Health for All: A Public Health
Vision* --- ------ --- -- --- ----
William H. McBeath, MD, MPH
Theme: "Forging the Future: Health Objectives for the Year
John MacBeath's Regimen Sanitatis
In the early 16th century, John MacBeath resided in the Hebrides off the west coast of Scotland where he was physician to the Lord of the Isles. There he compiled a Gaelic medical manuscript entitled Regimen Sanitatis, or the Rule of Health.1 His manuscript affirms that the first two rules of health are (1) it is right to guard the healthy state in healthy persons and (2) it is duty to foresee those going into unhealth. That's how they said "health promotion and disease prevention" in medieval times. The manuscript goes on to address several important aspects of contemporary Highlands practice, such as bloodletting and religious observance; but its main theme is healthful living, especially proper diet. One of its many aphorisms is "have a cheerful mind, a moderate diet, and take exercise." It includes a delightful Scottish morning health routine, which
goes: upon arising, one should * first stretch the arms and chest * expel the superfluities * wash hands, face, and eyes * rub the teeth * make moderate walking in high clean places * take food, after exercise
(I suppose it's a little "clannish" for me to refer to "Uncle John's" work, but after 400 years, he's otherwise not much cited.)
This year our annual meeting program theme is "Forging the Future: Health Objectives for the Year 2000." It is a rich theme, calling us to move forward boldly with both purpose and forcepurpose guided by the goals we define, and force arising from a commitment to shape the future that can be. It's been said that goals and objectives are descriptions of the future we desire.2 In future-oriented endeavors like disease prevention and health promotion, these targets can motivate action and give direction to interventions. This morning, let us consider together a bold vision for budding a great health future for the public and the goals we choose to describe it.
Envisioning the Future-2000 as Metaphor It is the nature of public health to search out the causes of "unhealth" in the community so as to prevent them, and to discern the determinants of health so as to promote them. Periodically, we make special concerted efforts to "foresee unhealth" that can be expected and to "guard health" that can be achieved. We plan ahead. William H. McBeath is the Executive Director of the American Public Health Association. Requests for reprints should be sent to William H. McBeath, Executive Director, American Public Health Association, 1015 Fifteenth Street, Washington, DC 20005. *This Convention Keynote Address and 15th Margaret Baggett Dolan Lecture was presented on October 1, 1990, during the Opening General Session of the 118th Annual Meeting of the American Public Health Association in New York City.
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Annual reports and 5-year plans abound. The close of each decade invites us to mark its passage with a review of past perfornance and a preview of future prospects; even more so the coming and going of a century. But now we sense the approaching of theyear 2000-a milestone of monumental symbolic importance. For years our imagination has been drawn to thoughts of "the 21st century." "2000" and "2001" have become metaphors for a nascent future of vast potential, emerging with dramatic possibilities for weal or for woe. In the imagery of biblical language, the dawning of a new millennium excites visions of a new and golden age of promise.3 And that apocalyptic literature also provides the motto on the APHA seal"and the leaves of the tree were for the healing of the nations."
Today's World Health Needs As this new epoch approaches, the nations of the earth are in great need of healing. * Tuberculosis is raging with 1.7 billion of the world's inhabitants now infected, 20 million with active disease, and 3 million dying annually.4 * Malaria is staging a comeback with 270 million cases in some hundred countries putting at risk about 40% of the world
population.4 * Throughout the world, at least 8 million people have HIV infection. More than half of these will develop AIDS within the decade. Nearly a half million are already ill with HIV disease.4 * In the developing countries, every minute six children under 5 years die and another six are seriously disabled from one of the six diseases that can be prevented by immunization: diphtheria, whooping cough, tetanus, measles, polio, and tuberculosis. That's three and a quarter million preventable child deaths a year. Another three and a half million such children die each year from acute diarrheathe largest single cause of death of young children.5 * Worldwide eradication of polio is technically possible by the year 2000, but 200 000 new cases are still being reported annually.4 * The killer diseases of western affluence are spreading, with cardiovascular disease and cancer now accounting, respectively, for 12 million and 5 million deaths annually worldwide.4 December 1991, Vol. 81, No. 12
* Unless global spread ofthe "brown plague" is reversed, 500 million persons living today will be killed by a single drug-tobacco.4 * WHO reports that if current trends continue, 200 million people may die prematurely from preventable causes in the 1990s.4 * At UNICEF's World Summit for Children, which is closing today in this city, reports indicate 15 million children under 5 die each year, most from preventable causes.
II. Prevention Renaissance of the 1970s There is reason to hope these trends will be improved, in part because of ambitious global efforts led by WHO and UNICEF,6 and in part because of a veritable renaissance of national prevention initiatives that emerged during the 1970s.
1974-Lalonde's A New Perspective on the Health of Canadians In 1974, the Canadian Minister of Health and Welfare issued a working paper entitled A New Perspective on the Health of Canadians. 7 It became a classic. While acknowledging the Canadian health care system as "the equal of any in the world," the Lalonde report drew attention to other determinants of Canadian health which were "of equal or greater importance." Health determinants were portrayed in the now popular "health field concept" with its elements of human biology, environment, life-style, and health care organization.
1974-1976-DHEW's Forward Plan for Health In the same year (1974) our US Department of Health, Education and Welfare published a Forward Plan for Health-FY 1977418 with the department's 5-year projection for health programming. The major theme or emphasis area of the plan was prevention.
1976-UK's Prevention & Health: Everybody's Business In British fashion, the government of the United Kingdom launched its prevention renaissance with a Parliamentary "white paper" on prevention, followed in 1976 by a popular health department document: Prevention and Health: Everybody's Business. 9
1978-CDC's National Strategy for Disease Prevention Back in the United States, the Centers for Disease Control
(CDC) was vigorously asserting its role as lead federal agency for prevention. In 1977, CDC published proportional allocations of the contributing factors of mortality to Lalonde's four "health field elements."10 This produced the often-cited observation that, in the United States, about 50% of premature mortality is deemed attributable to life-style, 20% to human biology, 20% to environment, and 10% to health care. The next year CDC published Recommendations for a National Strategyfor Disease Prevention, 11 which prioritized 31 important preventable health problems in the fields of environment, life-style, and medical services-in effect, predicting the outline of today's national health objectives. 1979- PHAP's Model Standards Earlier, CDC began collaboration with APHA and the national organizations of state and local health officials to develop "model standards" for communityoriented preventive health services. In local application, the standards take the form of quantifiable community-specific objectives for reducing present levels of preventable morbidity and mortality. The HEW secretary officially submitted the first volume of Model Standards to the Congress in 1979. CDC has continued support for the model standards work group to test, refine, and expand the standards. A second editionl2 was published by APHA in 1985 and is now in use in scores oflocal and state agencies across the country. A third edition of the model standards, entitled Healthy Communities 2000,13 will be published in a few months as the local implementation companion to Healthy People 2000.14
1977-WHO's Global Strategy for
Health forAll by the Year 2000 During this period, the prevention initiative of grandest scale was international.15 In 1977, the World Health Assembly resolved that "the main social target of governments and WHO in the coming decades should be the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life."'5'P15) A major means toward the attainment of this goal has been the promotion of primary health care, newly defined as "essential basic health services," made
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accessible to everyone, given in a way acceptable to individuals, families, and communities, requiring their full participation, and provided at a cost the community can afford. Essential health services were deemed to be basic environmental sanitation, adequate supply of safe water, promotion of proper nutrition, control of local endemic disease, health education, family planning services, maternal and child care, immunization against major diseases, and treatment for common diseases and injuries. Each WHO member state was invited to formulate "national policies, strategies, and plans of action" for attaining the Health for All 2000 goals, and many have. Particularly in developing countries these national plans build on the new "primary health care." Among developed countries, several governments demonstrating a heightened interest in prevention programming have adopted or adapted features from the Health for All 2000 movement. Although our US government supported initiation of the Health for All 2000 programs, over the last several years this country has violated its treaty obligations and withheld over $150 million of its basic dues to WHO. There is evidence the world health situation has been improving in recent years. For example, life expectancy has risen in the developing countries, now standing at almost 60 years (compared to 73.4 years in the developed countries). The proportion of the world's children receiving immunizations has grown from 5% to 60% during the last decade.
HI. Heal Pmmoion in the 1980s 1979-Swgeon General's Healthy People Today in the United States, a major stream of Public Health Service prevention activity flows from the 1979 surgeon general's report on health promotion and
disease prevention, entitled Healthy People.16 That report declared health goals for American infants, children, youth, adults, and elderly, and proposed 15 "actions for health."Healthy People became the basis and guide for expanded Public Health Service activities in health promotion and disease prevention throughout the 1980s. The centerpiece of that effort was to be the "national health objectives." 1562 American Journal of Public Health
1980-Promoting Health, Preventing Disease: Objectives for the Nation For 1990, there were 226 specific and quantifiable objectives deemed necessary to attain the goals established in Healthy People, covering all priority areas. They were published in 1980 as Promoting Health, Preventing Disease: Objectives for the Nation,17 and immediately began to draw both praise and criticism. Over time, the 1990 objectives gained wide acceptance and official standing within the health field, their value increasingly demonstrated by reference and use among public health professionals. Assessment at middecade18,19 showed that about half the objectives would probably be achieved by 1990, one fourth would probably not be achieved, and one fourth still could not be measured. * How shall we interpret such results? * Were some objectives set too high or too low? * Was the effort to achieve them sufficient? * For each objective, were the effects achieved proportionate to effort expended? * Were the best objectives chosen? * Were important objectives omitted? * In the end, was more disease prevented and better health promoted because these objectives existed?
IV. Health Objectivesfor the 1990-sHealthy People 2000 Pro: Suvival and Continuation That these initial objectives survived the difficult 1980s relatively intact is one measure of their success. So is the con-
tinuing interest and involvement displayed in preparation of the new national health objectives for the year 2000.
Pro: The Development Process Three years ago, the decision to advance to a second generation of decade objectives launched an arduous, multistage, deliberative process that included 22 expert working groups, regional and national hearings, and review and comment by a consortium of 300 national organizations, includingAPHA, several federal agencies, and all state health
departments. Regrettably, in a recent move that shows callous disregard for the consensus opinion of hundreds of professionals who
participated in that review process, key administration officials have arbitrarily deleted and diluted several important objectives from the review draft at the last moment, rather than displease powerful corporate interests and far right extremists. APHA has already petitioned the secretary to respect the professional review process and to restore objectives on gun control, family planning, and tobacco to their postreview wording. The development phase culminated earlier this month when the new objectives were introduced to the public at a national Washington conference called for that purpose.
Pm: Three Broad National Goals By most measures, Healthy People 2000: National Health Promotion and Disease Prevention Objectivesl4 is a major accomplishment with many positive attributes. Most notably, it begins with three broad national health goals for the decade: * increasing the span of healthy life for Americans * reducing health disparities among Americans * achieving access to preventive services for all Americans These are worthy goals, which deserve our support and should challenge our professional commitment.
Pmo: T7e Aura of Official Adoption Federal endorsement of these goals and objectives lends importance to them as national priorities. The whole objectives process and the resulting document will raise professional and public consciousness of important national health needs.
Pro: Succinct and Tangible Plew of Problems For the year 2000, there are 298 unique objectives in 22 priority areas, showing a balance between outcome and process measures. The brevity and clarity of most objectives give a concrete reality to health problems and potentials and will equip various publics to appreciate and embrace prevention goals.
Pm: Tool for Health Program Development The broad range and targeted nature of the objectives provides an important tool for program development by providing national validation of local effort and for program evaluation by providing com-
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parative measures to justify support, to monitor progress, and to revise course if indicated.
Pro: Continuing Platform for Public
Accountability Assurance of a second cycle tends to institutionalize an ongoing objectives process that will remain open for continuing dialogue. This will encourage and equip public accountability by providing reference standards for affirming or challenging governmental plans and actions. Because they are goals for the nation that is APHA's home, and because they are being made public so close to this meeting, you can expect to hear much analysis and criticism of Healthy People 2000 throughout this week. Sessions will probe the special interests of each APHA section, and subplenary special sessions will afford a rare opportunity for all of us to be oriented and challenged. Also remember that APHA is not only this annual meeting; it is your collective professional presence throughout the year. In the months ahead, our Program Development Board will be undertaking a more definitive review of Healthy People 2000, with all APHA components participating. Because Healthy People 2000 is so big and so new, most comments on the objectives will have to await more deliberate review; but it is already clear that Healthy People 2000 will be an imperfect guide for forging the health future in the next decade.
Con: No Action Implementation Plan It has been said that perfection of means and confusion of goals characterize our age. Healthy People 2000 can claim to clarify our confusion of goals, but it contributes little to a perfection of our means. Wanting is an action plan for implementation to achieve the goals and objectives set. The document seems to draw us a picture of the "Emerald City," but never shows us a "yellow brick road." The objectives themselves deserve more. They deserve clear delineation of actions required to achieve them; and they deserve careful projection of the resources and collective effort required to support them. Compared with other national prevention plans mentioned earlier, Healthy People 2000 must be given a grade of "incomplete" because it lacks a coherent implementation scheme or action agenda. In 1974, the Lalonde report closed with 74 specific proposals for national gov-
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emmental action in health promotion, regulation, research, health care, and goal set-
ting. Fifteen years ago, during the Nixon administration, DHEW's Forward Plan for Health8 proposed 83 specific "options for action"-over half of them in the categories of "legislation, enforcement, and regulation," and "social and economic incentives." That Fonvard Plan revealed a stronger leaning toward assertive governmental action for health than can readily be discerned in departmental pronouncements of the 1980s.
CDC'sNationalStrategyforDisease Prevention"1 in 1978 recommended 115 major steps for intervening on high priority health problems. Almost all of them called for governmental implementation actions by CDC with other federal, state, and local health agencies. The potential of Healthy People 2000 is sold short by the Administration's timidity to address the tough issues involved with implementation. In a 672-page document, no space is found to call for increased funding. It may be said that was not the intent of the objectives process. If so, our federal health leadership owes us a corollary effort immediately. As it stands, Healthy People 2000 may be filled with good stuff; but it is a cup half empty. Con: Overemphasis on Individual
Responsibility A second major problem with Healthy People 2000 is its pervasive overemphasis on individual responsibility for health. Since Lalonde popularized the term "life-style" in referring to the health effects of human behavior patterns, many have reinforced and compounded the erroneous assumption that personal behavior is largely subject to voluntary control by individual choice. Of course, the major fallacy in that assumption is that one's life-style is always heavily influenced by one's life situation. As public health people, we know better, and we must say so. To a large extent, health depends on the political, social, cultural, economic, and physical environments in which we live. These environments can and do limit the health choices open to any of us, and
they are increasingly influenced by public policy and corporate practices which control or promote products that damage health. For many, their life environment does not encourage capacities nor afford opportunities for adopting healthy lifestyles. If you
have decent air to breathe, live in a low-crime neighborhood, have a meaningful job with adequate pay, work in a safe environment, have money to choose good food and time to enjoy preparing it, can afford to take vacations, have a safe place for your children to play,
enjoy life and look forward to the future; then (maybe) you can choose health.20 Millions of Americans have no such choice. Certainly individuals have a duty to act in the best interest of their own health, but we also share a community obligation to act collectively for the health of all. The latter is largely ignored in most health promotion efforts in this country today.
Con: An Abrogation of
Governmental Responsibility in Health "While interest (in prevention) is higher and commitment greater than it has ever been, the organization of public resources to prevent the dependency associated with disease and injury has not met the challenges of the end of the twentieth and the beginning of the twenty-first century. "2l(p95) One thing is clear, in this country we have seen a broad scale retreat of government from public health over this period. One status quo ante underlying Healthy People 2000 is neglect of support for America's public health infrastructure. Although state and local health departments are called upon to help reach the objectives, their limited resources and budgetary needs are ignored. This silence only encourages the continuing erosion of local public health support in this country. An ambitious initiative led by the Association of State and Territorial Health Officials intends to tie the year 2000 objectives to a new federal/state program designed to attain them. The Health Objectives 2000 Act will fund disease prevention and health promotion programs aimed at priority objectives of states and localities. Is it coincidence that over the last 15 years national prevention initiatives emphasizing individual responsibility have paralleled the rise of conservative governments seeldng to reduce public expenditures and privatize, even commercialize, the delivery of health services, e.g., in Canada, the United States, and the United American Journal of Public Health 1563
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Kingdom? In a time of rising health care costs and tight budgets, it may seem cheap and expedient for governments to "blame the victims" by preaching individual lifestyle change. It certainly would be more demanding to adopt "healthy public policies" that make "the right choices, the easy choices." It's also clearly more expensive in the short run to adequately fund health service programs.
Elsewhere: A New Health Promotion and the New Public Health" In parts of Canada, Great Britain, and Scandinavia, governmental and private groups are repenting of exaggerated stress on individual life-style, and embracing an expanded concept of health promotion.22 It emphasizes active public participation in the adoption of multisectoral healthy public policies to create supportive environments that potentiate the determinants of health.23,24 The result is health promotion affirming a community life-style that makes "healthy choices" the "easy choices." This new public health recognizes that most influences on health lie beyond the reach ofmedical care and public health education.25 It redirects our energies to the importance of policies that promote public action toward improving the several aspects of ordinary daily life that are the real precursors to health.
V. Health Prio,itesfor the 21st
Centuy Some have expressed disappointment that no definitive national priorities were advanced from among the objectives for 1990 or 2000. The broad participation of so many specalized interests in developing this inclusive list of objectives would have made it difficult to reach consensus on a few ranked priorities, even if that had been an intended outcome of the process. (APHA, with its diverse interests and multiple intentions, has a similar problem.)
Top Ptiority: Health Equity But the absence of priorities invites others to propose their own. I believe our top priority in the decade ahead, as an association, as public health professionals, and as a nation, must be the pursuit of health equity. The WHO constitution says: "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, 1564 American Journal of Public Health
economic or social condition."26(Pl) It's been over 40years since the United States signed that treaty. Still, for too many Americans, that "fundamental right" is today an empty phrase, a false hope, and a broken promise. In the decade ahead we must move vigorously to make health a fundamental right in this country, and not a fundamental wrong. Remember that one of the three broad national goals espoused by Healthy People 2000 is to "reduce health disparities among Americans." We also commend the way it assesses several health disparities by income level, educational attainment, and race and ethnicity, and sets special population targets for several objectives. It is left for us to proclaim these health gaps as an indictment against our society-and declare our determination to address this intolerable injustice which somehow we continue to tolerate. The topic for this year's national Delta Omega essay contest is "Public Health as Social Justice." If public health is social justice, we must dare to dream of equity in health by the 21st century. All human beings must be assured equal access to health opportunity. The present inequalities in group health status are unacceptable because they largely reflect unbearable social inequities in the distribution of food, housing, education, employment, income, and medical careinequities that are inexcusable in an affluent, democratic society. They must be redressed as fast and as far as possible.
Piority: A National Health Program Few will be surprised that Healthy People 2000 did not call for a national health program with universal coverage and comprehensive benefits; but no one should be surprised that such a program is a primary APHA objective for this decade. We want a national health program for everyone-one that responds to individual needs, emphasizes prevention, and does not discriminate.27 We will seek no less, and we want it now. As time passes, Medicare pays for less, Medicaid covers fewer people, private health insurance costs more, and increasing millions of Americans still have no health care protection at all. Shame on any member of Congress who runs on special interest money, bails out S&L crooks, and then freezes out support for decent health care. To its credit, as another of its broad
national goals, Healthy People 2000 seeks to "achieve access to preventive services
for all Americans." That very desirable
goal and its related objectives specifically call for the financing of services recommended by the US Preventive Services Task Force.28
Assuring that all Americans receive all the clinical preventive services they need would truly be a major achievement. While the objectives don't say how that can be accomplished, the only rational scenario is inclusion of such services within the comprehensive benefits of a national health program with universal eligibility-or, as APHA puts it, "health care for all of us." Let's exploit this goal in our fight for national health care reform.
Pniority: Access to Better Living Standards Our concerns for equity will not let us slacken our efforts until all share unfettered access to quality health care based on need. It is inexcusable for Americans still to be denied essential medical care because they lack money. But removing barriers to care will not, by itself, bring health. As professed experts on the determinants of health, we know that personal health services are an essential, but marginal contributor to improved health status. Recently, a sequel to the noted Black Report in Great Britain dramatically demonstrated that after decades of universal access to health services, health inequalities not only persist, but are increasing.29 We must assure access, not only of medical care, but also to a better standard of living-assuring nutritious food, basic education, safe water, decent housing, secure employment, and adequate income-these are the prerequisites of a healthy life-style.
V. CAll to Learshiq The most pervasive risk factor for disease and injury in America today is poverty. How can we launch and sustain the massive effort needed to prevent the diseases of poverty, and to promote health among the disadvantaged? Answer: We must prod our governments, especiaLly the federal government, to give priority to this crisis.
Leadeship by Governmts To quote again from the WHO constitution: "Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures. "26(p') More recently the Institute of Medicine's
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Committee on the Future of Public Health has found that one core function of public health agencies at all levels of government is to assure their constituents that necessary health services are provided.30 We look particularly to our federal, state, and local officials for leadership in flfilling all the essential functions: assessment, policy development, and assurance.
Leadershi by Public Health Professionals Whether employed in the public or private sectors, each of us as public health professionals owes a dual responsibility to scientific validity and to social advocacy, employing both technical and political skills in the fight against poverty. Margaret Dolan, for whom this annual lectureship is named, was just such a committed professional-as nurse, teacher, administrator, and organizational leader. She was complete scientist and consummate advocate. She, and others like her who have served with distinction in the leadership of this Association, would call us to develop a new vision of health for all and to shape tomorrow's world for its fufilfmnent.
Leadeship by APHA APHA cannot be satisfied with simply calling others to lead. Our own constitution calls for the Association itself to "exercise leadership with health professionals and the general public in health policy development and action, with particular focus on the interrelationship between health and the quality of life." In exercising such leadership we usually rely upon the authority inherent in professional expertise. Does our expertise prepare us for this mission? Achieving optimal health for all our people will require strong political will and broad public consensus that such a goal should, can, and will be achieved. Most of us will have to develop political skills now lacking if we are to mobilize constituency support and influence social policy for such a cause. Let's do it together. APHA pledges to be a faithful advocate in this cause. Come join in.
VH. Clsin Vlsion In closing, I paraphrase a pledge from the European Targets forHealth forAl3l as a health vision deserving of this Association, of our public health profession, and of the American people. * We shall seek to forge a futurewith all being born healthy to parents who
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want them and who have the time, the means, and the skills needed to bring them up and care for them properly. * We shall seek to forge a futurewith all being educated in societies that endorse the basic values of healthy living, encourage individual choice, and allow it to be exercised freely. * We shall seek to forge a futurewith all being assured the basic requirements for health, and being effectively protected against disease and accidents. * We shall seek to forge a futurewith all living in a stimulating environment of social interaction, free from the fear of war, with full opportunities for playing satisfying economic and social roles. * We shall seek to forge a futurewith all growing old in a society that supports the maintenance of their capacities, provides for a secure, purposeful retirement, offers care when care is needed, and finaLly allows them to die with dignity. By working together, we shall achieve such a vision, and future generations will rise up to call us "blessed." O
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