mothers who breastfeed their babies in the early postpartum period\nand to at least 50 percent the proportion who continue breastfeeding until their babies are 5 to 6 months old.\n(Baseline: 54 percent at discharge from birth site and 21 percent at 5 to 6 months in 1988)\nSpecial Population Targets\nMothers Breastfeeding Their Babies:\n1988 Baseline\n2000 Target\nDuring Early Postpartum Period-\n2.11a Low-income mothers\n32%\n75%\n2.11b Black mothers\n25%\n75%\n2.11c Hispanic mothers\n51%\n75%\n2.11d American Indian/Alaska Native mothers\n47%\n75%\nAt Age 5-6 Months-\n2.11a Low-income mothers\n9%\n50%\n2.11b Black mothers\n8%\n50%\n2.11c Hispanic mothers\n16%\n50%\n2.11d American Indian/Alaska Native mothers\n28%\n50%\n2.12* Increase to at least 75 percent the proportion of parents and caregivers who use feeding practices that prevent baby\nbottle tooth decay. (Baseline data available in 1991)\nSpecial Population Targets\nAppropriate Feeding Practices\nBaseline\n2000 Target\n2.12a Parents and caregivers with less than high school education\n-\n65%\n2.12b American Indian/Alaska Native parents and caregivers\nI\n65%\n2.13 Increase to at least 85 percent the proportion of people aged 18 and older who use food labels to make nutritious food\nselections. (Baseline: 74 percent used labels to make food selections in 1988)\nServices and Protection Objectives\n2.14\nAchieve useful and informative nutrition labeling for virtually all processed foods and at least 40 percent of fresh\nmeats, poultry, fish, fruits, vegetables, baked goods, and ready-to-eat carry-away foods. (Baseline: 60 percent of\nsales of processed foods regulated by FDA had nutrition labeling in 1988; baseline data on fresh and carry-away\nfoods unavailable)\n94\nA. Summary List of Objectives\n2.15\nIncrease to at least 5,000 brand items the availability of processed food products that are reduced in fat and saturated\nfat. (Baseline: 2,500 items reduced in fat in 1986)\nNote: A brand item is defined as a particular flavor and/or size of a specific brand and is typically the consumer\nunit of purchase.\n2.16 Increase to at least 90 percent the proportion of restaurants and institutional food service operations that offer\nidentifiable low-fat, low-calorie food choices, consistent with the Dietary Guidelines for Americans. (Baseline:\nAbout 70 percent of fast food and family restaurant chains with 350 or more units had at least one low-fat,\nlow-calorie item on their menu in 1989)\n2.17\nIncrease to at least 90 percent the proportion of school lunch and breakfast services and child care food services with\nmenus that are consistent with the nutrition principles in the Dietary Guidelines for Americans. (Baseline data\navailable in 1993)\n2.18\nIncrease to at least 80 percent the receipt of home food services by people aged 65 and older who have difficulty in\npreparing their own meals or are otherwise in need of home-delivered meals. (Baseline data available in 1991)\n2.19 Increase to at least 75 percent the proportion of the Nation's schools that provide nutrition education from preschool\nthrough 12th grade, preferably as part of quality school health education. (Baseline data available in 1991)\n2.20\nIncrease to at least 50 percent the proportion of worksites with 50 or more employees that offer nutrition education\nand/or weight management programs for employees. (Baseline: 17 percent offered nutrition education activities\nand 15 percent offered weight control activities in 1985)\n2.21\nIncrease to at least 75 percent the proportion of primary care providers who provide nutrition assessment and\ncounseling and/or referral to qualified nutritionists or dietitians. (Baseline: Physicians provided diet counseling\nfor an estimated 40 to 50 percent of patients in 1988)\n3. Tobacco\nHealth Status Objectives\n3.1*\nReduce coronary heart disease deaths to no more than 100 per 100,000 people. (Age-adjusted baseline: 135 per\n100,000 in 1987)\nSpecial Population Target\nCoronary Deaths (per 100,000)\n1987 Baseline\n2000 Target\n3.1a\nBlacks\n163\n115\n3.2*\nSlow the rise in lung cancer deaths to achieve a rate of no more than 42 per 100,000 people. (Age-adjusted baseline:\n37.9 per 100,000 in 1987)\nNote: In its publications, the National Cancer Institute age adjusts cancer death rates to the 1970 U.S. population.\nUsing the 1970 standard, the equivalent baseline and target values for this objective would be 47.9 and 53 per\n100,000, respectively.\n3.3\nSlow the rise in deaths from chronic obstructive pulmonary disease to achieve a rate of no more than 25 per 100,000\npeople. (Age-adjusted baseline: 18.7 per 100,000 in 1987)\nNote: Deaths from chronic obstructive pulmonary disease include deaths due to chronic bronchitis, emphysema,\nasthma, and other chronic obstructive pulmonary diseases and allied conditions.\nRisk Reduction Objectives\n3.4*\nReduce cigarette smoking to a prevalence of no more than 15 percent among people aged 20 and older. (Baseline: 29\npercent in 1987, 32 percent for men and 27 percent for women)\nSpecial Population Targets\nCigarette Smoking Prevalence\n1987 Baseline\n2000 Target\n3.4a\nPeople with a high school education or less aged 20 and older\n34%\n20%\n3.4b\nBlue-collar workers aged 20 and older\n36%\n20%\n3.4c\nMilitary personnel\n42%⁺\n20%\n3.4d\nBlacks aged 20 and older\n34%\n18%\n3.4e\nHispanics aged 20 and older\n33%⁺\n18%\n3.4f\nAmerican Indians/Alaska Natives\n42-70%\n20%\n3.4g\nSoutheast Asian men\n55%⁺\n20%\n3.4h\nWomen of reproductive age\n29%⁺⁺\n12%\n3.4i\nPregnant women\n25%\n10%\n3.4j\nWomen who use oral contraceptives\n36% ⁸⁸\n10%\n1988 baseline 982-84 baseline for Hispanics aged 20-74 1979-87 estimates for different tribes\n+1984-88 baseline ++ Baseline for women aged 18-44 1985 baseline §§ 1983 baseline\nNote: A cigarette smoker is a person who has smoked at least 100 cigarettes and currently smokes cigarettes.\n95\nHealthy People 2000\n3.5\nReduce the initiation of cigarette smoking by children and youth so that no more than 15 percent have become regular\ncigarette smokers by age 20. (Baseline: 30 percent of youth had become regular cigarette smokers by ages 20\nthrough 24 in 1987)\nSpecial Population Target\nInitiation of Smoking\n1987 Baseline\n2000 Target\n3.5a\nLower socioeconomic status youth⁺\n40%\n18%\n+ As measured by people aged 20-24 with a high school education or less\n3.6\nIncrease to at least 50 percent the proportion of cigarette smokers aged 18 and older who stopped smoking cigarettes\nfor at least one day during the preceding year. (Baseline: In 1986, 34 percent of people who smoked in the\npreceding year stopped for at least one day during that year)\n3.7\nIncrease smoking cessation during pregnancy so that at least 60 percent of women who are cigarette smokers at the\ntime they become pregnant quit smoking early in pregnancy and maintain abstinence for the remainder of their\npregnancy. (Baseline: 39 percent of white women aged 20 through 44 quit at any time during pregnancy in 1985)\nSpecial Population Target\nCessation and Abstinence During Pregnancy\n1985 Baseline\n2000 Target\n3.7a\nWomen with less than a high school education\n28%⁺\n45%\n+ Baseline for white women aged 20-44\n3.8\nReduce to no more than 20 percent the proportion of children aged 6 and younger who are regularly exposed to tobacco\nsmoke at home. (Baseline: More than 39 percent in 1986, as 39 percent of households with one or more children\naged 6 or younger had a cigarette smoker in the household)\nNote: Regular exposure to tobacco smoke at home is defined as the occurrence of tobacco smoking anywhere in the\nhome on more than 3 days each week.\n3.9\nReduce smokeless tobacco use by males aged 12 through 24 to a prevalence of no more than 4 percent. (Baseline: 6.6\npercent among males aged 12 through 17 in 1988; 8.9 percent among males aged 18 through 24 in 1987)\nSpecial Population Target\nSmokeless Tobacco Use\n1986-87 Baseline\n2000 Target\n3.9a\nAmerican Indian/Alaska Native youth\n18-64%\n10%\nNote: For males aged 12 through 17, a smokeless tobacco user is someone who has used snuff or chewing tobacco\nin the preceding month. For males aged 18 through 24, a smokeless tobacco user is someone who has used either\nsnuff or chewing tobacco at least 20 times and who currently uses snuff or chewing tobacco.\nServices and Protection Objectives\n3.10\nEstablish tobacco-free environments and include tobacco use prevention in the curricula of all elementary, middle,\nand secondary schools, preferably as part of quality school health education. (Baseline: 17 percent of school\ndistricts totally banned smoking on school premises or at school functions in 1988; antismoking education was\nprovided by 78 percent of school districts at the high school level, 81 percent at the middle school level, and 75\npercent at the elementary school level in 1988)\n3.11\nIncrease to at least 75 percent the proportion of worksites with a formal smoking policy that prohibits or severely\nrestricts smoking at the workplace. (Baseline: 27 percent of worksites with 50 or more employees in 1985; 54\npercent of medium and large companies in 1987)\n3.12 Enact in 50 States comprehensive laws on clean indoor air that prohibit or strictly limit smoking in the workplace and\nenclosed public places (including health care facilities, schools, and public transportation). (Baseline: 42 States\nand the District of Columbia had laws restricting smoking in public places; 31 States restricted smoking in public\nworkplaces; but only 13 States had comprehensive laws regulating smoking in private as well as public worksites\nand at least 4 public places, including restaurants, as of 1988)\n3.13\nEnact and enforce in 50 States laws prohibiting the sale and distribution of tobacco products to youth younger than\nage 19. (Baseline: 44 States and the District of Columbia had, but rarely enforced, laws regulating the sale and/or\ndistribution of cigarettes or tobacco products to minors in 1990; only 3 set the age of majority at 19 and only 6\nprohibited cigarette vending machines accessible to minors)\nNote: Model legislation proposed by DHHS recommends licensure of tobacco vendors, civil money penalties and\nlicense suspension or revocation for violations, and a ban on cigarette vending machines.\n3.14\nIncrease to 50 the number of States with plans to reduce tobacco use, especially among youth. (Baseline: 12 States\nin 1989)\n3.15\nEliminate or severely restrict all forms of tobacco product advertising and promotion to which youth younger than age\n18 are likely to be exposed. (Baseline: Radio and television advertising of tobacco products were prohibited, but\nother restrictions on advertising and promotion to which youth may be exposed were minimal in 1990)\n3.16\nIncrease to at least 75 percent the proportion of primary care and oral health care providers who routinely advise\ncessation and provide assistance and followup for all of their tobacco-using patients. (Baseline: About 52 percent\nof internists reported counseling more than 75 percent of their smoking patients about smoking cessation in 1986;\nabout 35 percent of dentists reported counseling at least 75 percent of their smoking patients about smoking in\n1986)\n96\nA. Summary List of Objectives\n4. Alcohol and Other Drugs\nHealth Status Objectives\n4.1\nReduce deaths caused by alcohol-related motor vehicle crashes to no more than 8.5 per 100,000 people. (Age-adjusted\nbaseline: 9.8 per 100,000 in 1987)\nSpecial Population Targets\nAlcohol-Related Motor Vehicle Crash Deaths\n(per 100,000)\n1987 Baseline\n2000 Target\n4.1a\nAmerican Indian/Alaska Native men\n52.2\n44.8\n4.1b\nPeople aged 15-24\n21.5\n18\n4.2\nReduce cirrhosis deaths to no more than 6 per 100,000 people. (Age-adjusted baseline: 9.1 per 100,000 in 1987)\nSpecial Population Targets\nCirrhosis Deaths (per 100,000)\n1987 Baseline\n2000 Target\n4.2a\nBlack men\n22\n12\n4.2b\nAmerican Indians/Alaska Natives\n25.9\n13\n4.3\nReduce drug-related deaths to no more than 3 per 100,000 people. (Age-adjusted baseline: 3.8 per 100,000 in 1987)\n4.4\nReduce drug abuse-related hospital emergency department visits by at least 20 percent. (Baseline data available in\n1991)\nRisk Reduction Objectives\n4.5\nIncrease by at least 1 year the average age of first use of cigarettes, alcohol, and marijuana by adolescents aged 12\nthrough 17. (Baseline: Age 11.6 for cigarettes, age 13.1 for alcohol, and age 13.4 for marijuana in 1988)\n4.6\nReduce the proportion of young people who have used alcohol, marijuana, and cocaine in the past month, as follows:\nSubstance/Age\n1988 Baseline\n2000 Target\nAlcohol/aged 12-17\n25.2%\n12.6%\nAlcohol/aged 18-20\n57.9%\n29%\nMarijuana/aged 12-17\n6.4%\n3.2%\nMarijuana/aged 18-25\n15.5%\n7.8%\nCocaine/aged 12-17\n1.1%\n0.6%\nCocaine/aged 18-25\n4.5%\n2.3%\nNote: The targets of this objective are consistent with the goals established by the Office of National Drug Control\nPolicy, Executive Office of the President.\n4.7\nReduce the proportion of high school seniors and college students engaging in recent occasions of heavy drinking of\nalcoholic beverages to no more than 28 percent of high school seniors and 32 percent of college students.\n(Baseline: 33 percent of high school seniors and 41.7 percent of college students in 1989)\nNote: Recent heavy drinking is defined as having 5 or more drinks on one occasion in the previous 2-week period\nas monitored by self-reports.\n4.8\nReduce alcohol consumption by people aged 14 and older to an annual average of no more than 2 gallons of ethanol per\nperson. (Baseline: 2.54 gallons of ethanol in 1987)\n4.9\nIncrease the proportion of high school seniors who perceive social disapproval associated with the heavy use of\nalcohol, occasional use of marijuana, and experimentation with cocaine, as follows:\nBehavior\n1989 Baseline\n2000 Target\nHeavy use of alcohol\n56.4%\n70%\nOccasional use of marijuana\n71.1%\n85%\nTrying cocaine once or twice\n88.9%\n95%\nNote: Heavy drinking is defined as having 5 or more drinks once or twice each weekend.\n4.10\nIncrease the proportion of high school seniors who associate risk of physical or psychological harm with the heavy use\nof alcohol, regular use of marijuana, and experimentation with cocaine, as follows:\nBehavior\n1989 Baseline\n2000 Target\nHeavy use of alcohol\n44%\n70%\nRegular use of marijuana\n77.5%\n90%\nTrying cocaine once or twice\n54.9%\n80%\nNote: Heavy drinking is defined as having 5 or more drinks once or twice each weekend.\n4.11\nReduce to no more than 3 percent the proportion of male high school seniors who use anabolic steroids. (Baseline:\n4.7 percent in 1989)\nServices and Protection Objectives\n4.12\nEstablish and monitor in 50 States comprehensive plans to ensure access to alcohol and drug treatment programs for\ntraditionally underserved people. (Baseline data available in 1991)\n97\nHealthy People 2000\n4.13\nProvide to children in all school districts and private schools primary and secondary school educational programs on\nalcohol and other drugs, preferably as part of quality school health education. (Baseline: 63 percent provided\nsome instruction, 39 percent provided counseling, and 23 percent referred students for clinical assessments in 1987)\n4.14\nExtend adoption of alcohol and drug policies for the work environment to at least 60 percent of worksites with 50 or\nmore employees. (Baseline data available in 1991)\n4.15\nExtend to 50 States administrative driver's license suspension/revocation laws or programs of equal effectiveness for\npeople determined to have been driving under the influence of intoxicants. (Baseline: 28 States and the District of\nColumbia in 1990)\n4.16\nIncrease to 50 the number of States that have enacted and enforce policies, beyond those in existence in 1989, to\nreduce access to alcoholic beverages by minors.\nNote: Policies to reduce access to alcoholic beverages by minors may include those that address restriction of the\nsale of alcoholic beverages at recreational and entertainment events at which youth make up a majority of par-\nticipants/consumers, product pricing, penalties and license-revocation for sale of alcoholic beverages to minors,\nand other approaches designed to discourage and restrict purchase of alcoholic beverages by minors.\n4.17\nIncrease to at least 20 the number of States that have enacted statutes to restrict promotion of alcoholic beverages that\nis focused principally on young audiences. (Baseline data available in 1992)\n4.18\nExtend to 50 States legal blood alcohol concentration tolerance levels of .04 percent for motor vehicle drivers aged 21\nand older and .00 percent for those younger than age 21. (Baseline: 0 States in 1990)\n4.19\nIncrease to at least 75 percent the proportion of primary care providers who screen for alcohol and other drug use\nproblems and provide counseling and referral as needed. (Baseline data available in 1992)\n5. Family Planning\nHealth Status Objectives\n5.1\nReduce pregnancies among girls aged 17 and younger to no more than 50 per 1,000 adolescents. (Baseline: 71.1\npregnancies per 1,000 girls aged 15 through 17 in 1985)\nSpecial Population Targets\nPregnancies (per 1,000)\n1985 Baseline\n2000 Target\n5.1a\nBlack adolescent girls aged 15-19\n186⁺\n120\n5.1b\nHispanic adolescent girls aged 15-19\n158\n105\nNon-white adolescents\nNote: For black and Hispanic adolescent girls, baseline data are unavailable for those aged 15 through 17. The\ntargets for these two populations are based on data for women aged 15 through 19. If more complete data become\navailable, a 35-percent reduction from baseline figures should be used as the target.\n5.2\nReduce to no more than 30 percent the proportion of all pregnancies that are unintended. (Baseline: 56 percent of\npregnancies in the previous 5 years were unintended, either unwanted or earlier than desired, in 1988)\nSpecial Population Target\nUnintended Pregnancies\n1988 Baseline\n2000 Target\n5.2a\nBlack women\n78%\n40%\n5.3\nReduce the prevalence of infertility to no more than 6.5 percent. (Baseline: 7.9 percent of married couples with wives\naged 15 through 44 in 1988)\nSpecial Population Targets\nPrevalence of Infertility\n1988 Baseline\n2000 Target\n5.3a\nBlack couples\n12.1%\n9%\n5.3b\nHispanic couples\n12.4%\n9%\nNote: Infertility is the failure of couples to conceive after 12 months of intercourse without contraception.\nRisk Reduction Objectives\n5.4*\nReduce the proportion of adolescents who have engaged in sexual intercourse to no more than 15 percent by age 15\nand no more than 40 percent by age 17. (Baseline: 27 percent of girls and 33 percent of boys by age 15; 50\npercent of girls and 66 percent of boys by age 17; reported in 1988)\n5.5\nIncrease to at least 40 percent the proportion of ever sexually active adolescents aged 17 and younger who have\nabstained from sexual activity for the previous 3 months. (Baseline: 26 percent of sexually active girls aged 15\nthrough 17 in 1988)\n5.6\nIncrease to at least 90 percent the proportion of sexually active, unmarried people aged 19 and younger who use\ncontraception, especially combined method contraception that both effectively prevents pregnancy and provides\nbarrier protection against disease. (Baseline: 78 percent at most recent intercourse and 63 percent at first\nintercourse; 2 percent used oral contraceptives and the condom at most recent intercourse; among young women\naged 15 through 19 reporting in 1988)\nNote: Strategies to achieve this objective must be undertaken sensitively to avoid indirectly encouraging or condon-\ning sexual activity among teens who are not yet sexually active.\n98\nA. Summary List of Objectives\n5.7\nIncrease the effectiveness with which family planning methods are used, as measured by a decrease to no more than 5\npercent in the proportion of couples experiencing pregnancy despite use of a contraceptive method. (Baseline:\nApproximately 10 percent of women using reversible contraceptive methods experienced an unintended pregnancy\nin 1982)\nServices and Protection Objectives\n5.8\nIncrease to at least 85 percent the proportion of people aged 10 through 18 who have discussed human sexuality,\nincluding values surrounding sexuality, with their parents and/or have received information through another\nparentally endorsed source, such as youth, school, or religious programs. (Baseline: 66 percent of people aged 13\nthrough 18 have discussed sexuality with their parents; reported in 1986)\nNote: This objective, which supports family communication on a range of vital personal health issues, will be track-\ned using the National Health Interview Survey, a continuing, voluntary, national sample survey of adults who report\non household characteristics including such items as illnesses, injuries, use of health services, and demographic\ncharacteristics.\n5.9\nIncrease to at least 90 percent the proportion of pregnancy counselors who offer positive, accurate information about\nadoption to their unmarried patients with unintended pregnancies. (Baseline: 60 percent of pregnancy counselors\nin 1984)\nNote: Pregnancy counselors are any providers of health or social services who discuss the management or out-\ncome of pregnancy with a woman after she has received a diagnosis of pregnancy.\n5.10* Increase to at least 60 percent the proportion of primary care providers who provide age-appropriate preconception\ncare and counseling. (Baseline data available in 1992)\n5.11* Increase to at least 50 percent the proportion of family planning clinics, maternal and child health clinics, sexually\ntransmitted disease clinics, tuberculosis clinics, drug treatment centers, and primary care clinics that screen,\ndiagnose, treat, counsel, and provide (or refer for) partner notification services for HIV infection and bacterial\nsexually transmitted diseases (gonorrhea, syphilis, and chlamydia). (Baseline: 40 percent of family planning\nclinics for bacterial sexually transmitted diseases in 1989)\n6. Mental Health and Mental Disorders\nHealth Status Objectives\n6.1*\nReduce suicides to no more than 10.5 per 100,000 people. (Age-adjusted baseline: 11.7 per 100,000 in 1987)\nSpecial Population Targets\nSuicides (per 100,000)\n1987 Baseline\n2000 Target\n6.1a\nYouth aged 15-19\n10.3\n8.2\n6.1b\nMen aged 20-34\n25.2\n21.4\n6.1c\nWhite men aged 65 and older\n46.1\n39.2\n6.1d\nAmerican Indian/Alaska Native men in Reservation States 15\n12.8\n6.2*\nReduce by 15 percent the incidence of injurious suicide attempts among adolescents aged 14 through 17. (Baseline\ndata available in 1991)\n6.3\nReduce to less than 10 percent the prevalence of mental disorders among children and adolescents. (Baseline: An\nestimated 12 percent among youth younger than age 18 in 1989)\n6.4\nReduce the prevalence of mental disorders (exclusive of substance abuse) among adults living in the community to less\nthan 10.7 percent. (Baseline: One-month point prevalence of 12.6 percent in 1984)\n6.5\nReduce to less than 35 percent the proportion of people aged 18 and older who experienced adverse health effects from\nstress within the past year. (Baseline: 42.6 percent in 1985)\nSpecial Population Target\n1985 Baseline\n2000 Target\n6.5a\nPeople with disabilities\n53.5%\n40%\nNote: For this objective, people with disabilities are people who report any limitation in activity due to chronic\nconditions.\nRisk Reduction Objectives\n6.6\nIncrease to at least 30 percent the proportion of people aged 18 and older with severe, persistent mental disorders who\nuse community support programs. (Baseline: 15 percent in 1986)\n6.7\nIncrease to at least 45 percent the proportion of people with major depressive disorders who obtain treatment.\n(Baseline: 31 percent in 1982)\n99\nHealthy People 2000\n6.8\nIncrease to at least 20 percent the proportion of people aged 18 and older who seek help in coping with personal and\nemotional problems. (Baseline: 11.1 percent in 1985)\nSpecial Population Target\n1985 Baseline\n2000 Target\n6.8a\nPeople with disabilities\n14.7%\n30%\n6.9\nDecrease to no more than 5 percent the proportion of people aged 18 and older who report experiencing significant\nlevels of stress who do not take steps to reduce or control their stress. (Baseline: 21 percent in 1985)\nServices and Protection Objectives\n6.10*\nIncrease to 50 the number of States with officially established protocols that engage mental health, alcohol and drug,\nand public health authorities with corrections authorities to facilitate identification and appropriate intervention to\nprevent suicide by jail inmates. (Baseline data available in 1992)\n6.11\nIncrease to at least 40 percent the proportion of worksites employing 50 or more people that provide programs to\nreduce employee stress. (Baseline: 26.6 percent in 1985)\n6.12\nEstablish mutual help clearinghouses in at least 25 States. (Baseline: 9 States in 1989)\n6.13\nIncrease to at least 50 percent the proportion of primary care providers who routinely review with patients their\npatients' cognitive, emotional, and behavioral functioning and the resources available to deal with any problems\nthat are identified. (Baseline data available in 1992)\n6.14\nIncrease to at least 75 percent the proportion of providers of primary care for children who include assessment of\ncognitive, emotional, and parent-child functioning, with appropriate counseling, referral, and followup, in their\nclinical practices. (Baseline data available in 1992)\n7. Violent and Abusive Behavior\nHealth Status Objectives\n7.1\nReduce homicides to no more than 7.2 per 100,000 people. (Age-adjusted baseline: 8.5 per 100,000 in 1987)\nSpecial Population Targets\nHomicide Rate (per 100,000)\n1987 Baseline\n2000 Target\n7.1a\nChildren aged 3 and younger\n3.9\n3.1\n7.1b\nSpouses aged 15-34\n1.7\n1.4\n7.1c\nBlack men aged 15-34\n90.5\n72.4\n7.1d\nHispanic men aged 15-34\n53.1\n42.5\n7.1e\nBlack women aged 15-34\n20.0\n16.0\n7.1f\nAmerican Indians/Alaska Natives in Reservation States\n14.1\n11.3\n7.2*\nReduce suicides to no more than 10.5 per 100,000 people. (Age-adjusted baseline: 11.7 per 100,000 in 1987)\nSpecial Population Targets\nSuicides (per 100,000)\n1987 Baseline\n2000 Target\n7.2a\nYouth aged 15-19\n10.3\n8.2\n7.2b\nMen aged 20-34\n25.2\n21.4\n7.2c\nWhite men aged 65 and older\n46.1\n39.2\n7.2d\nAmerican Indian/Alaska Native men in Reservation States 15\n12.8\n7.3\nReduce weapon-related violent deaths to no more than 12.6 per 100,000 people from major causes. (Age-adjusted\nbaseline: 12.9 per 100,000 by firearms, 1.9 per 100,000 by knives, in 1987)\n7.4\nReverse to less than 25.2 per 1,000 children the rising incidence of maltreatment of children younger than age 18.\n(Baseline: 25.2 per 1,000 in 1986)\nType-Specific Targets\nIncidence of Types of Maltreatment (per 1,000)\n1986 Baseline\n2000 Target\n7.4a\nPhysical abuse\n5.7\n<5.7\n7.4b\nSexual abuse\n2.5\n<2.5\n7.4c\nEmotional abuse\n3.4\n<3.4\n7.4d\nNeglect\n15.9\n<15.9\n7.5\nReduce physical abuse directed at women by male partners to no more than 27 per 1,000 couples. (Baseline: 30 per\n1,000 in 1985)\n7.6\nReduce assault injuries among people aged 12 and older to no more than 10 per 1,000 people. (Baseline: 11.1 per\n1,000 in 1986)\n100\nA. Summary List of Objectives\n7.7\nReduce rape and attempted rape of women aged 12 and older to no more than 108 per 100,000 women. (Baseline:\n120 per 100,000 in 1986)\nSpecial Population Target\nIncidence of Rape and Attempted Rape (per 100,000) 1986 Baseline\n2000 Target\n7.7a\nWomen aged 12-34\n250\n225\n7.8*\nReduce by 15 percent the incidence of injurious suicide attempts among adolescents aged 14 through 17. (Baseline\ndata available in 1991)\nRisk Reduction Objectives\n7.9\nReduce by 20 percent the incidence of physical fighting among adolescents aged 14 through 17. (Baseline data\navailable in 1991)\n7.10\nReduce by 20 percent the incidence of weapon-carrying by adolescents aged 14 through 17. (Baseline data available\nin 1991)\n7.11\nReduce by 20 percent the proportion of people who possess weapons that are inappropriately stored and therefore\ndangerously available. (Baseline data available in 1992)\nServices and Protection Objectives\n7.12\nExtend protocols for routinely identifying, treating, and properly referring suicide attempters, victims of sexual\nassault, and victims of spouse, elder, and child abuse to at least 90 percent of hospital emergency departments.\n(Baseline data available in 1992)\n7.13\nExtend to at least 45 States implementation of unexplained child death review systems. (Baseline data available in\n1991)\n7.14 Increase to at least 30 the number of States in which at least 50 percent of children identified as neglected or\nphysically or sexually abused receive physical and mental evaluation with appropriate followup as a means of\nbreaking the intergenerational cycle of abuse. (Baseline data available in 1993)\n7.15 Reduce to less than 10 percent the proportion of battered women and their children turned away from emergency\nhousing due to lack of space. (Baseline: 40 percent in 1987)\n7.16\nIncrease to at least 50 percent the proportion of elementary and secondary schools that teach nonviolent conflict\nresolution skills, preferably as a part of quality school health education. (Baseline data available in 1991)\n7.17\nExtend coordinated, comprehensive violence prevention programs to at least 80 percent of local jurisdictions with\npopulations over 100,000. (Baseline data available in 1993)\n7.18* Increase to 50 the number of States with officially established protocols that engage mental health, alcohol and drug,\nand public health authorities with corrections authorities to facilitate identification and appropriate intervention to\nprevent suicide by jail inmates. (Baseline data available in 1992)\n8. Educational and Community-Based Programs\nHealth Status Objective\n8.1*\nIncrease years of healthy life to at least 65 years. (Baseline: An estimated 62 years in 1980)\nSpecial Population Targets\nYears of Healthy Life\n1980 Baseline\n2000 Target\n8.1a\nBlacks\n56\n60\n8.1b\nHispanics\n62\n65\n8.1c\nPeople aged 65 and older\n12⁺\n14⁺\nYears of healthy life remaining at age 65\nNote: Years of healthy life (also referred to as quality-adjusted life years) is a summary measure of health that com-\nbines mortality (quantity of life) and morbidity and disability (quality of life) into a single measure. For people\naged 65 and older, active life-expectancy, a related summary measure, also will be tracked.\nRisk Reduction Objective\n8.2\nIncrease the high school graduation rate to at least 90 percent, thereby reducing risks for multiple problem behaviors\nand poor mental and physical health. (Baseline: 79 percent of people aged 20 through 21 had graduated from high\nschool with a regular diploma in 1989)\nNote: This objective and its target are consistent with the National Education Goal to increase high school gradua-\ntion rates. The baseline estimate is a proxy. When a measure is chosen to monitor the National Education Goal,\nthe same measure and data source will be used to track this objective.\n101\nHealthy People 2000\nServices and Protection Objectives\n8.3\nAchieve for all disadvantaged children and children with disabilities access to high quality and developmentally\nappropriate preschool programs that help prepare children for school, thereby improving their prospects with\nregard to school performance, problem behaviors, and mental and physical health. (Baseline: 47 percent of\neligible children aged 4 were afforded the opportunity to enroll in Head Start in 1990)\nNote: This objective and its target are consistent with the National Education Goal to increase school readiness\nand its objective to increase access to preschool programs for disadvantaged and disabled children. The baseline\nestimate is an available, but partial, proxy. When a measure is chosen to monitor this National Education Objec-\ntive, the same measure and data source will be used to track this objective.\n8.4\nIncrease to at least 75 percent the proportion of the Nation's elementary and secondary schools that provide planned\nand sequential kindergarten through 12th grade quality school health education. (Baseline data available in 1991)\n8.5\nIncrease to at least 50 percent the proportion of postsecondary institutions with institutionwide health promotion\nprograms for students, faculty, and staff. (Baseline: At least 20 percent of higher education institutions offered\nhealth promotion activities for students in 1989-90)\n8.6\nIncrease to at least 85 percent the proportion of workplaces with 50 or more employees that offer health promotion\nactivities for their employees, preferably as part of a comprehensive employee health promotion program.\n(Baseline: 65 percent of worksites with 50 or more employees offered at least one health promotion activity in\n1985; 63 percent of medium and large companies had a wellness program in 1987)\n8.7\nIncrease to at least 20 percent the proportion of hourly workers who participate regularly in employer-sponsored health\npromotion activities. (Baseline data available in 1992)\n8.8\nIncrease to at least 90 percent the proportion of people aged 65 and older who had the opportunity to participate during\nthe preceding year in at least one organized health promotion program through a senior center, lifecare facility, or\nother community-based setting that serves older adults. (Baseline data available in 1992)\n8.9\nIncrease to at least 75 percent the proportion of people aged 10 and older who have discussed issues related to nutrition,\nphysical activity, sexual behavior, tobacco, alcohol, other drugs, or safety with family members on at least one\noccasion during the preceding month. (Baseline data available in 1991)\nNote: This objective, which supports family communication on a range of vital personal health issues, will be track-\ned using the National Health Interview Survey, a continuing, voluntary, national sample survey of adults who report\non household characteristics including such items as illnesses, injuries, use of health services, and demographic\ncharacteristics.\n8.10\nEstablish community health promotion programs that separately or together address at least three of the Healthy\nPeople 2000 priorities and reach at least 40 percent of each State's population. (Baseline data available in 1992)\n8.11\nIncrease to at least 50 percent the proportion of counties that have established culturally and linguistically appropriate\ncommunity health promotion programs for racial and ethnic minority populations. (Baseline data available in\n1992)\nNote: This objective will be tracked in counties in which a racial or ethnic group constitutes more than 10 percent\nof the population.\n8.12\nIncrease to at least 90 percent the proportion of hospitals, health maintenance organizations, and large group practices\nthat provide patient education programs, and to at least 90 percent the proportion of community hospitals that offer\ncommunity health promotion programs addressing the priority health needs of their communities. (Baseline: 66\npercent of 6,821 registered hospitals provided patient education services in 1987; 60 percent of 5,677 community\nhospitals offered community health promotion programs in 1987)\n8.13\nIncrease to at least 75 percent the proportion of local television network affiliates in the top 20 television markets that\nhave become partners with one or more community organizations around one of the health problems addressed by\nthe Healthy People 2000 objectives. (Baseline data available in 1991)\n8.14\nIncrease to at least 90 percent the proportion of people who are served by a local health department that is effectively\ncarrying out the core functions of public health. (Baseline data available in 1992)\nNote: The core functions of public health have been defined as assessment, policy development, and assurance.\nLocal health department refers to any local component of the public health system, defined as an administrative and\nservice unit of local or State government concerned with health and carrying some responsibility for the health of a\njurisdiction smaller than a State.\n102\nA. Summary List of Objectives\n9. Unintentional Injuries\nHealth Status Objectives\n9.1\nReduce deaths caused by unintentional injuries to no more than 29.3 per 100,000 people. (Age-adjusted baseline: 34.5\nper 100,000 in 1987)\nSpecial Population Targets\nDeaths Caused By Unintential Injuries (per 100,000)\n1987 Baseline\n2000 Target\n9.1a\nAmerican Indians/Alaska Natives\n82.6\n66.1\n9.1b\nBlack males\n64.9\n51.9\n9.1c\nWhite males\n53.6\n42.9\n9.2\nReduce nonfatal unintentional injuries so that hospitalizations for this condition are no more than 754 per 100,000\npeople. (Baseline: 887 per 100,000 in 1988)\n9.3\nReduce deaths caused by motor vehicle crashes to no more than 1.9 per 100 million vehicle miles traveled and 16.8 per\n100,000 people. (Baseline: 2.4 per 100 million vehicle miles traveled (VMT) and 18.8 per 100,000 people (age\nadjusted) in 1987)\nSpecial Population Targets\nDeaths Caused By Motor Vehicle Crashes (per 100,000)\n1987 Baseline\n2000 Target\n9.3a\nChildren aged 14 and younger\n6.2\n5.5\n9.3b\nYouth aged 15-24\n36.9\n33\n9.3c\nPeople aged 70 and older\n22.6\n20\n9.3d\nAmerican Indians/Alaska Natives\n46.8\n39.2\nType-Specific Targets\nDeaths Caused By Motor Vehicle Crashes\n1987 Baseline\n2000 Target\n9.3e\nMotorcyclists\n40.9/100 million VMT &\n33/100 million VMT &\n1.7/100,000\n1.5/100,000\n9.3f\nPedestrians\n3.1/100,000\n2.7/100,000\n9.4\nReduce deaths from falls and fall-related injuries to no more than 2.3 per 100,000 people. (Age-adjusted baseline:\n2.7 per 100,000 in 1987)\nSpecial Population Targets\nDeaths From Falls and Fall-Related Injuries (per 100,000)\n1987 Baseline\n2000 Target\n9.4a\nPeople aged 65-84\n18\n14.4\n9.4b\nPeople aged 85 and older\n131.2\n105.0\n9.4c\nBlack men aged 30-69\n8\n5.6\n9.5\nReduce drowning deaths to no more than 1.3 per 100,000 people. (Age-adjusted baseline: 2.1 per 100,000 in 1987)\nSpecial Population Targets\nDrowning Deaths (per 100,000)\n1987 Baseline\n2000 Target\n9.5a\nChildren aged 4 and younger\n4.2\n2.3\n9.5b\nMen aged 15-34\n4.5\n2.5\n9.5c\nBlack males\n6.6\n3.6\n9.6\nReduce residential fire deaths to no more than 1.2 per 100,000 people. (Age-adjusted baseline: 1.5 per 100,000 in\n1987)\nSpecial Population Targets\nResidential Fire Deaths (per 100,000)\n1987 Baseline\n2000 Target\n9.6a\nChildren aged 4 and younger\n4.4\n3.3\n9.6b\nPeople aged 65 and older\n4.4\n3.3\n9.6c\nBlack males\n5.7\n4.3\n9.6d\nBlack females\n3.4\n2.6\nType-Specific Target\n1983 Baseline\n2000 Target\n9.6e\nResidential fire deaths caused by smoking\n17%\n5%\n9.7\nReduce hip fractures among people aged 65 and older so that hospitalizations for this condition are no more than 607\nper 100,000. (Baseline: 714 per 100,000 in 1988)\nSpecial Population Target\nHip Fractures (per 100,000)\n1988 Baseline\n2000 Target\n9.7a\nWhite women aged 85 and older\n2,721\n2,177\n103\nHealthy People 2000\n9.8\nReduce nonfatal poisoning to no more than 88 emergency department treatments per 100,000 people. (Baseline: 103\nper 100,000 in 1986)\nSpecial Population Target\nNonfatal Poisoning (per 100,000)\n1986 Baseline\n2000 Target\n9.8a\nAmong children aged 4 and younger\n650\n520\n9.9\nReduce nonfatal head injuries so that hospitalizations for this condition are no more than 106 per 100,000 people.\n(Baseline: 125 per 100,000 in 1988)\n9.10\nReduce nonfatal spinal cord injuries so that hospitalizations for this condition are no more than 5 per 100,000 people.\n(Baseline: 5.9 per 100,000 in 1988)\nSpecial Population Target\nNonfatal Spinal Cord Injuries (per 100,000)\n1988 Baseline\n2000 Target\n9.10a Males\n8.9\n7.1\n9.11\nReduce the incidence of secondary disabilities associated with injuries of the head and spinal cord to no more than 16\nand 2.6 per 100,000 people, respectively. (Baseline: 20 per 100,000 for serious head injuries and 3.2 per 100,000\nfor spinal cord injuries in 1986)\nNote: Secondary disabilities are defined as those medical conditions secondary to traumatic head or spinal cord in-\njury that impair independent and productive lifestyles.\nRisk Reduction Objectives\n9.12\nIncrease use of occupant protection systems, such as safety belts, inflatable safety restraints, and child safety seats, to\nat least 85 percent of motor vehicle occupants. (Baseline: 42 percent in 1988)\nSpecial Population Target\nUse of Occupant Protection Systems\n1988 Baseline\n2000 Target\n9.12a Children aged 4 and younger\n84%\n95%\n9.13\nIncrease use of helmets to at least 80 percent of motorcyclists and at least 50 percent of bicyclists. (Baseline: 60\npercent of motorcyclists in 1988 and an estimated 8 percent of bicyclists in 1984)\nServices and Protection Objectives\n9.14\nExtend to 50 States laws requiring safety belt and motorcycle helmet use for all ages. (Baseline: 33 States and the\nDistrict of Columbia in 1989 for automobiles; 22 States, the District of Columbia, and Puerto Rico for motorcycles)\n9.15\nEnact in 50 States laws requiring that new handguns be designed to minimize the likelihood of discharge by children.\n(Baseline: 0 States in 1989)\n9.16\nExtend to 2,000 local jurisdictions the number whose codes address the installation of fire suppression sprinkler\nsystems in those residences at highest risk for fires. (Baseline data available in 1991)\n9.17 Increase the presence of functional smoke detectors to at least one on each habitable floor of all inhabited residential\ndwellings. (Baseline: 81 percent of residential dwellings in 1989)\n9.18\nProvide academic instruction on injury prevention and control, preferably as part of quality school health education, in\nat least 50 percent of public school systems (grades K through 12). (Baseline data available in 1991)\n9.19* Extend requirement of the use of effective head, face, eye, and mouth protection to all organizations, agencies, and\ninstitutions sponsoring sporting and recreation events that pose risks of injury. (Baseline: Only National\nCollegiate Athletic Association football, hockey, and lacrosse; high school football; amateur boxing; and amateur\nice hockey in 1988)\n9.20 Increase to at least 30 the number of States that have design standards for signs, signals, markings, lighting, and other\ncharacteristics of the roadway environment to improve the visual stimuli and protect the safety of older drivers and\npedestrians. (Baseline data available in 1992)\n9.21\nIncrease to at least 50 percent the proportion of primary care providers who routinely provide age-appropriate\ncounseling on safety precautions to prevent unintentional injury. (Baseline data available in 1992)\n9.22 Extend to 50 States emergency medical services and trauma systems linking prehospital, hospital, and rehabilitation\nservices in order to prevent trauma deaths and long-term disability. (Baseline: 2 States in 1987)\n10. Occupational Safety and Health\nHealth Status Objectives\n10.1 Reduce deaths from work-related injuries to no more than 4 per 100,000 full-time workers. (Baseline: Average of 6\nper 100,000 during 1983-87)\nSpecial Population Targets\nWork-Related Deaths (per 100,000)\n1983-87 Average\n2000 Target\n10.1a Mine workers\n30.3\n21\n10.1b Construction workers\n25.0\n17\n10.1c Transportation workers\n15.2\n10\n10.1d Farm workers\n14.0\n9.5\n104\nA. Summary List of Objectives\n10.2 Reduce work-related injuries resulting in medical treatment, lost time from work, or restricted work activity to no\nmore than 6 cases per 100 full-time workers. (Baseline: 7.7 per 100 in 1987)\nSpecial Population Targets\nWork-Related Injuries (per 100)\n1983-87 Average\n2000 Target\n10.2a Construction workers\n14.9\n10\n10.2b Nursing and personal care workers\n12.7\n9\n10.2c\nFarm workers\n12.4\n8\n10.2d Transportation workers\n8.3\n6\n10.2e Mine workers\n8.3\n6\n10.3 Reduce cumulative trauma disorders to an incidence of no more than 60 cases per 100,000 full-time workers.\n(Baseline: 100 per 100,000 in 1987)\nSpecial Population Targets\nCumulative Trauma Disorders (per 100,000)\n1987 Baseline\n2000 Target\n10.3a Manufacturing industry workers\n355\n150\n10.3b Meat product workers\n3,920\n2,000\n10.4 Reduce occupational skin disorders or diseases to an incidence of no more than 55 per 100,000 full-time workers.\n(Baseline: Average of 64 per 100,000 during 1983-87)\n10.5* Reduce hepatitis B infections among occupationally exposed workers to an incidence of no more than 1,250 cases.\n(Baseline: An estimated 6,200 cases in 1987)\nRisk Reduction Objectives\n10.6\nIncrease to at least 75 percent the proportion of worksites with 50 or more employees that mandate employee use of\noccupant protection systems, such as seatbelts, during all work-related motor vehicle travel. (Baseline data\navailable in 1991)\n10.7\nReduce to no more than 15 percent the proportion of workers exposed to average daily noise levels that exceed 85\ndBA. (Baseline data available in 1992)\n10.8\nEliminate exposures which result in workers having blood lead concentrations greater than 25 µg/dL of whole blood.\n(Baseline: 4,804 workers with blood lead levels above 25 µg/dL in 7 States in 1988)\n10.9* Increase hepatitis B immunization levels to 90 percent among occupationally exposed workers. (Baseline data\navailable in 1991)\nServices and Protection Objectives\n10.10 Implement occupational safety and health plans in 50 States for the identification, management, and prevention of\nleading work-related diseases and injuries within the State. (Baseline: 10 States in 1989)\n10.11 Establish in 50 States exposure standards adequate to prevent the major occupational lung diseases to which their\nworker populations are exposed (byssinosis, asbestosis, coal workers' pneumoconiosis, and silicosis). (Baseline\ndata available in 1991)\n10.12 Increase to at least 70 percent the proportion of worksites with 50 or more employees that have implemented\nprograms on worker health and safety. (Baseline data available in 1991)\n10.13 Increase to at least 50 percent the proportion of worksites with 50 or more employees that offer back injury\nprevention and rehabilitation programs. (Baseline: 28.6 percent offered back care activities in 1985)\n10.14 Establish in 50 States either public health or labor department programs that provide consultation and assistance to\nsmall businesses to implement safety and health programs for their employees. (Baseline data available in 1991)\n10.15 Increase to at least 75 percent the proportion of primary care providers who routinely elicit occupational health\nexposures as a part of patient history and provide relevant counseling. (Baseline data available in 1992)\n11. Environmental Health\nHealth Status Objectives\n11.1\nReduce asthma morbidity, as measured by a reduction in asthma hospitalizations to no more than 160 per 100,000\npeople. (Baseline: 188 per 100,000 in 1987)\nSpecial Population Targets\nAsthma Hospitalizations (per 100,000)\n1987 Baseline\n2000 Target\n11.1a Blacks and other nonwhites\n334\n265\n11.1b Children\n284⁺\n225\nChildren aged 14 and younger\n11.2* Reduce the prevalence of serious mental retardation among school-aged children to no more than 2 per 1,000\nchildren. (Baseline: 2.7 per 1,000 children aged 10 in 1985-88)\n105\nHealthy People 2000\n11.3 Reduce outbreaks of waterborne disease from infectious agents and chemical poisoning to no more than 11 per year.\n(Baseline: Average of 31 outbreaks per year during 1981-88)\nType-Specific Target\nAverage Annual Number of Waterborne Disease Outbreaks\n1981-88 Baseline 2000 Target\n11.3a People served by community water systems\n13\n6\nNote: Community water systems are public or investor-owned water systems that serve large or small communities,\nsubdivisions, or trailer parks with at least 15 service connections or 25 year-round residents.\n11.4 Reduce the prevalence of blood lead levels exceeding 15 µg/dL and 25 µg/dL among children aged 6 months through\n5 years to no more than 500,000 and zero, respectively. (Baseline: An estimated 3 million children had levels\nexceeding 15 µg/dL, and 234,000 had levels exceeding 25 µg/dL, in 1984)\nSpecial Population Target\nPrevalence of Blood Lead Levels Exceeding 15 µg/dL & 25 µg/dL 1984 Baseline\n2000 Target\n11.4a Inner-city low-income black children (annual family income\n234,900\n75,000\n<$6,000 in 1984 dollars)\n& 36,700\n& 0\nRisk Reduction Objectives\n11.5 Reduce human exposure to criteria air pollutants, as measured by an increase to at least 85 percent in the proportion of\npeople who live in counties that have not exceeded any Environmental Protection Agency standard for air quality\nin the previous 12 months. (Baseline: 49.7 percent in 1988)\nProportion Living in Counties That Have Not Exceeded Criteria Air Pollutant Standards in 1988 for:\nOzone\n53.6%\nCarbon monoxide\n87.8%\nNitrogen dioxide\n96.6%\nSulfur dioxide\n99.3%\nParticulates\n89.4%\nLead\n99.3%\nTotal (any of above pollutants)\n49.7%\nNote: An individual living in a county that exceeds an air quality standard may not actually be exposed to unheal-\nthy air. Of all criteria air pollutants, ozone is the most likely to have fairly uniform concentrations throughout an\narea. Exposure is to criteria air pollutants in ambient air. Due to weather fluctuations, multi-year averages may\nbe the most appropriate way to monitor progress toward this objective.\n11.6 Increase to at least 40 percent the proportion of homes in which homeowners/occupants have tested for radon\nconcentrations and that have either been found to pose minimal risk or have been modified to reduce risk to health.\n(Baseline: Less than 5 percent of homes had been tested in 1989)\nSpecial Population Targets\nTesting and Modification As Necessary\nBaseline\n2000 Target\n11.6a Homes with smokers and former smokers\n-\n50%\n11.6b Homes with children\n-\n50%\n11.7 Reduce human exposure to toxic agents by confining total pounds of toxic agents released into the air, water, and soil\neach year to no more than:\n0.24 billion pounds of those toxic agents included on the Department of Health and Human Services list of\ncarcinogens. (Baseline: 0.32 billion pounds in 1988)\n2.6 billion pounds of those toxic agents included on the Agency for Toxic Substances and Disease Registry list of\nthe most toxic chemicals. (Baseline: 2.62 billion pounds in 1988)\n11.8 Reduce human exposure to solid waste-related water, air, and soil contamination, as measured by a reduction in\naverage pounds of municipal solid waste produced per person each day to no more than 3.6 pounds. (Baseline: 4.0\npounds per person each day in 1988)\n11.9 Increase to at least 85 percent the proportion of people who receive a supply of drinking water that meets the safe\ndrinking water standards established by the Environmental Protection Agency. (Baseline: 74 percent of 58,099\ncommunity water systems serving approximately 80 percent of the population in 1988)\nNote: Safe drinking water standards are measured using Maximum Contaminant Level (MCL) standards set by the\nEnvironmental Protection Agency which define acceptable levels of contaminants. See Objective 11.3 for defini-\ntion of community water systems.\n11.10 Reduce potential risks to human health from surface water, as measured by a decrease to no more than 15 percent in\nthe proportion of assessed rivers, lakes, and estuaries that do not support beneficial uses, such as fishing and\nswimming. (Baseline: An estimated 25 percent of assessed rivers, lakes, and estuaries did not support designated\nbeneficial uses in 1988)\nNote: Designated beneficial uses, such as aquatic life support, contact recreation (swimming), and water supply,\nare designated by each State and approved by the Environmental Protection Agency. Support of beneficial use is a\nproxy measure of risk to human health, as many pollutants causing impaired water uses do not have human health\neffects (e.g., siltation, impaired fish habitat).\n106\nA. Summary List of Objectives\nServices and Protection Objectives\n11.11 Perform testing for lead-based paint in at least 50 percent of homes built before 1950. (Baseline data available in\n1991)\n11.12 Expand to at least 35 the number of States in which at least 75 percent of local jurisdictions have adopted\nconstruction standards and techniques that minimize elevated indoor radon levels in those new building areas\nlocally determined to have elevated radon levels. (Baseline: 1 State in 1989)\nNote: Since construction codes are frequently adopted by local jurisdictions rather than States, progress toward\nthis objective also may be tracked using the proportion of cities and counties that have adopted such construction\nstandards.\n11.13 Increase to at least 30 the number of States requiring that prospective buyers be informed of the presence of\nlead-based paint and radon concentrations in all buildings offered for sale. (Baseline: 2 States required disclosure\nof lead-based paint in 1989; 1 State required disclosure of radon concentrations in 1989; 2 additional States\nrequired disclosure that radon has been found in the State and that testing is desirable in 1989)\n11.14 Eliminate significant health risks from National Priority List hazardous waste sites, as measured by performance of\nclean-up at these sites sufficient to eliminate immediate and significant health threats as specified in health\nassessments completed at all sites. (Baseline: 1,082 sites were on the list in March of 1990; of these, health\nassessments have been conducted for approximately 1,000)\nNote: The Comprehensive Environmental Response, Compensation, and Liability Act of 1980 required the Environ-\nmental Protection Agency to develop criteria for determining priorities among hazardous waste sites and to develop\nand maintain a list of these priority sites. The resulting list is called the National Priorities List (NPL).\n11.15 Establish programs for recyclable materials and household hazardous waste in at least 75 percent of counties.\n(Baseline: Approximately 850 programs in 41 States collected household toxic waste in 1987; extent of recycling\ncollections unknown)\n11.16 Establish and monitor in at least 35 States plans to define and track sentinel environmental diseases. (Baseline: 0\nStates in 1990)\nNote: Sentinel environmental diseases include lead poisoning, other heavy metal poisoning (e.g., cadmium, ar-\nsenic, and mercury), pesticide poisoning, carbon monoxide poisoning, heatstroke, hypothermia, acute chemical\npoisoning, methemoglobinemia, and respiratory diseases triggered by environmental factors (e.g., asthma).\n12. Food and Drug Safety\nHealth Status Objectives\n12.1\nReduce infections caused by key foodborne pathogens to incidences of no more than:\nDisease (per 100,000)\n1987 Baseline\n2000 Target\nSalmonella species\n18\n16\nCampylobacter jejuni\n50\n25\nEscherichia coli 0157:H7\n8\n4\nListeria monocytogenes\n0.7\n0.5\n12.2\nReduce outbreaks of infections due to Salmonella enteritidis to fewer than 25 outbreaks yearly. (Baseline: 77\noutbreaks in 1989)\nRisk Reduction Objective\n12.3\nIncrease to at least 75 percent the proportion of households in which principal food preparers routinely refrain from\nleaving perishable food out of the refrigerator for over 2 hours and wash cutting boards and utensils with soap after\ncontact with raw meat and poultry. (Baseline: For refrigeration of perishable foods, 70 percent; for washing\ncutting boards with soap, 66 percent; and for washing utensils with soap, 55 percent, in 1988)\nServices and Protection Objectives\n12.4\nExtend to at least 70 percent the proportion of States and territories that have implemented model food codes for\ninstitutional food operations and to at least 70 percent the proportion that have adopted the new uniform food\nprotection code (\"Unicode\") that sets recommended standards for regulation of all food operations. (Baseline: For\ninstitutional food operations currently using FDA's recommended model codes, 20 percent; for the new Unicode to\nbe released in 1991, 0 percent, in 1990)\n12.5\nIncrease to at least 75 percent the proportion of pharmacies and other dispensers of prescription medications that use\nlinked systems to provide alerts to potential adverse drug reactions among medications dispensed by different\nsources to individual patients. (Baseline data available in 1993)\n12.6\nIncrease to at least 75 percent the proportion of primary care providers who routinely review with their patients aged\n65 and older all prescribed and over-the-counter medicines taken by their patients each time a new medication is\nprescribed. (Baseline data available in 1992)\n107\nHealthy People 2000\n13. Oral Health\nHealth Status Objectives\n13.1\nReduce dental caries (cavities) so that the proportion of children with one or more caries (in permanent or primary\nteeth) is no more than 35 percent among children aged 6 through 8 and no more than 60 percent among adolescents\naged 15. (Baseline: 53 percent of children aged 6 through 8 in 1986-87; 78 percent of adolescents aged 15 in\n1986-87)\nSpecial Population Targets\nDental Caries Prevalence\n1986-87 Baseline\n2000 Target\n13.1a Children aged 6-8 whose parents have less than high school education\n70%\n45%\n13.1b American Indian/Alaska Native children aged 6-8\n92%⁺\n45%\n52%+\n13.1c Black children aged 6-8\n61%\n40%\n13.1d American Indian/Alaska Native adolescents aged 15\n93%+\n70%\nIn primary teeth in 1983-84 *In permanent teeth in 1983-84\n13.2\nReduce untreated dental caries so that the proportion of children with untreated caries (in permanent or primary teeth)\nis no more than 20 percent among children aged 6 through 8 and no more than 15 percent among adolescents aged\n15. (Baseline: 27 percent of children aged 6 through 8 in 1986; 23 percent of adolescents aged 15 in 1986-87)\nSpecial Population Targets\nUntreated Dental Caries:\n1986-87 Baseline 2000 Target\nAmong Children-\n13.2a Children aged 6-8 whose parents have less than high school education\n43%\n30%\n13.2b American Indian/Alaska Native children aged 6-8\n64%⁺\n35%\n13.2c Black children aged 6-8\n38%\n25%\n13.2d Hispanic children aged 6-8\n36%+\n25%\nAmong Adolescents-\n13.2a Adolescents aged 15 whose parents have less than a high school education\n41%\n25%\n13.2b American Indian/Alaska Native adolescents aged 15\n84%⁺\n40%\n13.2c Black adolescents aged 15\n38%\n20%\n13.2d Hispanic adolescents aged 15\n31-47%\n25%\n1983-84 baseline\n+ 1982-84 baseline\n13.3\nIncrease to at least 45 percent the proportion of people aged 35 through 44 who have never lost a permanent tooth due\nto dental caries or periodontal diseases. (Baseline: 31 percent of employed adults had never lost a permanent tooth\nfor any reason in 1985-86)\nNote: Never lost a permanent tooth is having 28 natural teeth exclusive of third molars.\n13.4 Reduce to no more than 20 percent the proportion of people aged 65 and older who have lost all of their natural teeth.\n(Baseline: 36 percent in 1986)\nSpecial Population Target\nComplete Tooth Loss Prevalence\n1986 Baseline\n2000 Target\n13.4a Low-income people (annual family income <$15,000)\n46%\n25%\n13.5\nReduce the prevalence of gingivitis among people aged 35 through 44 to no more than 30 percent. (Baseline: 42\npercent in 1985-86)\nSpecial Population Targets\nGingivitis Prevalence\n1985 Baseline\n2000 Target\n13.5a Low-income people (annual family income <$12,500)\n50%\n35%\n13.5b American Indians/Alaska Natives\n95%⁺\n50%\n13.5c Hispanics\n50%\nMexican Americans\n74%⁺\nCubans\n79%\nPuerto Ricans\n82%\n+\n1983-84 baseline\n+ 1982-84 baseline\n13.6\nReduce destructive periodontal diseases to a prevalence of no more than 15 percent among people aged 35 through 44.\n(Baseline: 24 percent in 1985-86)\nNote: Destructive periodontal disease is one or more sites with 4 millimeters or greater loss of tooth attachment.\n13.7\nReduce deaths due to cancer of the oral cavity and pharynx to no more than 10.5 per 100,000 men aged 45 through 74\nand 4.1 per 100,000 women aged 45 through 74. (Baseline: 12.1 per 100,000 men and 4.1 per 100,000 women in\n1987)\n108\nA. Summary List of Objectives\nRisk Reduction Objectives\n13.8\nIncrease to at least 50 percent the proportion of children who have received protective sealants on the occlusal\n(chewing) surfaces of permanent molar teeth. (Baseline: 11 percent of children aged 8 and 8 percent of\nadolescents aged 14 in 1986-87)\nNote: Progress toward this objective will be monitored based on prevalence of sealants in children at age 8 and at\nage 14, when the majority of first and second molars, respectively, are erupted.\n13.9\nIncrease to at least 75 percent the proportion of people served by community water systems providing optimal levels\nof fluoride. (Baseline: 62 percent in 1989)\nNote: Optimal levels of fluoride are determined by the mean maximum daily air temperature over a 5-year period\nand range between 0.7 and 1.2 parts of fluoride per one million parts of water (ppm).\n13.10 Increase use of professionally or self-administered topical or systemic (dietary) fluorides to at least 85 percent of\npeople not receiving optimally fluoridated public water. (Baseline: An estimated 50 percent in 1989)\n13.11* Increase to at least 75 percent the proportion of parents and caregivers who use feeding practices that prevent baby\nbottle tooth decay. (Baseline data available in 1991)\nSpecial Population Targets\nAppropriate Feeding Practices\nBaseline\n2000 Target\n13.11a Parents and caregivers with less than high school education\n-\n65%\n13.11b American Indian/Alaska Native parents and caregivers\n-\n65%\nServices and Protection Objectives\n13.12 Increase to at least 90 percent the proportion of all children entering school programs for the first time who have\nreceived an oral health screening, referral, and followup for necessary diagnostic, preventive, and treatment\nservices. (Baseline: 66 percent of children aged 5 visited a dentist during the previous year in 1986)\nNote: School programs include Head Start, prekindergarten, kindergarten, and 1st grade.\n13.13 Extend to all long-term institutional facilities the requirement that oral examinations and services be provided no\nlater than 90 days after entry into these facilities. (Baseline: Nursing facilities receiving Medicaid or Medicare\nreimbursement will be required to provide for oral examinations within 90 days of patient entry beginning in 1990;\nbaseline data unavailable for other institutions)\nNote: Long-term institutional facilities include nursing homes, prisons, juvenile homes, and detention facilities.\n13.14 Increase to at least 70 percent the proportion of people aged 35 and older using the oral health care system during\neach year. (Baseline: 54 percent in 1986)\nSpecial Population Targets\nProportion Using Oral Health Care System During Each Year\n1986 Baseline\n2000 Target\n13.14a Edentulous people\n11%\n50%\n13.14b People aged 65 and older\n42%\n60%\n13.15 Increase to at least 40 the number of States that have an effective system for recording and referring infants with cleft\nlips and/or palates to craniofacial anomaly teams. (Baseline: In 1988, approximately 25 States had a central\nrecording mechanism for cleft lip and/or palate and approximately 25 States had an organized referral system to\ncraniofacial anomaly teams)\n13.16* Extend requirement of the use of effective head, face, eye, and mouth protection to all organizations, agencies, and\ninstitutions sponsoring sporting and recreation events that pose risks of injury. (Baseline: Only National\nCollegiate Athletic Association football, hockey, and lacrosse; high school football; amateur boxing; and amateur\nice hockey in 1988)\n109\nHealthy People 2000\n14. Maternal and Infant Health\nHealth Status Objectives\n14.1\nReduce the infant mortality rate to no more than 7 per 1,000 live births. (Baseline: 10.1 per 1,000 live births in 1987)\nSpecial Population Targets\nInfant Mortality (per 1,000 live births)\n1987 Baseline\n2000 Target\n14.1a Blacks\n17.9\n11\n14.1b American Indians/Alaska Natives\n12.5⁺\n8.5\n14.1c Puerto Ricans\n12.9⁺\n8\nType-Specific Targets\nNeonatal and Postneonatal Mortality (per 1,000 live births)\n1987 Baseline\n2000 Target\n14.1d Neonatal mortality\n6.5\n4.5\n14.1e Neonatal mortality among blacks\n11.7\n7\n14.1f Neonatal mortality among Puerto Ricans\n8.6⁺\n5.2\n14.1g Postneonatal mortality\n3.6\n2.5\n14.1h Postneonatal mortality among blacks\n6.1\n4\n14.1i Postneonatal mortality among American Indians/Alaska Natives\n6.5⁺\n4\n14.1j Postneonatal mortality among Puerto Ricans\n4.3⁺\n2.8\n1984 baseline\nNote: Infant mortality is deaths of infants under 1 year; neonatal mortality is deaths of infants under 28 days; and\npostneonatal mortality is deaths of infants aged 28 days up to 1 year.\n14.2 Reduce the fetal death rate (20 or more weeks of gestation) to no more than 5 per 1,000 live births plus fetal deaths.\n(Baseline: 7.6 per 1,000 live births plus fetal deaths in 1987)\nSpecial Population Target\nFetal Deaths\n1987 Baseline\n2000 Target\n14.2a\nBlacks\n12.8⁺\n7.5⁺\n+\nPer 1,000 live births plus fetal deaths\n14.3\nReduce the maternal mortality rate to no more than 3.3 per 100,000 live births. (Baseline: 6.6 per 100,000 in 1987)\nSpecial Population Target\nMaternal Mortality\n1987 Baseline\n2000 Target\n14.3a Blacks\n14.2⁺\n5⁺\n+\nPer 100,000 live births\nNote: The objective uses the maternal mortality rate as defined by the National Center for Health Statistics. How-\never, if other sources of maternal mortality data are used, a 50-percent reduction in maternal mortality is the in-\ntended target.\n14.4 Reduce the incidence of fetal alcohol syndrome to no more than 0.12 per 1,000 live births. (Baseline: 0.22 per 1,000\nlive births in 1987)\nSpecial Population Targets\nFetal Alcohol Syndrome (per 1,000 live births)\n1987 Baseline\n2000 Target\n14.4a American Indians/Alaska Natives\n4\n2\n14.4b Blacks\n0.8\n0.4\nRisk Reduction Objectives\n14.5\nReduce low birth weight to an incidence of no more than 5 percent of live births and very low birth weight to no more\nthan 1 percent of live births. (Baseline: 6.9 and 1.2 percent, respectively, in 1987)\nSpecial Population Target\n1987 Baseline\n2000 Target\nLow Birth Weight\n14.5a Blacks\n12.7%\n9%\nVery Low Birth Weight\nBlacks\n2.7%\n2%\nNote: Low birth weight is weight at birth of less than 2,500 grams; very low birth weight is weight at birth of less\nthan 1,500 grams.\n14.6 Increase to at least 85 percent the proportion of mothers who achieve the minimum recommended weight gain during\ntheir pregnancies. (Baseline: 67 percent of married women in 1980)\nNote: Recommended weight gain is pregnancy weight gain recommended in the 1990 National Academy of\nScience's report, Nutrition During Pregnancy.\n110\nA. Summary List of Objectives\n14.7\nReduce severe complications of pregnancy to no more than 15 per 100 deliveries. (Baseline: 22 hospitalizations\n(prior to delivery) per 100 deliveries in 1987)\nNote: Severe complications of pregnancy will be measured using hospitalizations due to pregnancy-related com-\nplications.\n14.8 Reduce the cesarean delivery rate to no more than 15 per 100 deliveries. (Baseline: 24.4 per 100 deliveries in 1987)\nType-Specific Targets\nCesarean Delivery (per 100 deliveries)\n1987 Baseline\n2000 Target\n14.8a Primary (first time) cesarean delivery\n17.4\n12\n14.8b Repeat cesarean deliveries\n91.2⁺\n65⁺\nAmong women who had a previous cesarean delivery\n14.9* Increase to at least 75 percent the proportion of mothers who breastfeed their babies in the early postpartum period\nand to at least 50 percent the proportion who continue breastfeeding until their babies are 5 to 6 months old.\n(Baseline: 54 percent at discharge from birth site and 21 percent at 5 to 6 months in 1988)\nSpecial Population Targets\nMothers Breastfeeding Their Babies:\n1988 Baseline\n2000 Target\nDuring Early Postpartum Period-\n14.9a Low-income mothers\n32%\n75%\n14.9b Black mothers\n25%\n75%\n14.9c\nHispanic mothers\n51%\n75%\n14.9d American Indian/Alaska Native mothers\n47%\n75%\nAt Age 5-6 Months -\n14.9a Low-income mothers\n9%\n50%\n14.9b\nBlack mothers\n8%\n50%\n14.9c Hispanic mothers\n16%\n50%\n14.9d American Indian/Alaska Native mothers\n28%\n50%\n14.10 Increase abstinence from tobacco use by pregnant women to at least 90 percent and increase abstinence from alcohol,\ncocaine, and marijuana by pregnant women by at least 20 percent. (Baseline: 75 percent of pregnant women\nabstained from tobacco use in 1985)\nNote: Data for alcohol, cocaine, and marijuana use by pregnant women will be available from the National Mater-\nnal and Infant Health Survey, CDC, in 1991.\nServices and Protection Objectives\n14.11 Increase to at least 90 percent the proportion of all pregnant women who receive prenatal care in the first trimester of\npregnancy. (Baseline: 76 percent of live births in 1987)\nSpecial Population Targets\nProportion of Pregnant Women Receiving\nEarly Prenatal Care\n1987 Baseline\n2000 Target\n14.11a Black women\n61.1⁺\n90⁺\n14.11b American Indian/Alaska Native women\n60.2⁺\n90⁺\n14.11c Hispanic women\n61.0⁺\n90+\n+\nPercent of live births\n14.12* Increase to at least 60 percent the proportion of primary care providers who provide age-appropriate preconception\ncare and counseling. (Baseline data available in 1992)\n14.13 Increase to at least 90 percent the proportion of women enrolled in prenatal care who are offered screening and\ncounseling on prenatal detection of fetal abnormalities. (Baseline data available in 1991)\nNote: This objective will be measured by tracking use of maternal serum alpha-fetoprotein screening tests.\n14.14 Increase to at least 90 percent the proportion of pregnant women and infants who receive risk-appropriate care.\n(Baseline data available in 1991)\nNote: This objective will be measured by tracking the proportion of very low birth weight infants (less than 1,500\ngrams) born in facilities covered by a neonatologist 24 hours a day.\n14.15 Increase to at least 95 percent the proportion of newborns screened by State-sponsored programs for genetic\ndisorders and other disabling conditions and to 90 percent the proportion of newborns testing positive for disease\nwho receive appropriate treatment. (Baseline: For sickle cell anemia, with 20 States reporting, approximately 33\npercent of live births screened (57 percent of black infants); for galactosemia, with 38 States reporting,\napproximately 70 percent of live births screened)\nNote: As measured by the proportion of infants served by programs for sickle cell anemia and galactosemia.\nScreening programs should be appropriate for State demographic characteristics.\n14.16 Increase to at least 90 percent the proportion of babies aged 18 months and younger who receive recommended\nprimary care services at the appropriate intervals. (Baseline data available in 1992)\n111\nHealthy People 2000\n15. Heart Disease and Stroke\nHealth Status Objectives\n15.1* Reduce coronary heart disease deaths to no more than 100 per 100,000 people. (Age-adjusted baseline: 135 per\n100,000 in 1987)\nSpecial Population Target\nCoronary Deaths (per 100,000)\n1987 Baseline\n2000 Target\n15.1a Blacks\n163\n115\n15.2\nReduce stroke deaths to no more than 20 per 100,000 people. (Age-adjusted baseline: 30.3 per 100,000 in 1987)\nSpecial Population Target\nStroke Deaths (per 100,000)\n1987 Baseline\n2000 Target\n15.2a\nBlacks\n51.2\n27\n15.3\nReverse the increase in end-stage renal disease (requiring maintenance dialysis or transplantation) to attain an\nincidence of no more than 13 per 100,000. (Baseline: 13.9 per 100,000 in 1987)\nSpecial Population Target\nESRD Incidence (per 100,000)\n1987 Baseline\n2000 Target\n15.3a\nBlacks\n32.4\n30\nRisk Reduction Objectives\n15.4\nIncrease to at least 50 percent the proportion of people with high blood pressure whose blood pressure is under\ncontrol. (Baseline: 11 percent controlled among people aged 18 through 74 in 1976-80; an estimated 24 percent\nfor people aged 18 and older in 1982-84)\nSpecial Population Target\nHigh Blood Pressure Control\n1976-80 Baseline 1982-84 Baseline 2000 Target\n15.4a Men with high blood pressure\n6%\n16%\n40%\nNote: People with high blood pressure have blood pressure equal to or greater than 140 mm Hg systolic and/or 90\nmm Hg diastolic and/or take antihypertensive medication. Blood pressure control is defined as maintaining a blood\npressure less than 140 mm Hg systolic and 90 mm Hg diastolic. In NHANES II and the Seven States Study, control\nof hypertension did not include nonpharmacologic treatment. In NHANES III, those controlling their high blood\npressure without medication (e.g., through weight loss, low sodium diets, or restriction of alcohol) will be included.\n15.5\nIncrease to at least 90 percent the proportion of people with high blood pressure who are taking action to help control\ntheir blood pressure. (Baseline: 79 percent of aware hypertensives aged 18 and older were taking action to control\ntheir blood pressure in 1985)\nSpecial Population Targets\nTaking Action to Control Blood Pressure\n1985 Baseline\n2000 Target\n15.5a White hypertensive men aged 18-34\n51%⁺\n80%\n15.5b Black hypertensive men aged 18-34\n63%⁺\n80%\nBaseline for aware hypertensive men\nNote: High blood pressure is defined as blood pressure equal to or greater than 140 mm Hg systolic and/or 90 mm\nHg diastolic and/or taking antihypertensive medication. Actions to control blood pressure include taking medica-\ntion, dieting to lose weight, cutting down on salt, and exercising.\n15.6\nReduce the mean serum cholesterol level among adults to no more than 200 mg/dL. (Baseline: 213 mg/dL among\npeople aged 20 through 74 in 1976-80, 211 mg/dL for men and 215 mg/dL for women)\n15.7\nReduce the prevalence of blood cholesterol levels of 240 mg/dL or greater to no more than 20 percent among adults.\n(Baseline: 27 percent for people aged 20 through 74 in 1976-80, 29 percent for women and 25 percent for men)\n15.8\nIncrease to at least 60 percent the proportion of adults with high blood cholesterol who are aware of their condition\nand are taking action to reduce their blood cholesterol to recommended levels. (Baseline: 11 percent of all people\naged 18 and older, and thus an estimated 30 percent of people with high blood cholesterol, were aware that their\nblood cholesterol level was high in 1988)\nNote: \"High blood cholesterol\" means a level that requires diet and, if necessary, drug treatment. Actions to con-\ntrol high blood cholesterol include keeping medical appointments, making recommended dietary changes (e.g.,\nreducing saturated fat, total fat, and dietary cholesterol), and, if necessary, taking prescribed medication.\n15.9* Reduce dietary fat intake to an average of 30 percent of calories or less and average saturated fat intake to less than\n10 percent of calories among people aged 2 and older. (Baseline: 36 percent of calories from total fat and 13\npercent from saturated fat for people aged 20 through 74 in 1976-80; 36 percent and 13 percent for women aged 19\nthrough 50 in 1985)\n112\nA. Summary List of Objectives\n15.10* Reduce overweight to a prevalence of no more than 20 percent among people aged 20 and older and no more than\n15 percent among adolescents aged 12 through 19. (Baseline: 26 percent for people aged 20 through 74 in\n1976-80, 24 percent for men and 27 percent for women; 15 percent for adolescents aged 12 through 19 in 1976-80)\nSpecial Population Targets\nOverweight Prevalence\n1976-80 Baseline¹\n2000 Target\n15.10a Low-income women aged 20 and older\n37%\n25%\n15.10b Black women aged 20 and older\n44%\n30%\n15.10c Hispanic women aged 20 and older\n25%\nMexican-American women\n39%+\nCuban women\n34%+\nPuerto Rican women\n37%+\n15.10d American Indians/Alaska Natives\n29-75%\n30%\n15.10e People with disabilities\n36%+\n25%\n15.10f Women with high blood pressure\n50%\n41%\n15.10g Men with high blood pressure\n39%\n35%\nBaseline for people aged 20-74 1982-84 baseline for Hispanics aged 20-74\n§ 1984-88 estimates for different tribes\n1985 baseline for people aged 20-74 who report any limitation in activity due to chronic conditions\nNote: For people aged 20 and older, overweight is defined as body mass index (BMI) equal to or greater than 27.8\nfor men and 27.3 for women. For adolescents, overweight is defined as BMI equal to or greater than 23.0 for\nmales aged 12 through 14, 24.3 for males aged 15 through 17, 25.8 for males aged 18 through 19, 23.4 for females\naged 12 through 14, 24.8 for females aged 15 through 17, and 25.7 for females aged 18 through 19. The values for\nadolescents are the age- and gender-specific 85th percentile values of the 1976-80 National Health and Nutrition\nExamination Survey (NHANES II), corrected for sample variation. BMI is calculated by dividing weight in\nkilograms by the square of height in meters. The cut points used to define overweight approximate the 120 percent\nof desirable body weight definition used in the 1990 objectives.\n15.11* Increase to at least 30 percent the proportion of people aged 6 and older who engage regularly, preferably daily, in\nlight to moderate physical activity for at least 30 minutes per day. (Baseline: 22 percent of people aged 18 and\nolder were active for at least 30 minutes 5 or more times per week and 12 percent were active 7 or more times per\nweek in 1985)\nNote: Light to moderate physical activity requires sustained, rhythmic muscular movements, is at least equivalent\nto sustained walking, and is performed at less than 60 percent of maximum heart rate for age. Maximum heart rate\nequals roughly 220 beats per minute minus age. Examples may include walking, swimming, cycling, dancing, gar-\ndening and yardwork, various domestic and occupational activities, and games and other childhood pursuits.\n15.12* Reduce cigarette smoking to a prevalence of no more than 15 percent among people aged 20 and older. (Baseline:\n29 percent in 1987, 32 percent for men and 27 percent for women)\nSpecial Population Targets\nCigarette Smoking Prevalence\n1987 Baseline\n2000 Target\n15.12a People with a high school education or less aged 20 and older\n34%\n20%\n15.12b Blue-collar workers aged 20 and older\n36%\n20%\n15.12c Military personnel\n42%⁺\n20%\n15.12d Blacks aged 20 and older\n34%\n18%\n15.12e Hispanics aged 20 and older\n33%⁺\n18%\n15.12f American Indians/Alaska Natives\n42-70%\n20%\n15.12g Southeast Asian men\n55%+\n20%\n15.12h Women of reproductive age\n29%\n12%\n15.12i Pregnant women\n25%*\n10%\n15.12j Women who use oral contraceptives\n36%\n10%\n1988 baseline 1982-84 baseline for Hispanics aged 20-74 1979-87 estimates for different tribes\n*1984-88 baseline ++ Baseline for women aged 18-44 # 1985 baseline §§ 1983 baseline\nNote: A cigarette smoker is a person who has smoked at least 100 cigarettes and currently smokes cigarettes.\nServices and Protection Objectives\n15.13 Increase to at least 90 percent the proportion of adults who have had their blood pressure measured within the\npreceding 2 years and can state whether their blood pressure was normal or high. (Baseline: 61 percent of people\naged 18 and older had their blood pressure measured within the preceding 2 years and were given the systolic and\ndiastolic values in 1985)\nNote: A blood pressure measurement within the preceding 2 years refers to a measurement by a health professional\nor other trained observer.\n15.14 Increase to at least 75 percent the proportion of adults who have had their blood cholesterol checked within the\npreceding 5 years. (Baseline: 59 percent of people aged 18 and older had \"ever\" had their cholesterol checked in\n1988; 52 percent were checked \"within the preceding 2 years\" in 1988)\n113\nHealthy People 2000\n15.15 Increase to at least 75 percent the proportion of primary care providers who initiate diet and, if necessary, drug\ntherapy at levels of blood cholesterol consistent with current management guidelines for patients with high blood\ncholesterol. (Baseline data available in 1991)\nNote: Current treatment recommendations are outlined in detail in the Report of the Expert Panel on the Detection,\nEvaluation, and Treatment of High Blood Cholesterol in Adults, released by the National Cholesterol Education\nProgram in 1987. Guidelines appropriate for children are currently being established. Treatment recommenda-\ntions are likely to be refined over time. Thus, for the year 2000, \"current\" means whatever recommendations are\nthen in effect.\n15.16 Increase to at least 50 percent the proportion of worksites with 50 or more employees that offer high blood pressure\nand/or cholesterol education and control activities to their employees. (Baseline: 16.5 percent offered high blood\npressure activities and 16.8 percent offered nutrition education activities in 1985)\n15.17 Increase to at least 90 percent the proportion of clinical laboratories that meet the recommended accuracy standard\nfor cholesterol measurement. (Baseline: 53 percent in 1985)\n16. Cancer\nHealth Status Objectives\n16.1* Reverse the rise in cancer deaths to achieve a rate of no more than 130 per 100,000 people. (Age-adjusted baseline:\n133 per 100,000 in 1987)\nNote: In its publications, the National Cancer Institute age adjusts cancer death rates to the 1970 U.S. population.\nUsing the 1970 standard, the equivalent baseline and target values for this objective would be 171 and 175 per\n100,000, respectively.\n16.2* Slow the rise in lung cancer deaths to achieve a rate of no more than 42 per 100,000 people. (Age-adjusted baseline:\n37.9 per 100,000 in 1987)\nNote: In its publications, the National Cancer Institute age adjusts cancer death rates to the 1970 U.S. population.\nUsing the 1970 standard, the equivalent baseline and target values for this objective would be 47.9 and 53 per\n100,000, respectively.\n16.3 Reduce breast cancer deaths to no more than 20.6 per 100,000 women. (Age-adjusted baseline: 22.9 per 100,000 in\n1987)\nNote: In its publications, the National Cancer Institute age adjusts cancer death rates to the 1970 U.S. population.\nUsing the 1970 standard, the equivalent baseline and target values for this objective would be 27.2 and 25.2 per\n100,000, respectively.\n16.4 Reduce deaths from cancer of the uterine cervix to no more than 1.3 per 100,000 women. (Age-adjusted baseline: 2.8\nper 100,000 in 1987)\nNote: In its publications, the National Cancer Institute age adjusts cancer death rates to the 1970 U.S. population.\nUsing the 1970 standard, the equivalent baseline and target values for this objective would be 3.2 and 1.5 per\n100,000, respectively.\n16.5 Reduce colorectal cancer deaths to no more than 13.2 per 100,000 people. (Age-adjusted baseline: 14.4 per 100,000\nin 1987)\nNote: In its publications, the National Cancer Institute age adjusts cancer death rates to the 1970 U.S. population.\nUsing the 1970 standard, the equivalent baseline and target values for this objective would be 20.1 and 18.7 per\n100,000, respectively.\nRisk Reduction Objectives\n16.6* Reduce cigarette smoking to a prevalence of no more than 15 percent among people aged 20 and older. (Baseline:\n29 percent in 1987, 32 percent for men and 27 percent for women)\nSpecial Population Targets\nCigarette Smoking Prevalence\n1987 Baseline\n2000 Target\n16.6a People with a high school education or less aged 20 and older\n34%\n20%\n16.6b Blue-collar workers aged 20 and older\n36%\n20%\n16.6c Military personnel\n42%⁺\n20%\n16.6d Blacks aged 20 and older\n34%\n18%\n16.6e Hispanics aged 20 and older\n33%*\n18%\n16.6f American Indians/Alaska Natives\n42-70%\n20%\n16.6g Southeast Asian men\n55%+\n20%\n16.6h Women of reproductive age\n29%⁺\n12%\n16.6i Pregnant women\n25%⁺⁺\n10%\n16.6j Women who use oral contraceptives\n36%\n10%\n1988 baseline 1982-84 baseline for Hispanics aged 20-74 1979-87 estimates for different tribes\n*1984-88 baseline ++ Baseline for women aged 18-44 # 1985 baseline §§ 1983 baseline\nNote: A cigarette smoker is a person who has smoked at least 100 cigarettes and currently smokes cigarettes.\n114\nA. Summary List of Objectives\n16.7* Reduce dietary fat intake to an average of 30 percent of calories or less and average saturated fat intake to less than\n10 percent of calories among people aged 2 and older. (Baseline: 36 percent of calories from total fat and 13\npercent from saturated fat for people aged 20 through 74 in 1976-80; 36 percent and 13 percent for women aged 19\nthrough 50 in 1985)\nNote: The inclusion of a saturated fat target in this objective should not be interpreted as evidence that reducing\nonly saturated fat will reduce cancer risk. Epidemiologic and experimental animal studies suggest that the amount\nof fat consumed rather than the specific type of fat can influence the risk of some cancers.\n16.8* Increase complex carbohydrate and fiber-containing foods in the diets of adults to 5 or more daily servings for\nvegetables (including legumes) and fruits, and to 6 or more daily servings for grain products. (Baseline: 2½\nservings of fruits and vegetables and 3 servings of grain products for women aged 19 through 50 in 1985)\n16.9\nIncrease to at least 60 percent the proportion of people of all ages who limit sun exposure, use sunscreens and\nprotective clothing when exposed to sunlight, and avoid artificial sources of ultraviolet light (e.g., sun lamps,\ntanning booths). (Baseline data available in 1992)\nServices and Protection Objectives\n16.10 Increase to at least 75 percent the proportion of primary care providers who routinely counsel patients about tobacco\nuse cessation, diet modification, and cancer screening recommendations. (Baseline: About 52 percent of internists\nreported counseling more than 75 percent of their smoking patients about smoking cessation in 1986)\n16.11 Increase to at least 80 percent the proportion of women aged 40 and older who have ever received a clinical breast\nexamination and a mammogram, and to at least 60 percent those aged 50 and older who have received them within\nthe preceding 1 to 2 years. (Baseline: 36 percent of women aged 40 and older \"ever\" in 1987; 25 percent of\nwomen aged 50 and older \"within the preceding 2 years\" in 1987)\nSpecial Population Targets\nClinical Breast Exam & Mammogram:\n1987 Baseline\n2000 Target\nEver Received-\n16.11a Hispanic women aged 40 and older\n20%\n80%\n16.11b Low-income women aged 40 and older (annual family income <$10,000)\n22%\n80%\n16.11c Women aged 40 and older with less than high school education\n23%\n80%\n16.11d Women aged 70 and older\n25%\n80%\n16.11e Black women aged 40 and older\n28%\n80%\nReceived Within Preceding 2 Years—\n16.11a Hispanic women aged 50 and older\n18%\n60%\n16.11b Low-income women aged 50 and older (annual family income <$10,000)\n15%\n60%\n16.11c Women aged 50 and older with less than high school education\n16%\n60%\n16.11d Women aged 70 and older\n18%\n60%\n16.11e Black women aged 50 and older\n19%\n60%\n16.12 Increase to at least 95 percent the proportion of women aged 18 and older with uterine cervix who have ever received\na Pap test, and to at least 85 percent those who received a Pap test within the preceding 1 to 3 years. (Baseline: 88\npercent \"ever\" and 75 percent \"within the preceding 3 years\" in 1987)\nSpecial Population Targets\nPap Test:\n1987 Baseline\n2000 Target\nEver Received-\n16.12a Hispanic women aged 18 and older\n75%\n95%\n16.12b Women aged 70 and older\n76%\n95%\n16.12c Women aged 18 and older with less than high school education\n79%\n95%\n16.12d Low-income women aged 18 and older (annual family income <$10,000)\n80%\n95%\nReceived Within Preceding 3 Years—\n16.12a Hispanic women aged 18 and older\n66%\n80%\n16.12b Women aged 70 and older\n44%\n70%\n16.12c Women aged 18 and older with less than high school education\n58%\n75%\n16.12d Low-income women aged 18 and older (annual family income <$10,000)\n64%\n80%\n16.13 Increase to at least 50 percent the proportion of people aged 50 and older who have received fecal occult blood\ntesting within the preceding 1 to 2 years, and to at least 40 percent those who have ever received\nproctosigmoidoscopy. (Baseline: 27 percent received fecal occult blood testing during the preceding 2 years in\n1987; 25 percent had ever received proctosigmoidoscopy in 1987)\n16.14 Increase to at least 40 percent the proportion of people aged 50 and older visiting a primary care provider in the\npreceding year who have received oral, skin, and digital rectal examinations during one such visit. (Baseline: An\nestimated 27 percent received a digital rectal exam during a physician visit within the preceding year in 1987)\n16.15 Ensure that Pap tests meet quality standards by monitoring and certifying all cytology laboratories. (Baseline data\navailable in 1991)\n16.16 Ensure that mammograms meet quality standards by monitoring and certifying at least 80 percent of mammography\nfacilities. (Baseline: An estimated 18 to 21 percent certified by the American College of Radiology as of June\n1990)\n115\nHealthy People 2000\n17. Diabetes and Chronic Disabling Conditions\nHealth Status Objectives\nChronic Disabling Conditions\n17.1* Increase years of healthy life to at least 65 years. (Baseline: An estimated 62 years in 1980)\nSpecial Population Targets\nYears of Healthy Life\n1980 Baseline\n2000 Target\n17.1a Blacks\n56\n60\n17.1b Hispanics\n62\n65\n17.1c People aged 65 and older\n12⁺\n14⁺\nYears of healthy life remaining at age 65\nNote: Years of healthy life (also referred to as quality-adjusted life years) is a summary measure of health that com-\nbines mortality (quantity of life) and morbidity and disability (quality of life) into a single measure. For people\naged 65 and older, active life-expectancy, a related summary measure, also will be tracked.\n17.2 Reduce to no more than 8 percent the proportion of people who experience a limitation in major activity due to\nchronic conditions. (Baseline: 9.4 percent in 1988)\nSpecial Population Targets\nPrevalence of Disability\n1988 Baseline\n2000 Target\n17.2a Low-income people (annual family income <$10,000 in 1988)\n18.9%\n15%\n17.2b American Indians/Alaska Natives\n13.4%\n11%\n17.2c Blacks\n11.2%\n9%\n1983-85 baseline\nNote: Major activity refers to the usual activity for one's age-gender group whether it is working, keeping house,\ngoing to school, or living independently. Chronic conditions are defined as conditions that either (1) were first\nnoticed 3 or more months ago, or (2) belong to a group of conditions such as heart disease and diabetes, which are\nconsidered chronic regardless of when they began.\n17.3 Reduce to no more than 90 per 1,000 people the proportion of all people aged 65 and older who have difficulty in\nperforming two or more personal care activities, thereby preserving independence. (Baseline: 111 per 1,000 in\n1984-85)\nSpecial Population Target\nDifficulty Performing Self-Care Activities (per 1,000)\n1984-85 Baseline\n2000 Target\n17.3a People aged 85 and older\n371\n325\nNote: Personal care activities are bathing, dressing, using the toilet, getting in and out of bed or chair, and eating.\n17.4 Reduce to no more than 10 percent the proportion of people with asthma who experience activity limitation.\n(Baseline: Average of 19.4 percent during 1986-88)\nNote: Activity limitation refers to any self-reported limitation in activity attributed to asthma.\n17.5 Reduce activity limitation due to chronic back conditions to a prevalence of no more than 19 per 1,000 people.\n(Baseline: Average of 21.9 per 1,000 during 1986-88)\nNote: Chronic back conditions include intervertebral disk disorders, curvature of the back or spine, and other self-\nreported chronic back impairments such as permanent stiffness or deformity of the back or repeated trouble with\nthe back. Activity limitation refers to any self-reported limitation in activity attributed to a chronic back condition.\n17.6 Reduce significant hearing impairment to a prevalence of no more than 82 per 1,000 people. (Baseline: Average of\n88.9 per 1,000 during 1986-88)\nSpecial Population Target\nHearing Impairment (per 1,000)\n1986-88 Baseline\n2000 Target\n17.6a People aged 45 and older\n203\n180\nNote: Hearing impairment covers the range of hearing deficits from mild loss in one ear to profound loss in both\nears. Generally, inability to hear sounds at levels softer (less intense) than 20 decibels (dB) constitutes abnormal\nhearing. Significant hearing impairment is defined as having hearing thresholds for speech poorer than 25 dB.\nHowever, for this objective, self-reported hearing impairment (i.e., deafness in one or both ears or any trouble hear-\ning in one or both ears) will be used as a proxy measure for significant hearing impairment.\n17.7 Reduce significant visual impairment to a prevalence of no more than 30 per 1,000 people. (Baseline: Average of\n34.5 per 1,000 during 1986-88)\nSpecial Population Target\nVisual Impairment (per 1,000)\n1986-88 Baseline\n2000 Target\n17.7a People aged 65 and older\n87.7\n70\nNote: Significant visual impairment is generally defined as a permanent reduction in visual acuity and/or field of\nvision which is not correctable with eyeglasses or contact lenses. Severe visual impairment is defined as inability to\nread ordinary newsprint even with corrective lenses. For this objective, self-reported blindness in one or both eyes\nand other self-reported visual impairments (i.e., any trouble seeing with one or both eyes even when wearing glas-\nses or colorblindness) will be used as a proxy measure for significant visual impairment.\n116\nA. Summary List of Objectives\n17.8* Reduce the prevalence of serious mental retardation in school-aged children to no more than 2 per 1,000 children.\n(Baseline: 2.7 per 1,000 children aged 10 in 1985-88)\nNote: Serious mental retardation is defined as an Intelligence Quotient (I.Q.) less than 50. This includes in-\ndividuals defined by the American Association of Mental Retardation as profoundly retarded (1.Q. of 20 or less),\nseverely retarded (I.Q. of 21-35), and moderately retarded (I.Q. of 36-50).\nDiabetes\n17.9\nReduce diabetes-related deaths to no more than 34 per 100,000 people. (Age-adjusted baseline: 38 per 100,000 in\n1986)\nSpecial Population Targets\nDiabetes-Related Deaths (per 100,000)\n1986 Baseline\n2000 Target\n17.9a Blacks\n65\n58\n17.9b American Indians/Alaska Natives\n54\n48\nNote: Diabetes-related deaths refer to deaths from diabetes as an underlying or contributing cause.\n17.10 Reduce the most severe complications of diabetes as follows:\nComplications Among People With Diabetes\n1988 Baseline\n2000 Target\nEnd-stage renal disease\n1.5/1,000⁺\n1.4/1,000\nBlindness\n2.2/1,000\n1.4/1,000\nLower extremity amputation\n8.2/1,000⁺\n4.9/1,000\nPerinatal mortality\n5%\n2%\nMajor congenital malformations\n8%\n4%\n+ 1987 baseline *Among infants of women with established diabetes\nSpecial Population Targets for ESRD\nESRD Due to Diabetes (per 1,000)\n1983-86 Baseline\n2000 Target\n17.10a Blacks with diabetes\n2.2\n2\n17.10b American Indians/Alaska Natives with diabetes\n2.1\n1.9\nSpecial Population Target for Amputations\nLower Extremity Amputations Due to\nDiabetes (per 1,000)\n1984-87 Baseline 2000 Target\n17.10c Blacks with diabetes\n10.2\n6.1\nNote: End-stage renal disease (ESRD) is defined as requiring maintenance dialysis or transplantation and is\nlimited to ESRD due to diabetes. Blindness refers to blindness due to diabetic eye disease.\n17.11 Reduce diabetes to an incidence of no more than 2.5 per 1,000 people and a prevalence of no more than 25 per 1,000\npeople. (Baselines: 2.9 per 1,000 in 1987; 28 per 1,000 in 1987)\nSpecial Population Targets\nPrevalence of Diabetes (per 1,000)\n1982-84 Baseline⁺ 2000 Target\n17.11a American Indians/Alaska Natives\n69⁺\n62\n17.11b Puerto Ricans\n55\n49\n17.11c Mexican Americans\n54\n49\n17.11d Cuban Americans\n36\n32\n17.11e Blacks\n36⁸\n32\n1982-84 baseline for people aged 20-74\n# 1987 baseline for American Indians/Alaska Natives aged 15 and older\n§ 1987 baseline for blacks of all ages\n117\nHealthy People 2000\nRisk Reduction Objectives\n17.12* Reduce overweight to a prevalence of no more than 20 percent among people aged 20 and older and no more than\n15 percent among adolescents aged 12 through 19. (Baseline: 26 percent for people aged 20 through 74 in\n1976-80, 24 percent for men and 27 percent for women; 15 percent for adolescents aged 12 through 19 in 1976-80)\nSpecial Population Targets\nOverweight Prevalence\n1976-80 Baseline¹\n2000 Target\n17.12a Low-income women aged 20 and older\n37%\n25%\n17.12b Black women aged 20 and older\n44%\n30%\n17.12c Hispanic women aged 20 and older\n25%\nMexican-American women\n39%\nCuban women\n34%\nPuerto Rican women\n37%⁺\n17.12d American Indians/Alaska Natives\n29-75%\n30%\n17.12e People with disabilities\n36%+\n25%\n17.12f Women with high blood pressure\n50%\n41%\n17.12g Men with high blood pressure\n39%\n35%\n1976-80 baseline for people aged 20-74\n1982-84 baseline for Hispanics aged 20-74\n§ 1984-88 estimates for different tribes\n+1985 baseline for people aged 20-74 who report any limitation in activity due to chronic conditions\nNote: For people aged 20 and older, overweight is defined as body mass index (BMI) equal to or greater than 27.8\nfor men and 27.3 for women. For adolescents, overweight is defined as BMI equal to or greater than 23.0 for\nmales aged 12 through 14, 24.3 for males aged 15 through 17, 25.8 for males aged 18 through 19, 23.4 for females\naged 12 through 14, 24.8 for females aged 15 through 17, and 25.7 for females aged 18 through 19. The values for\nadolescents are the age- and gender-specific 85th percentile values of the 1976-80 National Health and Nutrition\nExamination Survey (NHANES II), corrected for sample variation. BMI is calculated by dividing weight in\nkilograms by the square of height in meters. The cut points used to define overweight approximate the 120 percent\nof desirable body weight definition used in the 1990 objectives.\n17.13* Increase to at least 30 percent the proportion of people aged 6 and older who engage regularly, preferably daily, in\nlight to moderate physical activity for at least 30 minutes per day. (Baseline: 22 percent of people aged 18 and\nolder were active for at least 30 minutes 5 or more times per week and 12 percent were active 7 or more times per\nweek in 1985)\nNote: Light to moderate physical activity requires sustained, rhythmic muscular movements, is at least equivalent\nto sustained walking, and is performed at less than 60 percent of maximum heart rate for age. Maximum heart rate\nequals roughly 220 beats per minute minus age. Examples may include walking, swimming, cycling, dancing, gar-\ndening and yardwork, various domestic and occupational activities, and games and other childhood pursuits.\nServices and Protection Objectives\n17.14 Increase to at least 40 percent the proportion of people with chronic and disabling conditions who receive formal\npatient education including information about community and self-help resources as an integral part of the\nmanagement of their condition. (Baseline data available in 1991)\nType-Specific Targets\nPatient Education\n1983-84 Baseline\n2000 Target\n17.14a People with diabetes\n32% (classes)\n75%\n68% (counseling)\n17.14b People with asthma\n50%\n17.15 Increase to at least 80 percent the proportion of providers of primary care for children who routinely refer or screen\ninfants and children for impairments of vision, hearing, speech and language, and assess other developmental\nmilestones as part of well-child care. (Baseline data available in 1992)\n17.16 Reduce the average age at which children with significant hearing impairment are identified to no more than 12\nmonths. (Baseline: Estimated as 24 to 30 months in 1988)\n17.17 Increase to at least 60 percent the proportion of providers of primary care for older adults who routinely evaluate\npeople aged 65 and older for urinary incontinence and impairments of vision, hearing, cognition, and functional\nstatus. (Baseline data available in 1992)\n17.18 Increase to at least 90 percent the proportion of perimenopausal women who have been counseled about the benefits\nand risks of estrogen replacement therapy (combined with progestin, when appropriate) for prevention of\nosteoporosis. (Baseline data available in 1991)\n17.19 Increase to at least 75 percent the proportion of worksites with 50 or more employees that have a voluntarily\nestablished policy or program for the hiring of people with disabilities. (Baseline: 37 percent of medium and large\ncompanies in 1986)\nNote: Voluntarily established policies and programs for the hiring of people with disabilities are encouraged for\nworksites of all sizes. This objective is limited to worksites with 50 or more employees for tracking purposes.\n118\nA. Summary List of Objectives\n17.20 Increase to 50 the number of States that have service systems for children with or at risk of chronic and disabling\nconditions, as required by Public Law 101-239. (Baseline data available in 1991)\nNote: Children with or at risk of chronic and disabling conditions, often referred to as children with special health\ncare needs, include children with psychosocial as well as physical problems. This population encompasses children\nwith a wide variety of actual or potential disabling conditions, including children with or at risk for cerebral palsy,\nmental retardation, sensory deprivation, developmental disabilities, spina bifida, hemophilia, other genetic disor-\nders, and health-related educational and behavioral problems. Service systems for such children are organized net-\nworks of comprehensive, community-based, coordinated, and family-centered services.\n18. HIV Infection\nHealth Status Objectives\n18.1\nConfine annual incidence of diagnosed AIDS cases to no more than 98,000 cases. (Baseline: An estimated 44,000 to\n50,000 diagnosed cases in 1989)\nSpecial Population Targets\nDiagnosed AIDS Cases\n1989 Baseline\n2000 Target\n18.1a Gay and bisexual men\n26,000-28,000\n48,000\n18.1b Blacks\n14,000-15,000\n37,000\n18.1c Hispanics\n7,000-8,000\n18,000\nNote: Targets for this objective are equal to upper bound estimates of the incidence of diagnosed AIDS cases\nprojected for 1993.\n18.2\nConfine the prevalence of HIV infection to no more than 800 per 100,000 people. (Baseline: An estimated 400 per\n100,000 in 1989)\nSpecial Population Targets\nEstimated Prevalence of HIV Infection (per 100,000)\n1989 Baseline\n2000 Target\n18.2a Homosexual men\n2,000-42,000\n20,000\n18.2b Intravenous drug abusers\n30,000-40,000\n40,000\n18.2c Women giving birth to live-born infants\n150\n100\n⁺Per 100,000 homosexual men aged 15 through 24 based on men tested in selected sexually transmitted disease\nclinics in unlinked surveys; most studies find HIV prevalence of between 2,000 and 21,000 per 100,000\n⁺Per 100,000 intravenous drug abusers aged 15 through 24 in the New York city vicinity; in areas other than\nmajor metropolitan centers, infection rates in people entering selected drug treatment programs tested in\nunlinked surveys are often under 500 per 100,000\nRisk Reduction Objectives\n18.3* Reduce the proportion of adolescents who have engaged in sexual intercourse to no more than 15 percent by age 15\nand no more than 40 percent by age 17. (Baseline: 27 percent of girls and 33 percent of boys by age 15; 50\npercent of girls and 66 percent of boys by age 17; reported in 1988)\n18.4* Increase to at least 50 percent the proportion of sexually active, unmarried people who used a condom at last sexual\nintercourse. (Baseline: 19 percent of sexually active, unmarried women aged 15 through 44 reported that their\npartners used a condom at last sexual intercourse in 1988)\nSpecial Population Targets\nUse of Condoms\n1988 Baseline\n2000 Target\n18.4a Sexually active young women aged 15-19 (by their partners)\n26%\n60%\n18.4b Sexually active young men aged 15-19\n57%\n75%\n18.4c Intravenous drug abusers\n-\n60%\nNote: Strategies to achieve this objective must be undertaken sensitively to avoid indirectly encouraging or condon-\ning sexual activity among teens who are not yet sexually active.\n18.5\nIncrease to at least 50 percent the estimated proportion of all intravenous drug abusers who are in drug abuse\ntreatment programs. (Baseline: An estimated 11 percent of opiate abusers were in treatment in 1989)\n18.6 Increase to at least 50 percent the estimated proportion of intravenous drug abusers not in treatment who use only\nuncontaminated drug paraphernalia (\"works\"). (Baseline: 25 to 35 percent of opiate abusers in 1989)\n18.7 Reduce to no more than 1 per 250,000 units of blood and blood components the risk of transfusion-transmitted HIV\ninfection. (Baseline: 1 per 40,000 to 150,000 units in 1989)\nServices and Protection Objectives\n18.8\nIncrease to at least 80 percent the proportion of HIV-infected people who have been tested for HIV infection.\n(Baseline: An estimated 15 percent of approximately 1,000,000 HIV-infected people had been tested at publicly\nfunded clinics, in 1989)\n119\nHealthy People 2000\n18.9* Increase to at least 75 percent the proportion of primary care and mental health care providers who provide\nage-appropriate counseling on the prevention of HIV and other sexually transmitted diseases. (Baseline: 10\npercent of physicians reported that they regularly assessed the sexual behaviors of their patients in 1987)\nSpecial Population Target\nCounseling on HIV and STD Prevention\n1987 Baseline\n2000 Target\n18.9a Providers practicing in high incidence areas\n-\n90%\nNote: Primary care providers include physicians, nurses, nurse practitioners, and physician assistants. Areas of\nhigh AIDS and sexually transmitted disease incidence are cities and States with incidence rates of AIDS cases, HIV\nseroprevalence, gonorrhea, or syphilis that are at least 25 percent above the national average.\n18.10 Increase to at least 95 percent the proportion of schools that have age-appropriate HIV education curricula for\nstudents in 4th through 12th grade, preferably as part of quality school health education. (Baseline: 66 percent of\nschool districts required HIV education but only 5 percent required HIV education in each year for 7th through\n12th grade in 1989)\nNote: Strategies to achieve this objective must be undertaken sensitively to avoid indirectly encouraging or condon-\ning sexual activity among teens who are not yet sexually active.\n18.11 Provide HIV education for students and staff in at least 90 percent of colleges and universities. (Baseline data\navailable in 1995)\n18.12 Increase to at least 90 percent the proportion of cities with populations over 100,000 that have outreach programs to\ncontact drug abusers (particularly intravenous drug abusers) to deliver HIV risk reduction messages. (Baseline\ndata available in 1995)\nNote: HIV risk reduction messages include messages about reducing or eliminating drug use, entering drug treat-\nment, disinfection of injection equipment if still injecting drugs, and safer sex practices.\n18.13* Increase to at least 50 percent the proportion of family planning clinics, maternal and child health clinics, sexually\ntransmitted disease clinics, tuberculosis clinics, drug treatment centers, and primary care clinics that screen,\ndiagnose, treat, counsel, and provide (or refer for) partner notification services for HIV infection and bacterial\nsexually transmitted diseases (gonorrhea, syphilis, and chlamydia). (Baseline: 40 percent of family planning\nclinics for bacterial sexually transmitted diseases in 1989)\n18.14 Extend to all facilities where workers are at risk for occupational transmission of HIV regulations to protect workers\nfrom exposure to bloodborne infections, including HIV infection. (Baseline data available in 1992)\nNote: The Occupational Safety and Health Administration (OSHA) is expected to issue regulations requiring\nworker protection from exposure to bloodborne infections, including HIV, during 1991. Implementation of the\nOSHA regulations would satisfy this objective.\n19. Sexually Transmitted Diseases\nHealth Status Objectives\n19.1\nReduce gonorrhea to an incidence of no more than 225 cases per 100,000 people. (Baseline: 300 per 100,000 in 1989)\nSpecial Population Targets\nGonorrhea Incidence (per 100,000)\n1989 Baseline\n2000 Target\n19.1a Blacks\n1,990\n1,300\n19.1b Adolescents aged 15-19\n1,123\n750\n19.1c Women aged 15-44\n501\n290\n19.2 Reduce Chlamydia trachomatis infections, as measured by a decrease in the incidence of nongonococcal urethritis to\nno more than 170 cases per 100,000 people. (Baseline: 215 per 100,000 in 1988)\n19.3 Reduce primary and secondary syphilis to an incidence of no more than 10 cases per 100,000 people. (Baseline: 18.1\nper 100,000 in 1989)\nSpecial Population Target\nPrimary and Secondary Syphilis Incidence (per 100,000)\n1989 Baseline\n2000 Target\n19.3a Blacks\n118\n65\n19.4 Reduce congenital syphilis to an incidence of no more than 50 cases per 100,000 live births. (Baseline: 100 per\n100,000 live births in 1989)\n19.5 Reduce genital herpes and genital warts, as measured by a reduction to 142,000 and 385,000, respectively, in the\nannual number of first-time consultations with a physician for the conditions. (Baseline: 167,000 and 451,000 in\n1988)\n19.6 Reduce the incidence of pelvic inflammatory disease, as measured by a reduction in hospitalizations for pelvic inflam-\nmatory disease to no more than 250 per 100,000 women aged 15 through 44. (Baseline: 311 per 100,000 in 1988)\n19.7* Reduce sexually transmitted hepatitis B infection to no more than 30,500 cases. (Baseline: 58,300 cases in 1988)\n19.8 Reduce the rate of repeat gonorrhea infection to no more than 15 percent within the previous year. (Baseline: 20\npercent in 1988)\nNote: As measured by a reduction in the proportion of gonorrhea patients who, within the previous year, were\ntreated for a separate case of gonorrhea.\n120\nA. Summary List of Objectives\nRisk Reduction Objectives\n19.9*\nReduce the proportion of adolescents who have engaged in sexual intercourse to no more than 15 percent by age 15\nand no more than 40 percent by age 17. (Baseline: 27 percent of girls and 33 percent of boys by age 15; 50\npercent of girls and 66 percent of boys by age 17; reported in 1988)\n19.10* Increase to at least 50 percent the proportion of sexually active, unmarried people who used a condom at last sexual\nintercourse. (Baseline: 19 percent of sexually active, unmarried women aged 15 through 44 reported that their\npartners used a condom at last sexual intercourse in 1988)\nSpecial Population Targets\nUse of Condoms\n1988 Baseline\n2000 Target\n19.10a Sexually active young women aged 15-19 (by their partners)\n25%\n60%\n19.10b Sexually active young men aged 15-19\n57%\n75%\n19.10c Intravenous drug abusers\n-\n60%\nNote: Strategies to achieve this objective must be undertaken sensitively to avoid indirectly encouraging or condon-\ning sexual activity among teens who are not yet sexually active.\nServices and Protection Objectives\n19.11* Increase to at least 50 percent the proportion of family planning clinics, maternal and child health clinics, sexually\ntransmitted disease clinics, tuberculosis clinics, drug treatment centers, and primary care clinics that screen,\ndiagnose, treat, counsel, and provide (or refer for) partner notification services for HIV infection and bacterial\nsexually transmitted diseases (gonorrhea, syphilis, and chlamydia). (Baseline: 40 percent of family planning\nclinics for bacterial sexually transmitted diseases in 1989)\n19.12 Include instruction in sexually transmitted disease transmission prevention in the curricula of all middle and\nsecondary schools, preferably as part of quality school health education. (Baseline: 95 percent of schools reported\noffering at least one class on sexually transmitted diseases as part of their standard curricula in 1988)\nNote: Strategies to achieve this objective must be undertaken sensitively to avoid indirectly encouraging or condon-\ning sexual activity among teens who are not yet sexually active.\n19.13 Increase to at least 90 percent the proportion of primary care providers treating patients with sexually transmitted\ndiseases who correctly manage cases, as measured by their use of appropriate types and amounts of therapy.\n(Baseline: 70 percent in 1988)\n19.14* Increase to at least 75 percent the proportion of primary care and mental health care providers who provide\nage-appropriate counseling on the prevention of HIV and other sexually transmitted diseases. (Baseline: 10\npercent of physicians reported that they regularly assessed the sexual behaviors of their patients in 1987)\nSpecial Population Target\nCounseling on HIV and STD Prevention\n1987 Baseline\n2000 Target\n19.14a Providers practicing in high incidence areas\n-\n90%\nNote: Primary care providers include physicians, nurses, nurse practitioners, and physician assistants. Areas of\nhigh AIDS and sexually transmitted disease incidence are cities and States with incidence rates of AIDS cases, HIV\nseroprevalence, gonorrhea, or syphilis that are at least 25 percent above the national average.\n19.15 Increase to at least 50 percent the proportion of all patients with bacterial sexually transmitted diseases (gonorrhea,\nsyphilis, and chlamydia) who are offered provider referral services. (Baseline: 20 percent of those treated in\nsexually transmitted disease clinics in 1988)\nNote: Provider referral (previously called contact tracing) is the process whereby health department personnel\ndirectly notify the sexual partners of infected individuals of their exposure to an infected individual.\n20. Immunization and Infectious Diseases\nHealth Status Objectives\n20.1\nReduce indigenous cases of vaccine-preventable diseases as follows:\nDisease\n1988 Baseline\n2000 Target\nDiphtheria among people aged 25 and younger\n1\n0\nTetanus among people aged 25 and younger\n3\n0\nPolio (wild-type virus)\n0\n0\nMeasles\n3,058\n0\nRubella\n225\n0\nCongenital Rubella Syndrome\n6\n0\nMumps\n4,866\n500\nPertussis\n3,450\n1,000\n20.2 Reduce epidemic-related pneumonia and influenza deaths among people aged 65 and older to no more than 7.3 per\n100,000. (Baseline: Average of 9.1 per 100,000 during 1980 through 1987)\nNote: Epidemic-related pneumonia and influenza deaths are those that occur above and beyond the normal yearly\nfluctuations of mortality. Because of the extreme variability in epidemic-related deaths from year to year, the target\nis a 3-year average.\n121\nHealthy People 2000\n20.3* Reduce viral hepatitis as follows:\n(Per 100,000)\n1987 Baseline\n2000 Target\nHepatitis B (HBV)\n63.5\n40\nHepatitis A\n31\n23\nHepatitis C\n18.3\n13.7\nSpecial Population Targets for HBV\nHBV Cases\n1987 Estimated Baseline\n2000 Target\n20.3a Intravenous drug abusers\n30,000\n22,500\n20.3b\nHeterosexually active people\n33,000\n22,000\n20.3c\nHomosexual men\n25,300\n8,500\n20.3d\nChildren of Asians/Pacific Islanders\n8,900\n1,800\n20.3e\nOccupationally exposed workers\n6,200\n1,250\n20.3f Infants\n3,500\n550 new carriers\n20.3g Alaska Natives\n15\n1\n20.4 Reduce tuberculosis to an incidence of no more than 3.5 cases per 100,000 people. (Baseline: 9.1 per 100,000 in\n1988)\nSpecial Population Targets\nTuberculosis Cases (per 100,000)\n1988 Baseline\n2000 Target\n20.4a Asians/Pacific Islanders\n36.3\n15\n20.4b Blacks\n28.3\n10\n20.4c Hispanics\n18.3\n5\n20.4d American Indians/Alaska Natives\n18.1\n5\n20.5\nReduce by at least 10 percent the incidence of surgical wound infections and nosocomial infections in intensive care\npatients. (Baseline data available in late 1990)\n20.6\nReduce selected illness among international travelers as follows:\nIncidence\n1987 Baseline\n2000 Target\nTyphoid fever\n280\n140\nHepatitis A\n1,280\n640\nMalaria\n2,000\n1,000\n20.7\nReduce bacterial meningitis to no more than 4.7 cases per 100,000 people. (Baseline: 6.3 per 100,000 in 1986)\nSpecial Population Target\nBacterial Meningitis Cases (per 100,000)\n1987 Baseline\n2000 Target\n20.7a Alaska Natives\n33\n8\n20.8\nReduce infectious diarrhea by at least 25 percent among children in licensed child care centers and children in\nprograms that provide an Individualized Education Program (IEP) or Individualized Health Plan (IHP). (Baseline\ndata available in 1992)\n20.9\nReduce acute middle ear infections among children aged 4 and younger, as measured by days of restricted activity or\nschool absenteeism, to no more than 105 days per 100 children. (Baseline: 131 days per 100 children in 1987)\n20.10 Reduce pneumonia-related days of restricted activity as follows:\n1987 Baseline\n2000 Target\nPeople aged 65 and older (per 100 people)\n48 days\n38 days\nChildren aged 4 and younger (per 100 children)\n27 days\n24 days\nRisk Reduction Objectives\n20.11 Increase immunization levels as follows:\nBasic immunization series among children under age 2: at least 90 percent. (Baseline: 70-80 percent estimated in\n1989)\nBasic immunization series among children in licensed child care facilities and kindergarten through post-secondary\neducation institutions: at least 95 percent. (Baseline: For licensed child care, 94 percent; 97 percent for children\nentering school for the 1987-1988 school year; and for post-secondary institutions, baseline data available in 1992)\nPneumococcal pneumonia and influenza immunization among institutionalized chronically ill or older people: at\nleast 80 percent. (Baseline data available in 1992)\nPneumococcal pneumonia and influenza immunization among noninstitutionalized, high-risk populations, as\ndefined by the Immunization Practices Advisory Committee: at least 60 percent. (Baseline: 10 percent estimated\nfor pneumococcal vaccine and 20 percent for influenza vaccine in 1985)\nHepatitis B immunization among high-risk populations, including infants of surface antigen-positive mothers to at\nleast 90 percent; occupationally exposed workers to at least 90 percent; IV-drug users in drug treatment programs\nto at least 50 percent; and homosexual men to at least 50 percent. (Baseline data available in 1992)\n20.12 Reduce postexposure rabies treatments to no more than 9,000 per year. (Baseline: 18,000 estimated treatments in\n1987)\n122\nA. Summary List of Objectives\nServices and Protection Objectives\n20.13 Expand immunization laws for schools, preschools, and day care settings to all States for all antigens. (Baseline:\n9 States and the District of Columbia in 1990)\n20.14 Increase to at least 90 percent the proportion of primary care providers who provide information and counseling\nabout immunizations and offer immunizations as appropriate for their patients. (Baseline data available in 1992)\n20.15 Improve the financing and delivery of immunizations for children and adults so that virtually no American has a\nfinancial barrier to receiving recommended immunizations. (Baseline: Financial coverage for immunizations was\nincluded in 45 percent of employment-based insurance plans with conventional insurance plans; 62 percent with\nPreferred Provider Organization plans; and 98 percent with Health Maintenance Organization plans in 1989;\nMedicaid covered basic immunizations for eligible children and Medicare covered pneumococcal immunization\nfor eligible older adults in 1990)\n20.16 Increase to at least 90 percent the proportion of public health departments that provide adult immunization for\ninfluenza, pneumococcal disease, hepatitis B, tetanus, and diphtheria. (Baseline data available in 1991)\n20.17 Increase to at least 90 percent the proportion of local health departments that have ongoing programs for actively\nidentifying cases of tuberculosis and latent infection in populations at high risk for tuberculosis. (Baseline data\navailable in 1991)\nNote: Local health department refers to any local component of the public health system, defined as an administra-\ntive and service unit of local or State government concerned with health and carrying some responsibility for the\nhealth of a jurisdiction smaller than a State.\n20.18 Increase to at least 85 percent the proportion of people found to have tuberculosis infection who completed courses\nof preventive therapy. (Baseline: 89 health departments reported that 66.3 percent of 95,201 persons placed on\npreventive therapy completed their treatment in 1987)\n20.19 Increase to at least 85 percent the proportion of tertiary care hospital laboratories and to at least 50 percent the\nproportion of secondary care hospital and health maintenance organization laboratories possessing technologies for\nrapid viral diagnosis of influenza. (Baseline data available in 1992)\n21. Clinical Preventive Services\nHealth Status Objective\n21.1* Increase years of healthy life to at least 65 years. (Baseline: An estimated 62 years in 1980)\nSpecial Population Targets\nYears of Healthy Life\n1980 Baseline\n2000 Target\n21.1a Blacks\n56\n60\n21.1b Hispanics\n62\n65\n21.1c People aged 65 and older\n12⁺\n14⁺\nYears of healthy life remaining at age 65\nNote: Years of healthy life (also referred to as quality-adjusted life years) is a summary measure of health that com-\nbines mortality (quantity of life) and morbidity and disability (quality of life) into a single measure. For people\naged 65 and older, active life-expectancy, a related summary measure, also will be tracked.\nRisk Reduction Objective\n21.2\nIncrease to at least 50 percent the proportion of people who have received, as a minimum within the appropriate\ninterval, all of the screening and immunization services and at least one of the counseling services appropriate for\ntheir age and gender as recommended by the U.S. Preventive Services Task Force. (Baseline data available in\n1991)\nSpecial Population Targets\nReceipt of Recommended Services\nBaseline\n2000 Target\n21.2a Infants up to 24 months\nI\n90%\n21.2b Children aged 2-12\n-\n80%\n21.2c Adolescents aged 13-18\n-\n50%\n21.2d Adults aged 19-39\n|\n40%\n21.2e Adults aged 40-64\nI\n40%\n21.2f Adults aged 65 and older\n-\n40%\n21.2g Low-income people\n-\n50%\n21.2h Blacks\n-\n50%\n21.2i Hispanics\n-\n50%\n21.2j Asians/Pacific Islanders\n-\n50%\n21.2k American Indians/Alaska Natives\n-\n70%\n21.21 People with disabilities\n-\n80%\n123\nHealthy People 2000\nServices and Protection Objectives\n21.3\nIncrease to at least 95 percent the proportion of people who have a specific source of ongoing primary care for\ncoordination of their preventive and episodic health care. (Baseline: Less than 82 percent in 1986, as 18 percent\nreported having no physician, clinic, or hospital as a regular source of care)\nSpecial Population Targets\nPercentage With Source of Care\n1986 Baseline\n2000 Target\n21.3a Hispanics\n70%\n95%\n21.3b Blacks\n80%\n95%\n21.3c Low-income people\n80%\n95%\n21.4 Improve financing and delivery of clinical preventive services so that virtually no American has a financial barrier to\nreceiving, at a minimum, the screening, counseling, and immunization services recommended by the U.S.\nPreventive Services Task Force. (Baseline data available in 1992)\n21.5\nAssure that at least 90 percent of people for whom primary care services are provided directly by publicly funded\nprograms are offered, at a minimum, the screening, counseling, and immunization services recommended by the\nU.S. Preventive Services Task Force. (Baseline data available in 1992)\nNote: Publicly funded programs that provide primary care services directly include federally funded programs\nsuch as the Maternal and Child Health Program, Community and Migrant Health Centers, and the Indian Health\nService as well as primary care service settings funded by State and local governments. This objective does not in-\nclude services covered indirectly through the Medicare and Medicaid programs.\n21.6\nIncrease to at least 50 percent the proportion of primary care providers who provide their patients with the screening,\ncounseling, and immunization services recommended by the U.S. Preventive Services Task Force. (Baseline data\navailable in 1992)\n21.7\nIncrease to at least 90 percent the proportion of people who are served by a local health department that assesses and\nassures access to essential clinical preventive services. (Baseline data available in 1992)\nNote: Local health department refers to any local component of the public health system, defined as an administra-\ntive and service unit of local or State government concerned with health and carrying some responsibility for the\nhealth of a jurisdiction smaller than a State.\n21.8 Increase the proportion of all degrees in the health professions and allied and associated health profession fields\nawarded to members of underrepresented racial and ethnic minority groups as follows:\nDegrees Awarded To:\n1985-86 Baseline\n2000 Target\nBlacks\n5%\n8%\nHispanics\n3%\n6.4%\nAmerican Indians/Alaska Natives\n0.3%\n0.6%\nNote: Underrepresented minorities are those groups consistently below parity in most health profession schools—\nblacks, Hispanics, and American Indians and Alaska Natives.\n22. Surveillance and Data Systems\nObjectives\n22.1\nDevelop a set of health status indicators appropriate for Federal, State, and local health agencies and establish use of\nthe set in at least 40 States. (Baseline: No such set exists in 1990)\n22.2 Identify, and create where necessary, national data sources to measure progress toward each of the year 2000 national\nhealth objectives. (Baseline: 77 percent of the objectives have baseline data in 1990)\nType-Specific Target\n1989 Baseline\n2000 Target\n22.2a State level data for at least two-thirds of the objectives\n23 States⁺\n35 States\nMeasured using the 1989 Draft Year 2000 National Health Objectives\n22.3\nDevelop and disseminate among Federal, State, and local agencies procedures for collecting comparable data for each\nof the year 2000 national health objectives and incorporate these into Public Health Service data collection\nsystems. (Baseline: Although such surveys as the National Health Interview Survey may serve as a model, widely\naccepted procedures do not exist in 1990)\n22.4 Develop and implement a national process to identify significant gaps in the Nation's disease prevention and health\npromotion data, including data for racial and ethnic minorities, people with low incomes, and people with\ndisabilities, and establish mechanisms to meet these needs. (Baseline: No such process exists in 1990)\nNote: Disease prevention and health promotion data includes disease status, risk factors, and services receipt data.\nPublic health problems include such issue areas as HIV infection, domestic violence, mental health, environmental\nhealth, occupational health, and disabling conditions.\n124\nA. Summary List of Objectives\n22.5\nImplement in all States periodic analysis and publication of data needed to measure progress toward objectives for at\nleast 10 of the priority areas of the national health objectives. (Baseline: 20 States reported that they disseminate\nthe analyses they use to assess State progress toward the health objectives to the public and to health professionals\nin 1989)\nType-Specific Target\n1989 Baseline\n2000 Target\n22.5a Periodic analysis and publication of State progress toward the\nnational objectives for each racial or ethnic group that makes up\nat least 10 percent of the State population\n-\n25 States\nNote: Periodic is at least once every 3 years. Objectives include, at a minimum, one from each objectives\ncategory: health status, risk reduction, and services and protection.\n22.6 Expand in all States systems for the transfer of health information related to the national health objectives among\nFederal, State, and local agencies. (Baseline: 30 States reported that they have some capability for transfer of\nhealth data, tables, graphs, and maps to Federal, State, and local agencies that collect and analyze data in 1989)\nNote: Information related to the national health objectives includes State and national level baseline data, disease\nprevention/health promotion evaluation results, and data generated to measure progress.\n22.7\nAchieve timely release of national surveillance and survey data needed by health professionals and agencies to\nmeasure progress toward the national health objectives. (Baseline data available in 1993)\nNote: Timely release (publication of provisional or final data or public use data tapes) should be based on the use\nof the data, but is at least within one year of the end of data collection.\nAge-Related Objectives\n*Reduce the death rate for children by 15 percent to no more than 28 per 100,000 children aged 1 through 14, and for\ninfants by approximately 30 percent to no more than 7 per 1,000 live births. (Baseline: 33 per 100,000 for\nchildren in 1987 and 10.1 per 1,000 live births for infants in 1987)\nReduce the death rate for adolescents and young adults by 15 percent to no more than 85 per 100,000 people aged 15\nthrough 24. (Baseline: 99.4 per 100,000 in 1987)\nReduce the death rate for adults by 20 percent to no more than 340 per 100,000 people aged 25 through 64. (Baseline:\n423 per 100,000 in 1987)\n*Reduce to no more than 90 per 1,000 people the proportion of all people aged 65 and older who have difficulty in\nperforming two or more personal care activities (a reduction of about 19 percent), thereby preserving\nindependence. (Baseline: 111 per 1,000 in 1984-85)\n125\nB. Contributors to Healthy People 2000\nHealthy People 2000: National Health Promotion and Disease Prevention Objectives is the\nproduct of a national effort that has involved professionals and citizens, private organizations and\npublic agencies from every part of the Nation. Work on the report began in 1987 with the forma-\ntion of the Healthy People 2000 Consortium and the convening of public hearings across the\ncountry. Testimony from the public hearings became the primary resource material for working\ngroups of professionals to use in crafting the health objectives themselves. After extensive public\nreview and comment, involving more than 10,000 people, the objectives were refined and revised\nto produce the report.\nPreparation of the report was sponsored by the U.S. Public Health Service, through a project coor-\ndinated by the Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion).\nProject management was facilitated by the work of the PHS Steering Committee on the Healthy\nPeople 2000 Objectives; the Committee on Health Objectives for the Year 2000, Institute of\nMedicine, National Academy of Sciences; and the Secretary's Council on Health Promotion and\nDisease Prevention. Principal staff and editorial responsibility for the project was carried out by\nJames A. Harrell, Lynn M. Artz, Ashley Files, and David Baker. Other staff from the Office of\nDisease Prevention and Health Promotion helping in the coordination and development of the\noverall project included Barbara Anderson, John Bailar, Amber Barnato, Sandra Buesking, Mary\nJo Deering, Christopher DeGraw, Olga Emgushov, Martha G. Frazier, Toni M. Goodwin, Linda\nM. Harris, Douglas B. Kamerow, Thomas Kim, Loretta M. Logan, Patricia Lynch, Caroline Mc-\nNeil, Linda D. Meyers, Diane Rittenhouse, Marilyn K. Schulenberg, Sara L. White, Jennifer\nWoods, Christina Wypijewski, Michael Yao, and Daniel Yarano.\nWhile it is not possible to recognize herein all those citizens and officials who made contributions\nto Healthy People 2000, their efforts were central to development of the final product.\nPublic Health Service Office Directors and Agency Heads\nJames O. Mason, Assistant Secretary for Health, Washington, DC\nAudrey F. Manley, Deputy Assistant Secretary for Health, Washington, DC\nAntonia C. Novello, Surgeon General, Washington, DC\nPaul B. Simmons, Deputy Assistant Secretary for Health (Communications), Washington, DC\nJ. Michael McGinnis, Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion),\nWashington, DC\nSamuel Lin, Deputy Assistant Secretary for Health (Intergovernmental Affairs), Rockville, MD\nJohn D. Mahoney, Acting Deputy Assistant Secretary for Health (Operations), Washington, DC\nNabers Cabaniss, Deputy Assistant Secretary for Health (Population Affairs), Washington, DC\nJames M. Friedman, Acting Deputy Assistant Secretary for Health (Planning and Evaluation), Washington, DC\nFrank E. Young, Deputy Assistant Secretary for Health (Science and Environment), Washington, DC\nJames R. Allen, Director, National AIDS Program Office, Washington, DC\nHarold P. Thompson, Director, Office of International Health, Rockville, MD\nWilliam A. Robinson, Director, Office of Minority Health, Washington, DC\nWilmer D. Mizell, Executive Director, President's Council on Physical Fitness and Sports, Washington, DC\nAgency Heads\nJ. Jarrett Clinton, Acting Administrator, Agency for Health Care Policy and Research, Rockville, MD\nFrederick K. Goodwin, Administrator, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, MD\nWilliam L. Roper, Director, Centers for Disease Control, and Administrator, Agency for Toxic Substances\nand Disease Registry, Atlanta, GA\nJames S. Benson, Acting Commissioner of Food and Drugs, Food and Drug Administration, Rockville, MD\nRobert G. Harmon, Administrator, Health Resources and Services Administration, Rockville, MD\nEverett R. Rhoades, Director, Indian Health Service, Rockville, MD\nWilliam F. Raub, Acting Director, National Institutes of Health, Bethesda, MD\n127\nHealthy People 2000\nPublic Health Service Steering Committee on the Healthy\nPeople 2000 Objectives\nPHS Members, by Agency\nJames A. Harrell, Chair, Office of Disease Prevention and Health Promotion, Washington, DC\nMartha F. Katz, Vice-Chair, Office of Program Planning and Evaluation, Centers for Disease Control,\nAtlanta, GA\nElaine M. Johnson, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, MD\nMary A. Jansen (alternate), Alcohol, Drug Abuse, and Mental Health Administration, Rockville, MD\nDennis D. Tolsma (alternate), Centers for Disease Control, Atlanta, GA\nRonald W. Wilson, National Center for Health Statistics, Centers for Disease Control, Hyattsville, MD\nRonald L. Wilson, Food and Drug Administration, Rockville, MD\nRonald H. Carlson, Health Resources and Services Administration, Rockville, MD\nCraig Vanderwagen, Indian Health Service, Rockville, MD\nJohn H. Ferguson, National Institutes of Health, Bethesda, MD\nJohn T. Kalberer, Jr. (alternate), National Institutes of Health, Bethesda, MD\nEdward Sondik, National Cancer Institute, National Institutes of Health, Bethesda, MD\nGregory J. Morosco, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD\nJoan E. Blair, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD\nValerie Welsh, Office of Health Planning and Evaluation, Washington, DC\nWilliam A. Robinson, Office of Minority Health, Washington, DC\nRobert A. Scholle, Office of Population Affairs, Washington, DC\nChristine G. Spain, President's Council on Physical Fitness and Sports, Washington, DC\nOther Members\nKathleen A. Loughrey, American Public Health Association, Washington, DC\nMichael A. Stoto, Institute of Medicine, National Academy of Sciences, Washington, DC\nSecretary's Council on Health Promotion and Disease\nPrevention\nJames O. Mason, Chair, Washington, DC\nEdward N. Brandt, Jr., (Former Assistant Secretary for Health), Oklahoma City, OK\nStanley E. Broadnax, U.S. Conference of Local Health Officers, Cincinnati, OH\nTheodore Cooper, (Former Assistant Secretary for Health), Kalamazoo, MI\nAlan W. Cross, Association of Teachers of Preventive Medicine, Chapel Hill, NC\nGus T. Dalis, Association for the Advancement of Health Education, Downey, CA\nMerlin K. Duval, (Former Assistant Secretary for Health), Phoenix, AZ\nCharles C. Edwards, (Former Assistant Secretary for Health), LaJolla, CA\nRoger O. Egeberg, (Former Assistant Secretary for Health), Rockville, MD\nA. Garth Fisher, Provo, UT\nDonald A. Henderson, Association of Schools of Public Health, Baltimore, MD\nJoyce C. Lashof, Association of Schools of Public Health, Berkeley, CA\nPhilip R. Lee, (Former Assistant Secretary for Health), San Francisco, CA\nStephen H. Lipson, Indianapolis, IN\nJoel L. Nitzkin, National Association of County Health Officials, New Orleans, LA\nKevin M. Patrick, Association of Teachers of Preventive Medicine, San Diego, CA\nThomas M. Vernon, Jr., Association of State and Territorial Health Officials, Denver, CO\nJulius B. Richmond, (Former Assistant Secretary for Health), Boston, MA\nRobert Rodale (deceased), Emmaus, PA\nH. Denman Scott, Association of State and Territorial Health Officials, Providence, RI\nF. Douglas Scutchfield, American College of Preventive Medicine, San Diego, CA\nBailus Walker, Jr., American Public Health Association, Oklahoma City, OK\nMartin P. Wasserman, National Association of County Health Officials, Rockville, MD\nRobert E. Windom, (Former Assistant Secretary for Health), Sarasota, FL\n128\nB. Contributors to Healthy People 2000\nCommittee on Health Objectives for the Year 2000, Institute\nof Medicine, National Academy of Sciences\nMerlin K. Duval, Chair, Phoenix, AZ\nJack Elinson, Rutgers University, New Brunswick, NJ\nRobert I. Levy, Sandoz Research Institute, East Hanover, NJ (until 5/88)\nAnne Hubbard Mattson, Jefferson County Health Department, Birmingham, AL\nGilbert S. Omenn, University of Washington, Seattle, WA\nKatharine Bauer Sommers, Institute of Medicine, Washington, DC\nInstitute of Medicine Staff\nSamuel O. Thier, President\nCynthia Howe\nMichael A. Stoto, Study Director\nRoseanne Mctyre\nRuth Behrens\nJane S. Durch\nEnriqueta C. Bond\nConnie Rosemont\nMarty Ellington\nRenie Schapiro\nGary B. Ellis\nDonna D. Thompson\nKay C. Harris\nCoordinators of Priority Area Working Groups\nPhysical Activity and Fitness\nChristine G. Spain, President's Council on Physical Fitness and Sports, Washington, DC\nNutrition\nDarla E. Danford, National Institutes of Health (NIH), Bethesda, MD\nMarilyn G. Stephenson, Center for Food Safety and Applied Nutrition, Food and Drug Administration\n(FDA), Washington, DC\nTobacco\nRonald M. Davis, Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control\n(CDC), Rockville, MD\nJohn L. Bagrosky, Center for Chronic Disease Prevention, and Health Promotion (CDC), Rockville, MD\nAlcohol and Other Drugs\nMary A. Jansen, Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA), Rockville, MD\nFamily Planning\nRobert A. Scholle, Office of Population Affairs, Washington, DC\nMental Health and Mental Disorders\nMary A. Jansen, Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA), Rockville, MD\nViolent and Abusive Behavior\nJames A. Mercy, Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nMark L. Rosenberg, Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nEducational and Community-Based Programs\nDennis D. Tolsma, Centers for Disease Control, Atlanta, GA\nRonald H. Carlson, Health Resources and Services Administration (HRSA), Rockville, MD\nUnintentional Injuries\nJ. Lee Annest, Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nMark L. Rosenberg, Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nOccupational Safety and Health\nDonald E. Ward, Jr., National Institute for Occupational Safety and Health (CDC), Atlanta, GA\n129\nHealthy People 2000\nEnvironmental Health\nDaniel C. VanderMeer, National Institute of Environmental Health Sciences (NIH), Research Triangle Park, NC\nHenry Falk, Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nDaniel A. Hoffman, Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nFood and Drug Safety\nRonald L. Wilson, Food and Drug Administration, Rockville, MD\nI. David Wolfson, Food and Drug Administration, Rockville, MD\nOral Health\nHelen C. Gift, National Institute of Dental Research (NIH), Bethesda, MD\nStephen B. Corbin, Center for Prevention Services (CDC), Bethesda, MD\nMaternal and Infant Health\nAnn M. Koontz, Maternal and Child Health Bureau (HRSA), Rockville, MD\nCarol A. Delany, Maternal and Child Health Bureau (HRSA), Rockville, MD\nHeart Disease and Stroke\nJoan E. Blair, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD\nCancer\nEdward Sondik, National Cancer Institute (NIH), Bethesda, MD\nHelen I. Meissner, National Cancer Institute (NIH), Bethesda, MD\nDiabetes and Chronic Disabling Conditions\nBenjamin T. Burton, National Institute of Diabetes and Digestive and Kidney Diseases (NIH), Bethesda, MD\nJames S. Marks, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA\nHIV Infection\nJo Messore, National AIDS Program Office, Washington, DC\nSexually Transmitted Diseases\nWillard Cates, Jr., Center for Prevention Services (CDC), Atlanta, GA\nStephen A. Morse, Center for Infectious Diseases (CDC), Atlanta, GA\nImmunization and Infectious Diseases\nAlan R. Hinman, Center for Prevention Services (CDC), Atlanta, GA\nJames M. Hughes, Center for Infectious Diseases (CDC), Atlanta, GA\nClinical Preventive Services\nRonald H. Carlson, Health Resources and Services Administration, Rockville, MD\nDennis D. Tolsma, Centers for Disease Control, Atlanta, GA\nSurveillance and Data Systems\nRonald W. Wilson, National Center for Health Statistics (CDC), Hyattsville, MD\nPatricia M. Golden, National Center for Health Statistics (CDC), Hyattsville, MD\n130\nB. Contributors to Healthy People 2000\nMembers of Priority Area Working Groups and Other\nContributors\nThe following persons participated in development of the Healthy People 2000 objectives as mem-\nbers of working groups of professionals and in other significant roles. Many of them served on\ntwo or more working groups (as did a number of the priority area coordinators, who are not listed\nagain).\nEdgar Adams, National Institute on Drug Abuse (ADAMHA), Rockville, MD\nMichael Adams, Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nDavid F. Adcock, University of South Carolina Medical School, Columbia, SC\nSusan Addiss, Quinnipiack Valley Health District, Hamden, CT\nJ. Harrison Ager, National Institute of Diabetes and Digestive and Kidney Diseases (NIH), Bethesda, MD\nE. Joseph Alderman, Georgia Department of Human Resources, Atlanta, GA\nCaffilene Allen, Center for Infectious Diseases (CDC), Atlanta, GA\nDavid Allen, Louisville and Jefferson County Health Department, Louisville, KY\nMyron Allukian, Boston Department of Health and Hospitals, Boston, MA\nZili Amsel, National Institute on Drug Abuse (ADAMHA), Rockville, MD\nHenry Anderson, Wisconsin Department of Health and Social Services, Madison, WI\nDouglas L. Archer, Center for Food Safety and Applied Nutrition (FDA), Washington, DC\nKatherine L. Armstrong, Western Consortium for Public Health, Berkeley, CA\nJanet Arrowsmith, Food and Drug Administration, Rockville, MD\nGeorge Arsnow, Rehabilitation Services Administration, U.S. Department of Education, Washington, DC\nVictor Avitto, Health Resources and Services Administration, Rockville, MD\nChristine A. Bachrach, National Institute for Child Health and Human Development (NIH), Bethesda, MD\nShirley Bagley, National Institute on Aging (NIH), Bethesda, MD\nWendy Baldwin, National Institute for Child Health and Human Development (NIH), Bethesda, MD\nClaudia Baquet, National Cancer Institute (NIH), Bethesda, MD\nRobert Battjes, National Institute on Drug Abuse (ADAMHA), Rockville, MD\nJohn A. Beare, Washington State Department of Social and Health Services, Olympia, WA\nRobert W. Beck, Public Health Service, Rockville, MD\nChristopher Benjamin, Office of Program Planning and Evaluation (CDC), Atlanta, GA\nHeinz Berendes, National Institute of Child Health and Human Development (NIH), Bethesda, MD\nLeonard Berg, Washington University School of Medicine, St. Louis, MO\nNancy Zinneman Berger, Association of State and Territorial Public Health Nutrition Program Directors,\nHartford, CT\nLawrence Bergner, National Cancer Institute (NIH), Bethesda, MD\nBetty Jo Berland, National Institute on Disability and Rehabilitation Research, U.S. Department of Education,\nWashington, DC\nDarryl Bertolucci, National Institute on Alcohol Abuse and Alcoholism (ADAMHA), Rockville, MD\nRichard M. Biery, Kansas City Health Department, Kansas City, MO\nRick Birkel, National Resource Center for Worksite Health Promotion, Washington, DC\nCarl H. Blank, Training and Laboratory Program Office (CDC), Atlanta, GA\nJoseph H. Blount, Center for Prevention Services (CDC), Atlanta, GA\nJohn J. Boren, National Institute on Drug Abuse (ADAMHA), Rockville, MD\nGeorge Bouthilet, President's Committee on Mental Retardation, Washington, DC\nNoble N. Bowie, National Highway Traffic Safety Administration, U.S. Department of Transportation\n(DOT), Washington, DC\nElizabeth Brannon, Health Resources and Services Adminisration, Rockville, MD\nAlbert Brasile, Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nGeorge Brenneman, Indian Health Service, Rockville, MD\nEthel Briggs, National Council on the Handicapped, Washington, DC\nNorma T. Brinkley-Staley, Health Resources and Services Administration, Rockville, MD\nMartin Brown, National Cancer Institute (NIH), Bethesda, MD\nStuart T. Brown, DeKalb County Health Department, Decatur, GA\nGeorgia Buggs, Office of Minority Health, Washington, DC\nWilliam Bukoski, National Institute on Drug Abuse (ADAMHA), Rockville, MD\n131\nHealthy People 2000\nThomas Burns, Indian Health Service, Rockville, MD\nRichard Carnevale, Food Safety and Inspection Service, U.S. Department of Agriculture (USDA),\nWashington, DC\nJudith L. Carpenter, Office of Intergovernmental Affairs, Washington, DC\nCarl Caspersen, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA\nPhilip Chao, Food and Drug Administration, Rockville, MD\nBruce R. Chelikowsky, Indian Health Service, Rockville, MD\nJames Cleeman, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD\nCarolyn Clifford, National Cancer Institute (NIH), Bethesda, MD\nRonald F. Coene, National Center for Toxicological Research (FDA) Rockville, MD\nBarbara Cohen, Office of Population Affairs, Washington, DC\nElaine Cohen, Health Resources and Services Administration, Rockville, MD\nMitchell L. Cohen, Center for Infectious Diseases (CDC), Atlanta, GA\nJ. Gary Collins, National Center for Health Statistics (CDC), Hyattsville, MD\nRobert J. Collins, Indian Health Service, Rockville, MD\nEileen Connolly, Public Health Service-Region II, New York, NY\nGregory N. Connolly, Massachusetts Department of Public Health, Boston, MA\nFrances Cotter, National Institute on Alcohol Abuse and Alcoholism (ADAMHA), Rockville, MD\nNancy F. Couey, Centers for Disease Control, Atlanta, GA\nJames F. Coyle, Federal Emergency Management Agency, Emmitsburg, MD\nGeorge Curlin, National Institute of Allergy and Infectious Diseases (NIH), Bethesda, MD\nDorynne Czechowicz, National Institute on Drug Abuse (ADAMHA), Rockville, MD\nAnthony Angelo, Indian Health Service, Rockville, MD\nAda Davis, Bureau of Health Professions (HRSA), Rockville, MD\nJohn Dement, National Institute of Environmental Health Sciences (NIH), Research Triangle Park, NC\nRobert W. Denniston, Office for Substance Abuse Prevention (ADAMHA), Rockville, MD\nFrank Destefano, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA\nTerrence Donahue, Office of Justice Programs (DOT), Washington, DC\nDenise Dougherty, Office of Technology Assessment, U.S. Congress, Washington, DC\nJoseph S. Drage, National Institute of Neurological and Communicative Disorders and Stroke (NIH),\nBethesda, MD\nFrederick R. Drews, U.S. Army War College, Carlisle, PA\nPeter Drotman, Center for Infectious Diseases (CDC), Atlanta, GA\nThomas F. Drury, National Institute of Dental Research (NIH), Bethesda, MD\nRosemary E. Duffy, U.S. Department of Veterans Affairs (VA), Washington, DC\nMary C. Dufour, National Institute on Alcohol Abuse and Alcoholism (ADAMHA), Rockville, MD\nAllen B. Duncan, Food and Drug Administration, Rockville, MD\nThena M. Durham, Center for Prevention Services (CDC), Atlanta, GA\nSpike Duzor, Health Care Financing Administration, Baltimore, MD\nWilliam W. Dyal, Public Health Program Practice Office (CDC), Atlanta, GA\nMark Eberhardt, National Center for Health Statistics (CDC), Hyattsville, MD\nBrenda Edwards, National Cancer Institute (NIH), Bethesda, MD\nAnita Eichler, National Institute of Mental Health (ADAMHA), Rockville, MD\nElaine Eklund, American Association of University Affiliated Programs for Persons with Developmental\nDisabilities, Silver Spring, MD\nPennifer Erickson, National Center for Health Statistics (CDC), Hyattsville, MD\nNancy D. Ernst, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD\nJoyce D. K. Essien, Public Health Program Practice Office (CDC), Atlanta, GA\nDavid Evans, Agency for Toxic Substances and Disease Registry, Atlanta, GA\nVernard Evans, Administration on Developmental Disabilities, Office of Human Development Services\n(OHDS), Washington, DC\nAnn Fainsinger, Alliance for Aging Research, Washington, DC\nMary E. Farmer, National Institute for Mental Health (ADAMHA), Rockville, MD\nMarcia Fein, American Express, New York, NY\nMichael C. Fiore, University of Wisconsin, Madison, WI\nMichael Fishman, Maternal and Child Health Bureau (HRSA), Rockville, MD\n132\nB. Contributors to Healthy People 2000\nRebecca Fitch, Office of Special Education and Rehabilitation Services, U.S. Department of Education,\nWashington, DC\nWilliam FitzGerald, National Institute on Drug Abuse (ADAMHA), Rockville, MD\nAllan L. Forbes, Rockville, MD\nWillis R. Foster, National Institute of Diabetes and Digestive and Kidney Diseases (NIH), Bethesda, MD\nJudith Fradkin, National Institute of Diabetes and Digestive and Kidney Diseases (NIH), Bethesda, MD\nDolores M. Franklin, Department of Human Services, Washington, DC\nPaula Franklin, Office of Disability, Social Security Administration, Baltimore, MD\nP. Jean Frazier, University of Minnesota, Minneapolis, MN\nFrank J. Frodyma, Occupational Safety and Health Administration, U.S. Department of Labor (DOL),\nWashington, DC\nRobinson Fulwood, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD\nArthur S. Funke, Maternal and Child Health Bureau (HRSA), Rockville, MD\nLawrence J. Furman, Center for Prevention Services (CDC), Atlanta, GA\nJudy Galloway, National Institute on Drug Abuse (ADAMHA), Rockville, MD\nJ.T. Garrett, Indian Health Service, Rockville, MD\nBarbara Gerbert, University of California at San Francisco, San Francisco, CA\nMartin Gerry, U.S. Department of Health and Human Services, Washington, DC\nGeorge M. Gillespie, Pan American Health Organization, Washington, DC\nEvelyn Glass, Office of Population Affairs, Washington, DC\nTom Glynn, National Cancer Institute (NIH), Bethesda, MD\nDorothy Gohdes, Indian Health Service, Albuquerque, NM\nHarold Goldsmith, National Institute of Mental Health (ADAMHA), Rockville, MD\nSteve Gordon, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIH), Bethesda, MD\nPeter Greenwald, National Cancer Institute (NIH), Bethesda, MD\nTimothy W. Groza, National Institute for Occupational Safety and Health (CDC), Atlanta, GA\nAntoinette Hagey, U.S. Department of Defense, Washington, DC\nCarol Haines, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD\nEarl H. Handwerker, Center for Infectious Diseases (CDC), Atlanta, GA\nBenjamin Hankey, National Cancer Institute (NIH), Bethesda, MD\nKevin S. Hardwick, Public Health Service, Rockville, MD\nThomas Harford, National Institute on Alcohol Abuse and Alcoholism (ADAMHA), Rockville, MD\nWilliam Harlan, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD\nMary Harper, National Institute of Mental Health (ADAMHA), Rockville, MD\nPeter Hartsock, National Institute on Drug Abuse (ADAMHA), Rockville, MD\nHarry W. Haverkos, National Institute on Drug Abuse (ADAMHA), Rockville, MD\nBarbara Hawkins, Indiana University, Bloomington, IN\nBetty Hawks, Office of Minority Health, Washington, DC\nSuzanne G. Haynes, National Cancer Institute (NIH), Bethesda, MD\nArlene P. Hegg, National Institute of Mental Health (ADAMHA), Rockville, MD\nJames T. Heimbach, Human Nutrition Information Service (USDA), Hyattsville, MD\nGerry Hendershot, National Center for Health Statistics (CDC), Hyattsville, MD\nKenneth L. Herrmann, Center for Infectious Diseases (CDC), Atlanta, GA\nStephen P. Heyse, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIH), Bethesda, MD\nPenni St. Hilaire, Office of Intergovernmental Affairs, Rockville, MD\nWilliam Hiscock, Health Care Financing Administration, Baltimore, MD\nCarol Hogue, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA\nJohn Holland, National Defense University-Fort McNair, Washington, DC\nJohn Holloszy, Washington University School of Medicine, St. Louis, MO\nJanet Horan, Bureau of Health Professions (HRSA), Rockville, MD\nMargorie C. Horn, National Center for Health Statistics (CDC), Hyattsville, MD\nPhilip R. Horne, Center for Prevention Services (CDC), Atlanta, GA\nConstance Horner, U.S. Department of Health and Human Services, Washington, DC\nAlice M. Horowitz, National Institute of Dental Research (NIH), Bethesda, MD\nVernon Houk, Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nBettie Hudson, National Center for Health Statistics (CDC), Hyattsville, MD\n133\nHealthy People 2000\nRobert S. Hutchings, Center for Chronic Disease Prevention and Health Promotion (CDC), Rockville, MD\nKaren Hymbaugh, Indian Health Service, Albuquerque, NM\nGeorge J. Jackson, Food and Drug Administration, Washington, DC\nJack Jackson, Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nJoyce Stokes Jackson, Health Care Financing Administration, Baltimore, MD\nM. Yvonne Jackson, Indian Health Service, Rockville, MD\nWilliam R. Jarvis, Center for Infectious Diseases (CDC), Atlanta, GA\nPatrick E. Johannes, Indian Health Service, Albuquerque, NM\nBarry L. Johnson, Agency for Toxic Substances and Disease Registry, Atlanta, GA\nClifford Johnson, National Center for Health Statistics (CDC), Hyattsville, MD\nErnest W. Johnson, National Institute of Diabetes and Digestive and Kidney Diseases (NIH), Bethesda, MD\nSandie Johnson, Office for Substance Abuse Prevention (ADAMHA), Rockville, MD\nRhys Burton Jones, Wisconsin Division of Health, Madison, WI\nJames P. Kallenborn, Occupational Safety and Health Administration (DOL), Washington, DC\nGlenn Kamber, Office for Treatment Improvement (ADAMHA), Rockville, MD\nRobert Kane, University of Minnesota, Minneapolis, MN\nGeorge A. Kanuck, Office of Communication and Extramural Affairs (ADAMHA), Rockville, MD\nMurray L. Katcher, Wisconsin Department of Health, Madison, WI\nWendy Kaye, Agency for Toxic Substances and Disease Registry (ATSDR), Atlanta, GA\nJuliette S. Kendrick, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA\nMiller H. Kerr, Centers for Disease Control, Atlanta, GA\nLarry Kessler, National Cancer Institute (NIH), Bethesda, MD\nHenry M. Kissman, National Library of Medicine, Bethesda, MD\nDushanka V. Kleinman, National Institute of Dental Research (NIH), Bethesda, MD\nJoel Kleinman, National Center for Health Statistics (CDC), Hyattsville, MD\nRobert N. Kohmescher, Center for Prevention Services (CDC), Atlanta, GA\nAndrea Kopstein, National Institute on Drug Abuse (ADAMHA), Rockville, MD\nJohn M. Korn, Jr., Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA\nRichard Kotomori, Indian Health Service, Rockville, MD\nNicholas Kozel, National Institute on Drug Abuse (ADAMHA), Rockville, MD\nMarie Fanelli Kuczmarski, National Center for Health Statistics (CDC), Hyattsville, MD\nGeorge A. Kupfer, National Sanitation Foundation, Ann Arbor, MI\nThomas Lalley, National Institute of Mental Health (ADAMHA), Rockville, MD\nElizabeth Lambert, National Institute on Drug Abuse (ADAMHA), Rockville, MD\nGarland Land, Missouri Department of Health, Jefferson City, MO\nElaine Lanza, National Cancer Institute (NIH), Bethesda, MD\nLynn A. Larsen, Center for Food Safety and Applied Nutrition (FDA), Washington, DC\nJoyce Lazar, National Institute of Mental Health (ADAMHA), Rockville, MD\nBonnie Lee, Office of Health Affairs (FDA), Rockville, MD\nClaude Lenfant, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD\nBruce Leonard, Indian Health Service, Albuquerque, NM\nAlan Leshner, National Institute on Mental Health (ADAMHA), Rockville, MD\nJoel T. Levine, Health Resources and Services Administration, Rockville, MD\nLuise Light, National Cancer Institute (NIH), Bethesda, MD\nJames A. Lipton, National Institute of Dental Research (NIH), Bethesda, MD\nBarbara Lockhart, University of Iowa, Iowa City, IA\nBeverly B. Long, National Prevention Coalition, Atlanta, GA\nGloriana M. Lopez, Bureau of Health Care Delivery and Assistance (HRSA), Rockville, MD\nMax R. Lum, Office of External Affairs (ATSDR), Atlanta, GA\nGeraldine Maccannon, Office of Minority Health, Washington, DC\nMark J. Magenheim, Sarasota County Public Health Unit, Sarasota, FL\nDolores M. Malvitz, Center for Prevention Services (CDC), Atlanta, GA\nRonald Manderscheid, National Institute of Mental Health (ADAMHA), Rockville, MD\nAnn C. Maney, National Institute of Mental Health (ADAMHA), Rockville, MD\nMichael Marge, National Commission on Disability, Syracuse University, Syracuse, NY\nJames Y. Marshall, American Dental Association, Chicago, IL\n134\nB. Contributors to Healthy People 2000\nCarol A. Martin, Indian Health Service, Rockville, MD\nLaura Y. Martin, Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nWilliam J. Martone, Center for Infectious Diseases (CDC), Atlanta, GA\nJames Massey, National Center for Health Statistics (CDC), Hyattsville, MD\nWilliam J. Mayer, The Wyatt Company, Washington, DC\nRobert McAlister, Association of State and Territorial Health Officials, McLean, VA\nSheila McCarthy, Maternal and Child Health Bureau (HRSA), Rockville, MD\nPatrick McConnon, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA\nGeorge McCoy, Indian Health Service, City?\nSandra McElhaney, National Mental Health Association, Alexandria, VA\nSteve Uranga McKane, Hartford Health Department, Hartford, CT\nJeffrey W. McKenna, National Cancer Institute (NIH), Bethesda, MD\nJohn McKinlay, New England Research Institute, Watertown, MA\nMary McLean, Health Care Financing Administration, Washington, DC\nLaura McNally, Health Resources and Financing Administration, Rockville, MD\nMerle McPherson, Maternal and Child Health Bureau (HRSA), Rockville, MD\nRobert E. Mecklenburg, Potomac, MD\nFlorence Meltzer, Office of Population Affairs, Washington, DC\nRonald B. Merrill, Health Resources and Services Administration, Rockville, MD\nWalter Mertz, Human Nutrition Research Center (USDA), Beltsville, MD\nDorothy Meyer, Indian Health Service, Phoenix, AZ\nC. Arden Miller, University of North Carolina at Chapel Hill, Chapel Hill, NC\nWilliam Modzeleski, U.S. Department of Education, Washington, DC\nJudy Mohsberg, Office of Legislation and Policy (HCFA), Washington, DC\nMary Moien, National Center for Health Statistics (CDC), Hyattsville, MD\nJames M. Monroe, Center for Infectious Diseases (CDC), Atlanta, GA\nLaura E. Montgomery, National Center for Health Statistics (CDC), Hyattsville, MD\nJohn Moore, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA\nJulian M. Morris, National Eye Institute (NIH), Bethesda, MD\nJames A. Mortimer, VA Medical Center, Minneapolis, MN\nEve K. Moscicki, National Institute of Mental Health (ADAMHA), Rockville, MD\nAlanna Moshfegh, Human Nutrition Information Service (USDA), Hyattsville, MD\nDoris Mosley, Health Resources and Services Administration, Rockville, MD\nBarbara Nelson, National Institute for Occupational Safety and Health (CDC), Atlanta, GA\nGary Nelson, Centers for Disease Control, Atlanta, GA\nSusan Newcomer, National Institute for Child Health and Human Development (NIH), Bethesda, MD\nLinda C. Niessen, VA Medical Center, Perry Point, MD\nAnnette M. Nieves, Office of Minority Health, Washington, DC\nYuth Nimit, National Vaccine Program Office, Rockville, MD\nCharles Q. North, Albuquerque Indian Hospital, Indian Health Service, Albuquerque, NM\nRuth Nowjack-Raymer, National Institute of Dental Research (NIH), Bethesda, MD\nGodfrey P. Oakley, Jr., Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nJoanne Odenkirchen, National Cancer Institute (NIH), Bethesda, MD\nRichard Olson, Indian Health Service, Rockville, MD\nWalter A. Orenstein, Center for Prevention Services (CDC), Atlanta, GA\nMarcia C. Ory, National Institute on Aging (NIH), Bethesda, MD\nDonald C. Parks, Maternal and Child Health Bureau (HRSA), Rockville, MD\nSandra S. Parrino, National Commission on Disability, Briarcliff Manor, NY\nClifford H. Patrick, U.S. Department of Veteran Affairs, Durham, NC\nGregory Pawlson, George Washington University Medical Center, Washington, DC\nTerry F. Pechacek, National Cancer Institute (NIH), Bethesda, MD\nMarian Perlmutter, University of Michigan, Ann Arbor, MI\nJohn P. Pierce, University of California, San Diego, La Jolla, CA\nAnita Pikus, National Institute of Deafness and Other Communication Disorders (NIH), Bethesda, MD\nMargaret Porter, Office of the Assistant Secretary for Planning and Evaluation, Washington, DC\nBarry Portnoy, National Cancer Institute (NIH), Bethesda, MD\n135\nHealthy People 2000\nCurtis Posphisil, National Institute of Environmental Health Sciences (NIH), Research Triangle Park, NC\nArnold Potosky, National Cancer Institute (NIH), Bethesda, MD\nMorris Potter, Center for Infectious Diseases (CDC), Atlanta, GA\nKenneth Powell, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA\nWilliam Pratt, National Center for Health Statistics (CDC), Hyattsville, MD\nAnn E. Prendergast, Maternal and Child Health Bureau (HRSA), Rockville, MD\nPhilip Prorok, National Cancer Institute (NIH), Bethesda, MD\nGlenn Provost, Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nJames F. Quilty, Ohio Department of Public Health, Columbus, OH\nJoan White Quinlan, Office for Substance Abuse Prevention (ADAMHA), Rockville, MD\nThomas C. Quinn, Johns Hopkins Hospital, Baltimore, MD\nAmelie G. Ramirez, University of Texas Health Sciences Center at Houston, San Antonio, TX\nJuan Ramos, National Institute of Mental Health (ADAMHA), Rockville, MD\nDavid C. Ramsey, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA\nBetty Reid, State Department of Education, Baltimore, MD\nNicholas P. Reuter, Food and Drug Administration, Rockville, MD\nPeter H. Rheinstein, Center for Food Safety and Applied Nutrition (FDA), Rockville, MD\nCarolyn Rimes, Office of the Actuary (HCFA), Baltimore, MD\nAlice R. Ring, Centers for Disease Control, Atlanta, GA\nLaverdia Roach, President's Committee on Mental Retardation, Washington, DC\nDavid A. Robinson, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD\nEdward Roccella, National Heart, Lung, and Blood Institute (NIH), Bethesda, MD\nRose Mary Romano, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA\nJoan Rosenbach, Health Resources and Services Administration, Rockville, MD\nHarry Rosenberg, National Center for Health Statistics (CDC), Hyattsville, MD\nZeda Rosenberg, National Institute of Allergy and Infectious Diseases (NIH), Bethesda, MD\nLouis Rossiter, Health Care Financing Administration, Washington, DC\nRichard Rothenberg, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA\nCharles Rothwell, National Center for Health Statistics (CDC), Hyattsville, MD\nKathy Roy, National Council on the Handicapped, Washington, DC\nGeorge W. Rutherford, Jr., U.S. Consumer Product Safety Commission, Washington, DC\nRuth Sanchez-Way, Office of Population Affairs, Washington, DC\nRichard Sattin, Centers for Disease Control, Atlanta, GA\nSteven L. Sauter, National Institute for Occupational Safety and Health (CDC), Atlanta, GA\nJames Scanlon, Office of Health Planning and Evaluation, Washington, DC\nCharles Schade, American Public Health Association, Washington, DC\nPeter C. Scheidt, National Institute for Child Health and Human Development (NIH), Bethesda, MD\nSusan Schober, National Institute on Drug Abuse (ADAMHA), Rockville, MD\nEdyth Schoenrich, The Johns Hopkins University, Baltimore, MD\nBettina Scott, Office for Substance Abuse Prevention (ADAMHA), Rockville, MD\nMelvin Segal, Office for Substance Abuse Prevention (ADAMHA), Rockville, MD\nRaymond Seltser, Agency for Health Care Policy and Research, Rockville, MD\nFred R. Shank, Center for Food Safety and Applied Nutrition (FDA), Washington, DC\nMoira Shannon, National Center for Nursing Research (NIH), Bethesda, MD\nDonald Shopland, National Cancer Institute (NIH), Bethesda, MD\nCarl Shy, University of North Carolina at Chapel Hill, Chapel Hill, NC\nMervyn Silverman, American Foundation for AIDS Research, San Francisco, CA\nRobert Silverman, National Institute of Diabetes and Digestive and Kidney Diseases (NIH), Bethesda, MD\nJohn S. Small, National Institute of Dental Research (NIH), Bethesda, MD\nCharles Smart, National Cancer Institute (NIH), Bethesda, MD\nRichard J. Smith, Indian Health Service, Rockville, MD\nDixie E. Snider, Center for Prevention Services (CDC), Atlanta, GA\nHarrison C. Spencer, Center for Infectious Diseases (CDC), Atlanta, GA\nJack N. Spencer, Center for Prevention Services (CDC), Atlanta, GA\nBarry S. Stern, Bureau of Health Professions (HRSA), Rockville, MD\nDavid Stevens, Bureau of Health Care Delivery and Assistance (HRSA), Rockville, MD\n136\nB. Contributors to Healthy People 2000\nDorothy Stephens, Health Resources and Services Administration, Rockville, MD\nJohn A. Steward, Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nDeborah Jane Stokes, Association of Maternal and Child Health Programs, Gahanna, OH\nBob Stovenour, Administration on Developmental Disabilities (OHDS), Washington, DC\nNancy Stroup, Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nLinda A. Suydam, Center for Devices and Radiological Health (FDA), Rockville, MD\nElsie Taylor, National Institute on Alcohol Abuse and Alcoholism (ADAMHA), Rockville, MD\nGlenn Taylor, Health Resources and Services Administration, Rockville, MD\nWilliam Taylor, Center for Environmental Health and Injury Control (CDC), Atlanta, GA\nSteven Teutsch, Epidemiology Program Office (CDC), Atlanta, GA\nJ. Paul Thomas, National Institute on Disability and Rehabilitation Research, U.S. Department of Education,\nWashington, DC\nSusan B. Toal, Centers for Disease Control, Atlanta, GA\nJerome Tobis, University of California Medical Center, Irvine, Orange, CA\nFrederick T. Trowbridge, Center for Chronic Disease Prevention and Health Promotion (CDC), Atlanta, GA\nJeanne Trumble, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, MD\nJoan Van Nostrand, National Center for Health Statistics (CDC), Hyattsville, MD\nLyman Van Nostrand, Health Resources and Services Administration, Rockville, MD\nTina Vanderveen, National Institute on Drug Abuse (ADAMHA), Rockville, MD\nEcford Voit, National Institute of Mental Health (ADAMHA), Rockville, MD\nDiane Wagener, National Center for Health Statistics (CDC), Hyattsville, MD\nJohn B. Waller, Wayne State University, Detroit, MI\nLarry Wannemacher, Health Resources and Services Administration, Rockville, MD\nNancy Wartow, Administration on Aging, (OHDS), Washington, DC\nJudith N. Wasserheit, National Institute of Allergy and Infectious Diseases (NIH), Bethesda, MD\nNancy Watkins, Office of Program Planning and Evaluation (CDC), Atlanta, GA\nBill Weber, Bureau of Labor Statistics (DOL), Washington, DC\nLinda Webster, Information Resource Management Office (CDC), Atlanta, GA\nJane A. Weintraub, University of North Carolina, Chapel Hill, NC\nJames A. Weixel, Food and Drug Administration, Rockville, MD\nThomas Wells, Utah Department of Health, Salt Lake City, UT\nJanet Wetmore, National Institutes of Health, Bethesda, MD\nDaniel F. Whiteside, Bureau of Resources Development (HRSA), Rockville, MD\nJudith P. Wilkenfeld, Division of Advertising Practices, Federal Trade Commission, Washington, DC\nJames Willet, George Mason University, Fairfax, VA\nT. Franklin Williams, National Institute on Aging (NIH), Bethesda, MD\nDonna Wilson, National Institute for Occupational Safety and Health (CDC), Atlanta, GA\nDeborah M. Winn, National Center for Health Statistics (CDC), Hyattsville, MD\nSteven H. Woolf, Office of Disease Prevention and Health Promotion, Washington, DC\nMarilyn Woolfolk, University of Michigan, Ann Arbor, MI\nCatherine E. Woteki, Institute of Medicine, National Academy of Sciences, Washington, DC\nJames Young, President's Committee on Mental Retardation, Washington, DC\nJim F. Young, Administration on Children, Youth, and Families (OHDS), Washington, DC\nK. Lum Young, Nebraska Department of Health, Lincoln, NE\nPhyllis Zucker, Office of the Assistant Secretary for Planning and Evaluation, Washington, DC\nHealthy People 2000 Consortium\nNational Organizations\nAcademy of General Dentistry\nAmerican Academy of Child and Adolescent\nAerobics and Fitness Association of America\nPsychiatry\nAlcohol and Drug Problems Association of North\nAmerican Academy of Family Physicians\nAmerica\nAmerican Academy of Ophthalmology\nAlliance for Aging Research\nAmerican Academy of Orthopaedic Surgeons\nAlliance for Health\nAmerican Academy of Pediatric Dentistry\nAmateur Athletic Union of the United States\nAmerican Academy of Pediatrics\n137\nHealthy People 2000\nAmerican Alliance for Health, Physical Education,\nAmerican Lung Association\nRecreation, and Dance\nAmerican Meat Institute\nAmerican Art Therapy Association\nAmerican Medical Association\nAmerican Association for Clinical Chemistry\nAmerican Medical Student Association\nAmerican Association for Dental Research\nAmerican Nurses' Association\nAmerican Association for Marriage and Family\nAmerican Nutritionists Association\nTherapy\nAmerican Occupational Therapy Association\nAmerican Association for Respiratory Care\nAmerican Optometric Association\nAmerican Association for the Advancement of\nAmerican Orthopaedic Society for Sports Medicine\nScience\nAmerican Osteopathic Academy of Sports Medicine\nAmerican Association of Certified Orthoptists\nAmerican Osteopathic Association\nAmerican Association of Colleges of Osteopathic\nAmerican Osteopathic Hospital Association\nMedicine\nAmerican Pharmaceutical Association\nAmerican Association of Colleges of Pharmacy\nAmerican Association of Dental Schools\nAmerican Physical Therapy Association\nAmerican Physiological Society\nAmerican Association of Homes for the Aging\nAmerican Podiatric Medical Association\nAmerican Association of Occupational Health\nNurses\nAmerican Psychiatric Association\nAmerican Association of Pathologists' Assistants\nAmerican Psychiatric Nurses Association\nAmerican Association of Public Health Dentistry\nAmerican Psychological Association\nAmerican Public Health Association\nAmerican Association of Public Health Physicians\nAmerican Association of Retired Persons\nAmerican Red Cross\nAmerican Association of School Administrators\nAmerican Rehabilitation Counseling Association\nAmerican Association of Suicidology\nAmerican School Food Service Association\nAmerican Association of University Affiliated\nAmerican School Health Association\nPrograms for Persons with Developmental\nAmerican Social Health Association\nDisabilities\nAmerican Society for Clinical Nutrition\nAmerican Association on Mental Retardation\nAmerican Society for Microbiology\nAmerican Cancer Society\nAmerican Society for Parenteral and Enteral\nAmerican College Health Association\nNutrition\nAmerican College of Cardiology\nAmerican Society for Psycoprophylaxis in Obstetrics\nAmerican College of Clinical Pharmacy\nAmerican Society of Acupuncture\nAmerican College of Health Care Administrators\nAmerican Society of Addiction Medicine\nAmerican College of Healthcare Executives\nAmerican Society of Allied Health Professions\nAmerican College of Nurse-Midwives\nAmerican Society of Hospital Pharmacists\nAmerican College of Nutrition\nAmerican Society of Human Genetics\nAmerican College of Obstetricians and\nAmerican Society of Ocularists\nGynecologists\nAmerican Speech-Language-Hearing Association\nAmerican College of Occupational Medicine\nAmerican Spinal Injury Association\nAmerican College of Physicians\nAmerican Statistical Association\nAmerican College of Preventive Medicine\nAmerican Thoracic Society\nAmerican College of Radiology\nArthritis Foundation\nAmerican College of Sports Medicine\nAsian American Health Forum\nAmerican Council on Alcoholism\nAssociation for Applied Psychophysiology and\nAmerican Dental Association\nBiofeedback\nAmerican Dental Hygienists' Association\nAssociation for Fitness in Business\nAmerican Diabetes Association\nAssociation for Hospital Medical Education\nAmerican Dietetic Association\nAssociation for Practitioners in Infection Control\nAmerican Federation of Teachers\nAssociation for Retarded Citizens of the United States\nAmerican Geriatrics Society\nAssociation for the Advancement of Automotive\nMedicine\nAmerican Heart Association\nAmerican Home Economics Association\nAssociation for the Advancement of Health\nEducation\nAmerican Hospital Association\nAssociation for Vital Records and Health Statistics\nAmerican Indian Health Care Association\nAssociation of Academic Health Centers\nAmerican Institute for Preventive Medicine\nAssociation of American Indian Physicians\nAmerican Institute of Nutrition\nAssociation of American Medical Colleges\nAmerican Kinesiotherapy Association\nAssociation of Clinical Scientists\n138\nB. Contributors to Healthy People 2000\nAssociation of Community Health Nursing Educators\nMaternal and Child Health Network\nAssociation of Food and Drug Officials\nMaternity Center Association\nAssociation of Maternal and Child Health Programs\nMidwives' Alliance of North America\nAssociation of Pediatric Oncology Nurses\nMigrant Clinicians Network\nAssociation of Rehabilitation Nurses\nMothers Against Drunk Driving\nAssociation of Schools of Public Health\nNAACOG-The Organization of Obstetric,\nAssociation of State and Territorial Dental Directors\nGynecologic, and Neonatal Nurses\nAssociation of State and Territorial Directors of\nNARD-formerly National Association of Retail\nNursing\nDruggists\nAssociation of State and Territorial Directors of\nNational AIDS Network\nPublic Health Education\nNational Alliance for the Mentally Ill\nAssociation of State and Territorial Health Officials\nNational Alliance of Black School Educators\nAssociation of State and Territorial Public Health\nNational Alliance of Nurse Practitioners\nLaboratory Directors\nNational Association for Hispanic Elderly\nAssociation of State and Territorial Public Health\nNational Association for Home Care\nNutrition Directors\nNational Association for Human Development\nAssociation of State and Territorial Public Health\nNational Association for Music Therapy\nSocial Work\nNational Association for Sport and Physical\nAssociation of Teachers of Preventive Medicine\nEducation\nAssociation of Technical Personnel in\nNational Association of Biology Teachers\nOphthalmology\nNational Association of Childbearing Centers\nBlack Congress on Health, Law, and Economics\nNational Association of Community Health Centers\nBlue Cross and Blue Shield Association\nNational Association of Counties\nBoys Scouts of America\nNational Association of County Health Officials\nBusiness Roundtable\nNational Association of Elementary School Principals\nCamp Fire\nNational Association of Governors Councils on\nCardiovascular Credentialing International/National\nPhysical Fitness and Sports\nBoard of Cardiovascular Technology\nNational Association of Neonatal Nurses\nCatholic Health Association of the United States\nNational Association of Optometrists and Opticians\nChildren's Hospital National Medical Center\nNational Association of Pediatric Nurse Associates\nCollege of American Pathologists\nand Practitioners\nCouncil for Responsible Nutrition\nNational Association of RSVP Directors\nCouncil of Medical Specialty Societies\nNational Association of School Nurses\nDairy and Food Nutrition Council of the Southeast\nNational Association of Secondary School Principals\nEmergency Nurses Association\nNational Association of Social Workers\nEye Bank Association of America\nNational Association of State Alcohol and Drug\nFederation of American Societies for Experimental\nAbuse Directors\nBiology\nNational Association of State Boards of Education\nFederation of Nurses and Health Professionals\nNational Association of State NET Program\nFood Marketing Institute\nCoordinators\nFuture Homemakers of America\nNational Association of State School Nursing\nGerontological Society of America\nConsultants\nGirl Scouts of the United States of America\nNational Black Nurses Association\nGreat Lakes Association of Clinical Medicine\nNational Board of Medical Examiners\nGrocery Manufacturers of America\nNational Center for Health Education\nGroup Health Association of America\nNational Coalition of Hispanic Health and Human\nHealth Industry Manufacturers Association\nServices Organization\nHealth Insurance Association of America\nNational Commission Against Drunk Driving\nHighway Users Federation for Safety and Mobility\nNational Committee for Adoption\nInstitute of Food Technologists\nNational Committee for Prevention of Child Abuse\nInternational Association for Enterostomal Therapy\nNational Conference of State Legislatures\nInternational Lactation Consultant Association\nNational Consumers League\nInternational Life Sciences Institute\nNational Council for International Health\nInternational Patient Education Council\nNational Council for the Education of Health\nLa Leche League International\nProfessionals in Health Promotion\nLearning Disabilities Association of America\nNational Council on Alcoholism and Drug\nMarch of Dimes Birth Defects Foundation\nDependence\n139\nHealthy People 2000\nNational Council on Disability\nNational Society of Allied Health\nNational Council on Health Laboratory Services\nNational Society to Prevent Blindness\nNational Council on Patient Information and\nNational Strength and Conditioning Association\nEducation\nNational Stroke Association\nNational Council on Self-Help and Public Health\nNational Wellness Institute\nNational Council on the Aging\nNational Women's Health Network\nNational Dairy Council\nNEA Health Information Network\nNational Environmental Health Association\nNursing Network on Violence Against Women\nNational Extension Homemakers Council\nOncology Nursing Society\nNational Family Planning and Reproductive Health\nParalyzed Veterans of America\nAssociation\nPeople's Medical Society\nNational Federation of State High School\nPharmaceutical Manufacturers Association\nAssociations\nPlanned Parenthood Federation of America\nNational Food Processors Association\nPopulation Association of America\nNational Head Injury Foundation\nProduce Marketing Association\nNational Health Council\nSalt Institute\nNational Health Lawyers Association\nSalvation Army\nNational Hearing Aid Society\nSociety for Nutrition Education\nNational Institute for Fitness and Sport\nSociety for Public Health Education\nNational Kidney Foundation\nSociety of Behavioral Medicine\nNational League for Nursing\nSociety of Hospital Epidemiologists of America\nNational Lesbian and Gay Health Foundation\nSociety of Prospective Medicine\nNational Medical Association\nSociety of State Directors of Health, Physical\nNational Mental Health Association\nEducation, and Recreation\nNational Museum of Health and Medicine\nSouth Cove Community Health Center\nNational Nurses Society on Addictions\nState Family Planning Administrators\nNational Organization for Women\nUnited States Chamber of Commerce\nNational Organization on Adolescent Pregnancy and\nUnited States Conference of Mayors\nParenting\nUnited Way of America\nNational Osteoporosis Foundation\nVisiting Nurse Associations of America\nNational Pest Control Association\nVoluntary Hospitals of America\nNational Pressure Ulcer Advisory Panel\nWashington Business Group on Health\nNational PTA\nWellness Councils of America-WELCOA\nNational Recreation and Park Association\nWestern Consortium for Public Health\nNational Safety Council\nWomen's Sports Foundation\nNational School Boards Association\nState and Territorial Health Departments\nAlabama\nKansas\nNorth Dakota\nAlaska\nKentucky\nOhio\nAmerican Samoa\nLouisiana\nOklahoma\nArizona\nMaine\nOregon\nArkansas\nMaryland\nPennsylvania\nCalifornia\nMassachusetts\nPuerto Rico\nColorado\nMichigan\nRhode Island\nConnecticut\nMinnesota\nSouth Carolina\nDelaware\nMississippi\nSouth Dakota\nDistrict of Columbia\nMissouri\nTennessee\nFlorida\nMontana\nTexas\nGeorgia\nNebraska\nUtah\nGuam\nNevada\nVermont\nHawaii\nNew Hampshire\nVirginia\nIdaho\nNew Jersey\nWashington\nIllinois\nNew Mexico\nWest Virginia\nIndiana\nNew York\nWisconsin\nIowa\nNorth Carolina\nWyoming\n140\nC. Priority Area Lead Agencies\n1.\nPhysical Activity and Fitness\nPresident's Council on Physical\nFitness and Sports\n2.\nNutrition\nNational Institutes of Health\nFood and Drug Administration\n3.\nTobacco\nCenters for Disease Control\n4.\nAlcohol and Other Drugs\nAlcohol, Drug Abuse, and Mental\nHealth Administration\n5.\nFamily Planning\nOffice of Population Affairs\n6.\nMental Health and Mental Disorders\nAlcohol, Drug Abuse, and Mental\nHealth Administration\n7.\nViolent and Abusive Behavior\nCenters for Disease Control\n8.\nEducational and Community-Based Programs\nCenters for Disease Control\nHealth Resources and Services Administration\n9.\nUnintentional Injuries\nCenters for Disease Control\n10.\nOccupational Safety and Health\nCenters for Disease Control\n11.\nEnvironmental Health\nNational Institutes of Health\nCenters for Disease Control\n12.\nFood and Drug Safety\nFood and Drug Administration\n13.\nOral Health\nNational Institutes of Health\nCenters for Disease Control\n14.\nMaternal and Infant Health\nHealth Resources and Services Administration\n15.\nHeart Disease and Stroke\nNational Institutes of Health\n16.\nCancer\nNational Institutes of Health\n17.\nDiabetes and Chronic Disabling Conditions\nNational Institutes of Health\nCenters for Disease Control\n18.\nHIV Infection\nNational AIDS Program Office\n19.\nSexually Transmitted Diseases\nCenters for Disease Control\n20.\nImmunization and Infectious Diseases\nCenters for Disease Control\n21.\nClinical Preventive Services\nHealth Resources and Services Administration\nCenters for Disease Control\n22.\nSurveillance and Data Systems\nCenters for Disease Control\n141\nHealthy People 2000\n142\nIndex to Summary List of Objectives\nAbuse, Physical and Sexual\nfetal alcohol syndrome 14.4a\nchildren 7.4, 7.14\ngingivitis 13.5b\nemergency housing for victims 7.15\nhepatitis B 20.3g\nemergency room identification of victims 7.12\nhomicide 7.1f\nintergenerational cycle 7.14\ninfant mortality 14.1b\nwomen 7.5\nlimitation in major activity 17.2b\nAbuse, Substance (see Alcohol; Drugs)\nmeningitis 20.7a\nAccidents (see Injury)\nmotor vehicle crash deaths 9.3d\nAcquired Immunodeficiency Syndrome (see HIV\noverweight 2.3d\nInfection)\nprenatal care 14.11b\nActivity Limitation (see Disability)\npostneonatal mortality 14.1i\nAdoption 5.9\nrecommended primary care services 21.2k\nAdvertising\nsmokeless tobacco use 3.9a\nalcoholic beverages 4.17\nsuicide 6.1d\ntobacco products 3.15\ntuberculosis 20.4d\nAfrican Americans (see Black Americans;\nunintentional injury 9.1a\nMinority Groups, Racial And Ethnic)\nAnabolic Steroids (see Steroids, Anabolic)\nAgency for Toxic Substances and Disease\nAsbestosis (see Lung Disease)\nRegistry 11.7\nAsians and Pacific Islanders (see also Minority\nAIDS (see HIV Infection)\nGroups, Racial and Ethnic)\nAirbags (see Occupant Protection Systems)\ncigarette smoking 3.4g\nAir Pollutants 11.5\ngrowth retardation 2.4d, 2.4e\nAlaska Natives (see American Indians and Alas-\nhepatitis B 20.3d\nka Natives)\nrecommended clinical preventive services 21.2j\nAlcohol (see also Alcohol and Other Drugs sec-\ntuberculosis 20.4a\ntion, page 97)\nAssault\nabstinence during pregnancy 14.10\ninjuries 7.6\naccess by minors 4.16\nvictims 7.12\naverage age of first use 4.5\nAsthma\nconsumption per person 4.8\nlimitation in major activity 17.4\ndeterrence for driving under the influence 4.15\nmorbidity 11.1\ndiscussion in family 8.9\nAthletics (see Sporting Events)\neducational programs in schools 4.13\nAutomobiles (see Motor Vehicles)\nheavy drinking by high school and college students 4.7\nlegal blood alcohol concentration tolerance levels 4.18\nBabies (see Infants)\nperception of harm associated with heavy use 4.10\nBaby Bottle Tooth Decay 2.12, 13.11\nperception of social disapproval among high\nBack Conditions\nschool seniors 4.9\nactivity limitation 17.5\npromotion to young people 4.17\nworksite injury and rehabilitation programs 10.13\nrecent use by young people 4.6\nBack Injury and Rehabilitation (see Back Condi-\nrelated motor vehicle crashes 4.1\ntions)\ntreatment programs for underserved 4.12\nBirth Control (see Contraception)\nworksite policies 4.14\nBlack Americans (see also Minority Groups, Ra-\nAmerican Indians and Alaska Natives (see also\ncial and Ethnic)\nMinority Groups, Racial and Ethnic)\nadolescent pregnancy 5.1a\nalcohol-related motor vehicle crash deaths 4.1a\nAIDS 18.1b\nanemia 2.10d\nanemia 2.10e\nbaby bottle tooth decay 13.11b\namputation of lower-extremities due to diabetes 17.10a\nbreastfeeding 14.9d\nasthma 11.1a\ncigarette smoking 3.4f\nblood lead levels 11.4a\ncirrhosis 4.2b\nbreastfeeding 14.9\ndental caries 13.1b, 13.1d\nbreast examination and mammogram 16.11e\ndental caries, untreated 13.2b\ncigarette smoking 3.4d\ndiabetes 17.11a\ncirrhosis 4.2a\ndiabetes-related deaths 17.9b\ncoronary heart disease 15.1a\nend-stage renal disease due to diabetes 17.10b\ndiabetes 17.11e\n143\nHealthy People 2000\ndiabetes-related deaths 17.9a\nCavities (see Dental Caries)\ndental caries 13.1c\nCervical Cancer (see Cancer)\ndental caries, untreated 13.2c\nCesarean Delivery 14.8\ndrowning 9.5c\nChild Abuse (see Abuse, Physical and Sexual)\nend-stage renal disease 15.3a\nChild Care Centers\nend-stage renal disease due to diabetes 17.10a\nchildhood immunization levels 20.11\nfalls and fall-related injury 9.4c\nfood services 2.17\nfetal alcohol syndrome 14.4b\nimmunization laws 20.13\nfetal death 14.2a\ninfectious diarrhea 20.8\ngonorrhea 19.1a\nChild Death Review Systems 7.13\ngrowth retardation 2.4a\nChild Neglect\nhigh blood pressure control 15.5b\nevaluation and followup 7.14\nhomicide 7.1c, 7.1e\nincidence 7.4\ninfant mortality 14.1a\nChild Safety Seats (see Occupant Protection Sys-\ninfertility 5.3a\ntems)\nlimitation in major activity 17.2c\nChlamydia Trachomatis Infection 19.2\nlow birth weight 14.5a\nprovider referral services 19.15\nmaternal mortality 14.3a\nCholesterol, Blood\nneonatal mortality 14.1e\nhigh levels 15.7\noverweight 2.3b\nlaboratory standards for measurement 15.17\npost neonatal mortality 14.1h\nmanagement by diet/drug therapies 15.15\nprenatal care 14.11a\nmean serum 15.6\nrecommended clinical preventive services 21.2h\nreduction 15.8\nresidential fire deaths 9.6c, 9.6d\nscreening 15.14\nsource of ongoing primary care 21.3b\nworksite education and control programs 15.16\nstroke 15.2a\nChronic Disabling Conditions (see also Dis-\nsyphilis, primary and secondary 19.3a\nability; Diabetes and Chronic Disabling\ntuberculosis 20.4b\nConditions section, page 116)\nunintended pregnancy 5.2a\npatient education about community resources\n17.14\nunintentional injury 9.1b\nyears of healthy life 8.1a\nservice systems for children 17.20\nBlood Lead Levels 11.4\nChronic Obstructive Pulmonary Disease (see\nLung Disease)\nBlood Pressure\nCigarette Smoking (see Smoking)\ncontrol 15.4, 15.5\nCirrhosis\neducation programs at worksite 15.16\ndeaths 4.2\nscreening 15.13\nCities (see also Community; Counties)\nBlood Transfusions\nbuilding codes 9.16, 11.12\nHIV infection 18.8\ncomprehensive violence prevention programs 7.17\nBreastfeeding 2.11, 14.9\nHIV risk reduction outreach programs to drug\nBreast Cancer (see Cancer)\nabusers 18.12\nBreast Examinations (see Examinations, Routine;\nClearinghouses (see Mutual Help Clearin-\nMammography)\nghouses)\nBuilding Codes\nCleft Lip/Palate 13.15\nfire suppression sprinklers 9.16\nClinical Preventive Services (see also Examina-\nradon levels 11.12\ntions, Routine; Primary Care Providers;\nByssinosis 10.11\nClinical Preventive Services section,\npage 123)\nCalcium\nfinancial barriers 21.4\ndietary intake 2.8\nfrom primary care providers 21.6\nCampylobacter Jejuni 12.1\nfrom publicly funded programs 21.5\nCancer (see also Cancer section, page 114)\nlocal health department assurance of access 21.7\nbreast 16.3\nClinicians (see Primary Care Providers)\ncervical 16.4\nCocaine (see also Drugs)\ncolorectal 16.5\nabstinence during pregnancy 14.10\ndeaths 2.2, 16.1\nperception of harm associated with experimenta-\nlung 3.2, 16.2\ntion 4.10\noral cavity and pharynx 13.7\nperception of social disapproval among high\nCancer Prevention Screening (see Examinations,\nschool seniors 4.9\nRoutine; Primary Care Providers)\nrecent use by young people 4.6\n144\nIndex to Summary List of Objectives\nCollege (see Schools; School Health Promotion)\nprotective sealants 13.8\nColorectal Cancer (see Cancer)\nuntreated 13.2\nCommunication, Health (see Educational\nDentist (see Oral Health Care Provider)\nPrograms)\nDepressive Disorders 6.7\nCommunity (see also Cities; Counties; Educa-\nDetention Facilities (see Institutional Facilities)\ntional and Community-Based Programs\nDiabetes (see also Diabetes and Chronic Disa-\nsection, page 101)\nbling Conditions section, page 116)\nbuilding codes 9.16, 11.12\ncomplications 17.10\nfluoridated water systems 13.9\nincidence and prevalence 17.11\nhealth promotion programs\nrelated deaths 17.9\naddressing Healthy People 2000 priorities 8.10\nDiarrhea, infectious 20.8\nhospital-based patient education 8.12\nDietary Guidelines for Americans 2.16, 2.17\nserving older people 8.8\nDietary Intake\nserving racial and ethnic populations 8.11\ncholesterol 15.15\ntelevision partnership for health communi-\ncomplex carbohydrates and fiber-containing\ncation 8.13\nfoods 2.6\nviolence prevention 7.17\nfat 2.5, 15.9, 16.7\npatient education about available resources 17.14\nDigital Rectal Examinations (see Examinations,\nphysical activity and fitness facilities 1.11\nRoutine)\nprevalence of mental disorders 6.4\nDiphtheria\nprograms for recyclable materials and household\nindigenous cases 20.1\nhazardous waste 11.15\nimmunization 20.16\nresources for people with chronic and disabling\nDisability\nconditions 17.14\nactivity limitation\nsupport for people with mental disorders 6.6\ndue to asthma 17.4\nComparable Data (see Surveillance and Data\ndue to chronic back conditions 17.5\nSystems)\ndue to chronic conditions 17.2\nComplex Carbohydrates\ndue to pneumonia 20.10\ndietary intake 2.6, 16.8\ndetection\nCondoms (see also Contraception)\nnewborns 14.15\nuse among adolescents 18.4, 19.10\ninfants and children 17.15\nConflict Resolution, Non-Violent 7.16\nolder people 17.3\nCongenital Rubella Syndrome 20.1\npeople with disabilities\nContact Tracing 19.15\nadverse health effects from stress 6.5a\nContamination, Solid Waste-Related 11.8\nnational disease prevention and health\nContraception (see also Family Planning)\npromotion data 22.4\neffective use 5.7\noverweight 2.3e\nuse among adolescents 5.6, 18.4, 19.10\npatient education programs 17.14\nCoronary Heart Disease (see Heart Disease)\npreschool programs for children 8.3\nCorrectional Facilities (see also Institutional\nprograms for children with or at risk 17.20\nFacilities)\nsedentary lifestyles 1.5b\nsuicide in jails 6.10, 7.18\npolicies\nCounseling by Clinicians (see Primary Care\nworksite hiring policies 17.19\nProviders)\nsecondary\nCounties (see also Communities; Cities)\nassociated with head and spinal cord\nair quality standards 11.5\ninjuries 9.11\nbuilding codes 9.16, 11.12\nsensory impairments\nhealth promotion programs for minorities 8.11\nhearing impairment 17.6\nprograms for recyclable materials and household\nvisual impairment 17.7\nhazardous wastes 11.15\nDomestic Violence (see Abuse)\nviolence prevention programs 7.17\nDrinking Water (see Water)\nCraniofacial Anomaly Teams 13.15\nDrowning 9.5\nCriteria Air Pollutants (see Air Pollutants)\nCumulative Trauma Disorder (see Trauma)\nDrugs (see also Alcohol; Cocaine; Marijuana;\nMedication; Alcohol and Other Drugs\nData Systems (see Surveillance and Data Sys-\nsection, page 97)\ntems)\nabuse related deaths 4.3\nDental Caries\nabuse related emergency room visits 4.4\nloss of permanent teeth 13.3\naverage age at first use 4.5\nprevalence 13.1\ndeterrents for driving under the influence 4.15\n145\nHealthy People 2000\ndiscussion in family 8.9\nrestaurant menu choices 2.16\neducational programs in schools 4.13\nFecal Occult Blood Testing (see Examinations,\nintravenous drug abuse 18.5, 18.6, 18.12\nRoutine)\nprescription medications 12.5\nFetal Abnormalities\nscreening, counseling, and referral by clinicians\ndetection 14.13\n4.19\nFetal Alcohol Syndrome 14.4\ntreatment centers addressing HIV and sexually\nFetal Death 14.2\ntransmitted diseases 5.11, 18.13, 19.11\nFiber\ntreatment programs for underserved 4.12\ndietary intake 2.6, 16.8\nuse by youth 4.6\nFighting, Physical 7.9\nworksite policies 4.14\nFinancial Barriers\nEar Infection (see Infection)\nto clinical preventive services 21.4\nEducational Programs (see also Community;\nto immunizations 20.15\nPatient Education; School; Worksite;\nFirearms (see Weapons)\nEducational and Community-Based\nFires\nPrograms section, page 101)\ndeaths 9.6\nEmergency Room\nprotection 9.16, 9.17\ndrug abuse-related emergency room visits 4.4\nFitness Programs and Facilities\nemergency medical services and trauma sys-\ncommunity 1.11\ntems 9.22\neducation in schools 1.8, 1.9\nprotocols for suicide attempts 7.12\nworksite 1.10\nprotocols for victims of abuse and assault 7.12\nFlexibility (see Physical Activity)\nEmployer-Sponsored Programs (see Worksite)\nFluoride\nEnd-Stage Renal Disease (see Renal Disease,\ncommunity water systems 13.9\nEnd-Stage)\ntopical or dietary 13.10\nEndurance (see Physical Activity)\nFoodborne Pathogens (see Food Poisoning)\nEnvironmental Diseases, Sentinel\nFood and Drug Safety (see Food and Drug\nStates' plans to define and track 11.16\nSafety section, page 107)\nEnvironmental Health (see Environmental\nFood Labeling 2.13, 2.14\nHealth section, page 105)\nFood Poisoning\nEnvironmental Protection Agency\nincidence 12.1\nair quality standards 11.5\nsalmonella outbreaks 12.2\nsafe drinking water standards 11.9\nFood Preparation in Home\nEscherichia Coli 0157:H7 12.1\ndifficulty with 2.18\nEstrogen Replacement Therapy (see Os-\nlow-sodium 2.9\nteoporosis)\nsafe practices 12.3\nExaminations, Routine\nFood Safety\nbreast 16.11\nhousehold practices 12.3\ncervical (Pap test) 16.12\nState codes 12.4\ncolorectal 16.13\nFood Service\ndental 13.14\nhome delivery for older people 2.18\ndigital rectal 16.14\nlow-fat, low-calorie food choices 2.16\noral 16.14\nmodel food codes 12.4\nskin 16.14\nschool and child care 2.17\nExercise (see Physical Activity)\nFractures, Hip\nFalls\nolder people 9.7\ndeaths 9.4\nFruit\nFamily\ndaily intake 2.6, 16.8\ndiscussion of human sexuality 5.8\nGenetic Disorders\ndiscussion of health issues 8.9\nnewborn screening and follow-up 14.15\nFamily Planning (see also Family Planning sec-\nGenital Herpes (see Herpes, Genital)\ntion, page 98)\nGenital Warts (see Warts, Genital)\nclinics addressing HIV infection and sexually trans-\nmitted diseases 5.11, 18.13, 19.11\nGingivitis (see Periodontal Disease)\nGonorrhea\neffectiveness of use 5.7\nincidence 19.1\npreconception care and counseling 5.10, 14.12\nFat, Dietary\nprovider referral services 19.15\navailability of low-fat processed foods 2.15\nrepeat infection 19.8\ndietary intake 2.5, 15.9, 16.7\n146\nIndex to Summary List of Objectives\nGrain Products\nbreast examination and mammography 16.11a\ndaily intake 2.6, 16.8\nbreastfeeding 14.9c\nGrowth Retardation 2.4\ncigarette smoking 3.4e\ndental caries, untreated 13.2d\nHandguns (see Weapons)\ndiabetes 17.11b, 17.11c, 17.11d\nHazardous Waste\ngingivitis 13.5c\nhealth risk at sites 11.14\ngrowth retardation 2.4b, 2.4c\ncommunity collection of household 11.15\nhomicide 7.1d\nHead Injuries 9.9\ninfant mortality 14.1c\nsecondary disabilities 9.11\ninfertility 5.3b\nHealth Communication (see Educational Programs)\nneonatal mortality 14.1f\nHealth Departments (see Public Health Depart-\noverweight 2.3c\nments)\npap testing 16.12a\nHealth Maintenance Organizations 8.12\npostneonatal mortality 14.1j\nHealth Objectives (see National Disease Preven-\nprenatal care 14.11c\ntion and Health Promotion Objectives)\nrecommended clinical preventive services 21.2i\nHealth Professions\nsource of ongoing primary care 21.3a\nracial/ethnic minority representation 21.8\ntuberculosis 20.4c\nHealth Promotion Programs (see Community;\nyears of healthy life 8.1b\nPatient Education; Schools; Worksite)\nHIV Infection (see also HIV infection section,\nHealth Status Indicators\npage 119)\nset for Federal, State, local use 22.1\naddressed in health clinics 5.11, 18.13, 19.11\ncounseling on prevention of sexually trans-\nAIDS incidence 18.1\nmitted 18.9, 19.14\nHomes\noccupational exposure 18.14\nbuyer notification of lead-based paint and radon\nprevalence 18.2\nconcentration 11.13\ntesting 18.8\nchildren's exposure to tobacco smoke 3.8\ntransfusion-transmitted 18.7\nfire suppression sprinkler systems 9.16\nHealthy Life Span (see Quality-Adjusted Life\nmeal delivery for older people 2.18\nYears)\nnutritious food preparation 2.9\nHealthy People 2000 (see National Disease\nPrevention and Health Promotion Objec-\nresidential fires, deaths 9.6\ntives)\nsafe food preparation practices 12.3\nsmoke detectors 9.17\nHearing Impairment\ndetection in children 17.15, 17.16\ntesting for lead-based paint 11.11\ndetection in older people 17.17\ntesting for radon concentrations 11.6\nHomicide 7.1\nprevalence 17.6\nHeart Disease (see Heart Disease and Stroke sec-\nHospitals\ntion, page 112)\ncommunity health promotion 8.12\ncoronary 1.1, 2.1, 3.1, 15.1\ndrug abuse-related emergency department\nvisits 4.4\nHelmets\nState laws 9.14\nemergency medical and trauma systems 9.22\nuse by motorcyclists and bicyclists 9.13\npatient education programs 8.12\nHepatitis, Viral\nprotocols for addressing needs of victims of\nviolence and abuse 7.12\namong international travelers 20.6\nHuman Immunodeficiency Virus (see HIV Infec-\nimmunizations by public health depart-\ntion)\nments 20.16\nimmunization levels 10.9, 20.11\nImmunization (see also Immunization and Infec-\nreduction 20.3\ntious Diseases section, page 121)\nsexually transmitted infection 19.7\ncounseling and services by primary care provi-\nworksite exposure 10.5\nders 20.14\nHerpes, Genital 19.5\nfinancial barriers 20.15, 21.4\nHigh Blood Pressure (see Blood Pressure)\nHepatitis B 10.9\nHighway Design Standards 9.20\nlaws 20.13\nHigh School (see School)\nlevels among high-risk populations 20.11\nHip Fractures (see Fractures, Hip)\nprovision by Public Health Departments 20.16\nHispanic Americans (see also Minority Groups,\nreceipt of recommended services 21.2\nRacial and Ethnic)\nImmunization Practices Advisory Committee\nadolescent pregnancy 5.1b\n20.11\nAIDS 18.1c\n147\nHealthy People 2000\nIndoor Air\nLaboratories\nlaws 3.12\nclinical 15.17\nInfants (see also Maternal and Infant Health sec-\ncytology 16.15\ntion, page 110)\nrapid viral diagnosis of influenza 20.19\nbaby bottle tooth decay 2.12, 13.11\nLead-Based Paint\nbreastfeeding 2.11, 14.9\nhome buyer notification 11.13\nimmunization 20.11\nhome testing 11.11\nmortality 14.1\nLead Exposure\nreceipt of recommended primary care ser-\nand exposure to other criteria air pollutants 11.5\nvices 14.16\nchildren 11.4\nreferral to craniofacial anomaly teams 13.15\nhome 11.11\nrisk-appropriate care 14.14\nworksite 10.8\nscreening for developmental problems 17.15\nLimitation in Major Activity (see Disability)\nscreening for genetic disorders 14.15\nLiver Disease (see Cirrhosis)\nInfant Mortality 14.1\nLow Birth Weight 14.5\nInfection\nLow Income, People With\ndiarrhea 20.8\nanemia prevalence 2.10e\near 20.9\nblood lead levels 11.4a\nnosocomial and wound 20.5\nbreastfeeding 14.9a\nwaterborne disease 11.3\nbreast examinations and mammography 16.11b\nInfertility 5.3\ncigarette smoking initiation 3.5a\nInfluenza\nfinancial barriers to primary care 21.4\nepidemic-related deaths 20.2\ngingivitis prevalence 13.5a\nimmunization 20.11, 20.16\ngrowth retardation 2.4\nlaboratory capability for rapid viral diag-\niron deficiency 2.10a, 2.10c\nnosis 20.19\nlimitation in major activity 17.2a\nInjury (see also Unintentional Injuries section,\nloss of all natural teeth 13.4a\npage 103)\nnational disease prevention and health promotion\nassault 7.6\ndata 22.4\nback 10.13\noverweight 2.3a\ndeaths 9.1\npap testing 16.12d\nhead, non-fatal 9.9\npreschool programs for children 8.3\nhospitalizations 9.2\nrecommended clinical preventive services 21.2g\nprevention and control instruction in schools 9.18\nsedentary lifestyle 1.5c\nprevention counseling by primary care\nsource of ongoing primary care 21.3c\nproviders 9.21\nvigorous physical activity 1.4a\nsecondary disabilities 9.11\nLung Disease\nspinal cord, non-fatal 9.10\ncancer 3.2, 16.2\nsuicide attempts 6.2, 7.8\nchronic obstructive pulmonary disease 3.3\nwork-related 10.1, 10.2\noccupational 10.11\nInmates (see Correctional Facilities)\nLysteria Monocytogenes 12.1\nInstitutional Facilities\nfood services 2.4, 2.16\nMalaria 20.6\nimmunizations 20.11\nMammography\nprovision of oral health care 13.13\nand clinical breast examinations 16.11\nsuicide in jails 6.10, 7.18\nquality standards for facilities 16.16\nIntensive Care Units\nMarijuana\nand nosocomial infections 20.5\nabstinence during pregnancy 14.10\nIntravenous Drug Abuse\naverage age of first use 4.5\noutreach programs to prevent HIV infection 18.12\nperception of harm associated with regular\ntreatment programs 18.5\nuse 4.10\nuncontaminated drug paraphernalia 18.6\nperception of social disapproval among high\nIron Deficiency 2.10\nschool seniors 4.9\nIV Drug Abuse (see Intravenous Drug Abuse)\nrecent use by young people 4.6\nMaternal and Infant Health (see also Infants;\nJail (see Correctional Facilities)\nMaternal and Infant Health section,\nJuvenile Homes (see Institutional Facilities)\npage 110)\nclinics addressing HIV infection 5.11, 18.13, 19.11\nKnives (see Weapons)\nMaternal Mortality 14.3\n148\nIndex to Summary List of Objectives\nMeals (see Food Service; Restaurants)\nNursing Homes (see Institutional Facilities)\nMeasles 20.1\nNutrient Intake (see Dietary Intake)\nMedia (see Health Promotion Programs)\nNutrition (see also Nutrition section, page 93)\nMedication\ndiscussion in family 8.9\nanabolic steroid use 4.11\neducation in schools 2.19\nlinked pharmacy systems 12.5\neducation at worksite 2.20\nreview for older patients 12.6\nNutrition Labeling (see Food Labeling)\nMeningitis, Bacterial 20.7\nMental Disorders (see also Mental Health and\nOccupant Protection Systems\nMental Disorders section, page 99)\nrequirement by employers 10.6\namong adults living in community 6.4\nuse 9.12\namong children and adolescents 6.3\nOccupational Hazards\ncommunity support programs 6.6\nbloodborne infections, including HIV 18.14\nmental retardation 11.2, 17.8\ncounseling by primary care providers 10.15\nMental Health (see Mental Health and Mental\nhepatitis B 10.5, 10.9\nDisorders section, page 99)\ninjuries, fatal 10.1\npersonal and emotional problems 6.8\ninjuries, non-fatal 10.2\nMental Retardation 11.2, 17.8\nlead 10.8\nMiddle Ear Infection (see Infection)\nmajor occupational lung diseases 10.11\nMinority Groups, Racial and Ethnic (see also\nnoise 10.17\nAmerican Indians and Alaska Natives;\nOccupational Safety and Health (see also Oc-\nAsian and Pacific Islanders; Black\ncupational Hazards; Occupational Safety\nAmericans; Hispanic Americans)\nand Health section, page 104)\ncommunity-based health promotion programs 8.11\nstate plans addressing 10.10\nnational disease prevention and health promotion\nOral Cancer (see Cancer)\ndata 22.4\nOral Health (see also Oral Health section,\nracial/ethnic representation in health profes-\npage 108)\nsions 21.8\ncare at institutional facilities 13.13\nMotor Vehicles\ndental visits 13.14\nalcohol-related crash deaths 4.1\nscreening for children entering school 13.12\ncrash-related deaths 9.3\nOral Health Care Provider\noccupant protection systems 9.12\ntobacco-cessation counseling 3.16\nwork-related travel 10.6\nOsteoporosis\nMumps 20.1\nestrogen replacement therapy to prevent 17.18\nMuscular Strength and Endurance (see Physical\nOverweight 1.2, 2.3, 15.10, 17.12\nActivity)\nweight loss 1.7, 2.7\nMutual Help Clearinghouses 6.12\nPacific Islander Americans (see Asians and\nNational Disease Prevention and Health Promotion\nPacific Islanders)\nObjectives\nPap Smear (see Pap Testing)\ncommunity programs addressing 8.10\nPap Testing\ncomparable data at Federal, State, and local level\nquality standards 16.15\nfor each objective 22.3\nscreening 16.12\nnational data sources to measure progress 22.2\nPark and Recreation Space 1.11\nperiodic analysis and publication of data 22.5\nPartner Notification (see Sexually Transmitted\ntelevision partnerships with community organiza-\nDiseases)\ntions 8.13\nPathogens, Foodborne (see Food Poisoning)\nNational Health Objectives (see National Disease\nPatient Education (see also Education; Primary\nPrevention and Health Promotion Objec-\nCare Providers)\ntives)\nby HMOs, hospitals, and group practices 8.12\nNational Priorities List Hazardous Waste\nfor people with chronic and disabling condi-\nSites 11.14\ntions 17.14\nNative Americans (see American Indians and\nPelvic Inflammatory Disease 19.6\nAlaska Natives)\nPeriodontal Disease\nNewborns (see Infants)\ngingivitis 13.5\nNoise Exposure\nloss of permanent teeth 13.3\nat worksite 10.7\nprevalence 13.6\nNosocomial Infections (see Infection)\nPertussis 20.1\nNurse (see Primary Care Provider)\nPharmacies\nNurse Practitioner (see Primary Care Provider)\nlinked information systems 12.5\n149\nHealthy People 2000\nPhysical Activity (see also Physical Activity and\ncancer 16.10\nFitness section, page 91)\nchild development 17.15\ncommunity fitness facilities 1.11\nchildren's cognitive, emotional and parent-child\ncounseling by physicians 1.12\nfunctioning 6.14\ndiscussion in family 8.9\nfunction in older adults 17.17\nlack of 1.5\nnutrition 2.21\nregular moderate 1.3, 15.11, 17.13\noccupational health exposures 10.15\nregular vigorous 1.4\npatients' mental functioning 6.13\nschool physical education class 1.9\ncounseling, treatment, and referral\nstrength, endurance, and flexibility 1.6\nalcohol and other drug use problems 4.19\nweight loss 1.7, 2.7\ncholesterol management 15.15\nworksite programs 1.10\ncraniofacial anomalies 13.15\nPhysical Education\ndetection of fetal abnormalities 14.13\ndaily, in schools 1.8\ndiet modification 16.10\nactive 1.9\nHIV and other sexually transmitted disease preven-\nPhysician (see Primary Care Provider)\ntion 18.9, 19.14\nPhysician's Assistant (see Primary Care Provider)\nimmunizations 20.14\nPneumoconiosis 10.11\ninjury prevention 9.21\nPneumonia\nnutrition 2.21\ndays of restricted activity 20.10\noccupational health exposures 10.15\nepidemic-related deaths 20.2\nphysical activity 1.12\nimmunization levels 20.11\npreconception 5.10, 14.12\nimmunization by public health departments 20.16\nsexually transmitted diseases 19.13\nPoisoning\ntobacco-use cessation 3.16, 16.10\nchemical 11.3\nprovision of clinical preventive services 21.6\nnon-fatal 9.8\nPrisons (see Correctional Facilities)\nPolio 20.1\nProcessed Foods\nPollution (see also Environmental Health sec-\nnutrition labeling 2.14\ntion, page 105)\nlow-fat 2.15\nclean indoor air laws 3.12\nProctosigmoidoscopy (see Examinations,\nPregnancy\nRoutine)\nadolescents 5.1\nProtective Equipment\nbreastfeeding 2.11, 14.9\nsports and recreational 9.19, 13.16\ncalcium intake 2.8\nProvider Referral Services 19.15\ncesarian delivery 14.8\nPublic Health Departments\ncounseling on adoption 5.9\nlocal\nfetal death rate 14.2\nassessment of and assurance of access to clinical\nmaternal mortality rate 14.3\npreventive services 21.7\npreconception care and counseling 14.12\neffective service by 8.14\nprenatal care during first trimester 14.11\nsmall business safety and health programs 10.14\nprenatal detection of fetal abnormalities 14.13\nprograms for identification of tuberculosis 20.17\nrisk-appropriate care 14.14\nuse of health status indicators 22.1\nsevere complications 14.7\nprovision of adult immunizations 20.16\nsmoking cessation 3.7\nPublic Law 101-239 17.20\ntobacco, alcohol, and illicit drug use 14.10\nPublic Swimming Pools 1.11\nunintended 5.2\nweight gain 14.6\nQuality Adjusted Life Years 8.1, 17.1, 21.1\nPrenatal Care 14.11\nRabies\nPrescription Medications (see Medication)\ntreatment 20.12\nPrimary Care\nRadon Concentration\nclinics addressing HIV infection and sexually trans-\nconstruction standards and techniques to\nmitted diseases 5.11, 18.13, 19.11\nreduce 11.12\npreventive services 21.6\nrequired disclosure to home buyers 11.13\npreventive services in publicly funded\ntesting in homes 11.6\nprograms 21.5\nRape and Attempted Rape 7.7\nservices for babies 14.16\nRectal Examination (see Examinations, Routine)\nspecific ongoing source 21.3\nRecycling Programs 11.15\nPrimary Care Provider\nRenal Disease, End-Stage 15.3\nassessment and screening\nResidences (see Homes)\n150\nIndex to Summary List of Objectives\nRestaurants\ncondom use 18.4, 19.10\nlow-fat, low-calorie food choices 2.16\nSexually Transmitted Diseases (see also HIV In-\nRoadway Safety\nfection; Sexually Transmitted Diseases sec-\ndesign standards 9.20\ntion, page 120)\nRoutine Examinations (see Examinations,\nbarrier method protection against 5.6\nRoutine)\ncorrect patient management by primary care\nRubella 20.1\nproviders 19.13\npartner notification 5.11, 18.13, 19.11\nSafety\nprevention counseling by clinicians 18.9, 19.14\ncounseling by primary care providers 9.21\nprovider referral services 19.15\ndiscussion in family 8.9\nSexuality\nroadway design standards 9.20\ndiscussion in family 5.8\nworksite programs 10.12\nShelters\nSafety Belt (see Seat Belt)\nbattered women and children 7.15\nSalmonella Enteritidis\nSilicosis 10.11\nincidence rate 12.1\nSkin Disorders/Diseases 10.4\noutbreaks 12.2\nSkin Examinations (see Examinations, Routine)\nSalt\nSmoke Detectors 9.17\ndietary intake 2.9\nSmoking\nSaturated Fat (see Fat)\ncessation counseling by clinicians 3.16\nSchools\nchildren's exposure at home 3.8\nfood services 2.17\ncigarettes 3.4, 15.12, 16.6\ngraduation rate 8.2\naverage age of first use 4.5\nhealth education\ncessation attempts 3.6\nalcohol and other drug 4.9, 4.10, 4.13\ncessation during pregnancy 3.7\nconflict resolution 7.16\ninitiation by children and youth 3.5\nHIV, education curricula grades 4 through\nState policies limiting or prohibiting in public\n12 18.10\nplaces 3.12\nHIV, education at colleges and\nworksite policies 3.11\nuniversities 18.11\nSodium (see Salt)\ninjury prevention 9.18\nSolid Waste (see Waste)\nnutrition 2.19\nSpeech and Language Impairment\nphysical education 1.8, 1.9\ndetection in children 17.15\nquality, grades K through 12 8.4\nSpinal Cord Injuries (see Injury)\nsexuality 5.8\nSprinkler Systems, Fire Suppression\nsexually transmitted disease prevention 19.12\nresidential 9.16\ntobacco-use prevention 3.10\nSporting Events\nhealth promotion in post-secondary institutions 8.5\nuse of protective equipment 9.19, 13.16\nheavy drinking among high schools seniors and\nStates\ncollege students 4.7\ncommunity health promotion programs 8.10\nimmunization laws 20.13\ndata\nimmunization levels 20.11\ncomparable to Federal and local 22.3\noral health screening 13.12\nhealth status indicators 22.1\npreschool programs for disabled or disadvantaged\nperiodic analysis and publication 22.5\nchildren 8.3\nevaluation and followup of abused children 7.14\ntobacco-free 3.10\nlaws\nScreening (see Examinations, Routine)\ndisclosure of lead and radon concentrations to\nSealants, Protective Dental 13.8\nhome-buyers 11.13\nSeat Belt\ndriver's license revocation for driving under the\nlaws 9.14\ninfluence 4.15\nuse 9.12\nhandgun design 9.15\nSedentary Lifestyle 1.5\nimmunization in schools and day care\nSelf-Help (see also Mutual Help Clearinghouses)\ncenters 20.13\npatient education about resources 17.14\nlegal blood alcohol concentration tolerance\nSexual Abuse (see Abuse)\nlevels 4.18\nSexual Behavior (see Sexuality)\npromotion of alcohol to youth 4.17\nSexual Intercourse\nsafety belt and helmet use laws 9.14\nabstinence 5.5\nsale and distribution of tobacco to youth 3.13\namong adolescents 5.4, 18.3, 19.9\nsmoking in public places 3.12\n151\nHealthy People 2000\nmutual help clearinghouses 6.12\nTanning Booths (see Ultraviolet Radiation)\nplans\nTeeth\naccess to alcohol and drug treatment programs\nloss of all natural 13.4\n4.12\nmaintenance of all permanent 13.3\ndefining and tracking environmental dis-\nprotective sealants for children 13.8\neases 11.16\nTelevision\noccupational health and safety 10.10\nhealth communication 8.13\ntobacco use reduction 3.14\nTetanus\npolicies to reduce minors' access to alcohol 4.16\nindigenous cases 20.1\nprograms\nimmunization 20.16\nscreening for genetic disorders 14.15\nTobacco (see also Tobacco section, page 95)\nsmall business safety and health 10.14\nabstinence during pregnancy 14.10\nprotocols to prevent suicide in jails 6.10, 7.18\ncessation counseling 3.16\nstandards\nchildren's exposure to smoke in home 3.8\nconstruction 11.12\ndiscussion in family 8.9\noccupational exposure 10.11\nprevention education 3.10\nfood operations 12.4\nproduct sale and distribution 3.13\nroadway environment 9.20\nrestrictions on product advertising and promo-\nsystems\ntion 3.15\nchild death review 7.13\nsmoke-free environment 3.9\nemergency medical service and trauma\nState plans for reduction of use especially among\nsystems 9.22\nyouth 3.14\ninfant referral to craniofacial anomaly\nTooth Loss (see Teeth)\nteam 13.15\nToxic Agents 11.7\nservices for children with or at risk of chronic\nTrauma\nand disabling conditions 17.20\nemergency medical services 9.22\nSteroids, Anabolic 4.11\ncumulative trauma disorders 10.3\nStress\nTuberculosis\nadverse health effects 6.5\nclinics addressing HIV infection and sexually trans-\nreduction and control 6.9\nmitted diseases 5.11, 18.3, 19.11\nreduction programs at worksite 6.11\nidentification programs 20.17\nStroke (see also Heart Disease and Stroke sec-\nincidence 20.4\ntion, page 112)\npreventive therapy 20.18\ndeaths 15.2\nTyphoid Fever 20.6\nSubstance Abuse (see Alcohol; Drugs)\nSuicide\nUltraviolet Radiation 16.9\ninjuries attempts by adolescents 6.2, 7.8\nUnicode Food Protection Code 12.4\nprevention in jails 6.10, 7.18\nUnintentional Injuries (see Injury)\nprotocols in hospital emergency rooms 7.12\nUniversities (see Schools)\nrates 6.1, 7.2\nUrinary Incontinence 17.17\nSun Exposure (see Ultraviolet Radiation)\nUrethritis, Nongonococcal (see Chlamydia\nSun Lamps (see Ultraviolet Radiation)\nTrachomatis Infection)\nSurface Water (see Water)\nU.S. Department of Health and Human Ser-\nSurgical Wound Infections 20.5\nvices 11.7\nSurveillance and Data Systems (see also Surveil-\nU.S. Preventive Services Task Force\nlance and Data Systems section,\nrecommendations 21.2, 21.4, 21.5, 21.6\npage 124)\ndata transfer systems 22.6\nVaccine-Preventable Diseases\ncomparable Federal, State, and local data 22.3\nreduction 20.1\nnational data sources 22.2\nVegetables\nnational process to identify gaps 22.4\ndaily intake 2.6, 16.8\nperiodic analysis and publication to measure\nViolent and Abusive Behavior (see Violent and\nprogress towards objectives 22.5\nAbusive Behavior section, page 100)\ntimely release of national data 22.7\nVision Impairment\nSyphilis\ndetection in children 17.15\ncongenital 19.4\ndetection in older people 17.17\nprimary and secondary 19.3\nprevalence 17.7\nprovider referral services 19.15\nWarts, Genital 19.5\n152\nIndex to Summary List of Objectives\nWaste\nWorksite\nsites, hazardous 11.14\nfood services 2.16\nsolid, exposure and production 11.8\npolicies\nWater\nalcohol 4.14\ndrinking\ndrug 4.14\nfluoridation 13.9\nhiring of people with disabilities 17.19\nsafety standards 11.9\noccupant protection systems 10.6\nsurface 11.10\nsmoking 3.11\nWaterborne Disease Outbreaks 11.3\nhealth promotion programs\nWeapons\nback injury prevention and rehabilitation 10.13\ncarrying 7.10\nblood cholesterol education 15.16\nhandguns 9.15\nblood pressure education 15.16\ninappropriate storage 7.11\nhealth and safety 10.12, 10.14\nrelated violent deaths 7.3\nhiring of people with disabilities 17.19\nWeight\nnutrition education 2.20\ngain during pregnancy 14.6\nparticipation by hourly workers 8.7\nloss 1.7,2.7\nphysical activity and fitness 1.10\nmanagement programs for employees 2.20\nproportion of worksites that offer 8.6\nWomen\nstress reduction 6.11\nclinical breast exam and mammogram 16.11\nweight management 2.21\niron deficiency 2.10\nWound Infection (see Infection)\npap testing 16.12\nphysical abuse by male partners 7.5\nYears of Healthy Life (see Quality-Adjusted Life\nprevention of osteoporosis 17.18\nYears)\nrape and attempted rape 7.7\nshelters 7.15\n153\nSuperintendent of Documents 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These entities are allowed a 25-percent dis-\ncount on any publication delivered to their normal place of business.\nHealthy Communities 2000:\nModel Standards (3rd edition)\n1991\nGuidelines for Community Attainment of the Year 2000\nNational Health Objectives\nHealthy Communities 2000: Model Standards is the guidebook for successfully\napplying the objectives set out in Healthy People 2000 at the community level. It\nis a practical tool for planning programs to prevent illness, injury, and premature\ndeath. It provides comprehensive goals and objectives to help health profes-\nsionals and leaders work cooperatively to improve the health, environment, and\nquality of life in their communities.\nSpecial Features\nPrepared by national professional organizations as a companion document for Healthy\nPeople 2000.\nProvides community implementation strategies for the Year 2000 National Health Objectives.\nIncorporates 10 years of field experience and testing of Model Standards.\nSpecifies goals, objectives, and indicators for the 22 priority areas contained in Healthy\nPeople 2000.\nOffers a Community Implementation section detailing the necessary services required to\nsupport effective public health programming.\nAllows communities flexibility in quantifying outcome and risk factor objectives and in\nprioritizing services based on their own needs and resources.\nMaintains the concept basic to Model Standards of the importance of government and\nthe \"residual guarantor\" responsible for assuring provision of preventive services through\ncommunity agencies.\nPlease send me information about obtaining the 3rd edition of Healthy Communities\n2000: Model Standards when it is published in 1991.\nName\nOrganization\nAddress\nCity\nState/Province\nZip\nCountry\nPhone ( )\nA collaborative project of:\nSend your request to:\nAmerican Public Health Association\nAssociation of Schools of Public Health\nPublication Sales\nAssociation of State and Territorial Health Officials\nAmerican Public Health Association\nNational Association of County Health Officials\n1015 15th Street NW.\nUnited States Conference of Local Health Officers\nWashington, DC 20005\nCenters for Disease Control, Public Health Service,\nAvailable Spring 1991\nU.S. Department of Health and Human Services\nENT DEPARTMENT OF HEALTH\nU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES\nPUBLIC HEALTH SERVICE"
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