The future of public health: prospects in the United States for the 1990s.

Annu. Rev. Public Health 1990.11:1-29. Downloaded from www.annualreviews.org Access provided by 74.15.55.149 on 01/23/15. For personal use only.

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Annu. Rev. Public Health. 1990. 11:1-28 Copyri/?ht © 1990 by Annual Reviews Inc. All rights reserved


THE FUTURE OF PUBLIC HEALTH: Prospects in the United States for the 1990s Lester Breslow Health Promotion/Disease Prevention Center, University of Califurnia, Los Angeles, California 90024- I781

INTRODUCTION In its 1988 report,

The Future of Public Health, an Institute of Medicine

(10M) Committee noted "a growing perception ...that this nation has lost sight of its public health goals and has allowed the system of public health activities to fall into disarray" (16). The system of public health in the United States was designed mainly to cope with the epidemics of acute communicable disease, endemic tuberculo sis, and unacceptably high levels of infant and maternal mortality that prevailed during the latter nineteenth and early twentieth century. These problems were due largely to gross lack of sanitation, including fecal con tamination of water and food; crowding; and poor public understanding of basic hygiene. In response, many states and local jurisdictions developed health de partments to protect people against these severe threats to health.With strong support from legislative bodies, as well as technical and financial support from the federal government, state and local boards of health guided their activities. The departments established laboratories and epidemiologic ser vices for investigating the most pressing problems; adopted regulations, including measures of enforcement, for controlling environmental hazards; initiated public health nursing, maternal and child health and other personal health services; and undertook public health education. The formerly high rates of disease and mortality, which typically occur in developing industrial societies, have been vastly reduced through specific public health activities as well as improvements in the general level of living.

0163 -7 525/90/0510-000 I $02.00

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Meanwhile a new set of health problems emerged : epidemics of cancer, heart disea se , and other chronic diseases; how to dispose of toxic wastes from an expanded chemical industry; teen-age pregnancy, with its associated repro


ductive and disease consequences; care of the elderly; substance abuse; and

others . In these new circumstances, the governmental agencies t hat had been founded to deal with previous health priorities suffered two blows. On the one h and , their activities were curtailed because the concerns they were address ing had declined substantially; and on the other hand, they were deemed inadequate to confront the current challenges. Health departments commonly were merged with social welfare agencies, where the public health functions were neglected in favor of income maintenance and other welfare need s . In responding to the present and growing hazards t o health, the national and state governments did not turn to the infrastructure t hat had been effective against the earlier set of problems. Instead, legislators created new, separate agencies, apart from the established health departments , for environmental protection, occupational safety and health, water quality control, air pollution c ontrol, indigent medical service, and other health-related purposes . That fragmentation of public health function, the failure to maintain a coherent thrust against the major health problems of the day, left both the general

public and public health personnel bewildered concerning the role of public health. As the Chairman of the Institute of Medicine Committee on the Future

of Public Health stated , "there has been a growing sense t hat public health, as a profession, as a governmental activity, and as a commit ment of society is neither clearly defined , adequately supported, nor fully understood" ( 16). Complicating this situation were two kinds of tension between public health and the world around it, one long-standing and one fairly recent.The histori

medical practit ioners flared again as health leaders ventured to tackle some new problems. For example, many private practitioners regarded the chronic diseases as their exclusive domain for an individual-patient approach; accordingly, they resisted com munity-organized screening for cancer. Politicians also encountered d ifficul cal distrust of public health by private public

ties with public health officials. Many of the latter maintained in effect that

they alone possessed the competence to make decisions about community health matters and they merely needed funds to do the job as they saw it. Polit icians, however, spurred by highly publicized health crises, such as the probl em of providing medical services, commonly found their health officia ls to be aloof and defensive about their role, unwilling to enter into the dynamic processes of the "real", that is, the politica l , world. Reflecting on this uncertainty concerning the purpose of public health and

the tensions surrounding it , the 10M committee adopted a broad view of the field . It d id not limit its consideration to the current problems and conceptions


THE FUTURE OF PUBLIC HEALTH

3

about them . The committee defined the mission of public hea lth as "fulfilling society's interest in assuring conditions in which people can be healthy" ( 1 6 ) . Those conditions include a wide array: the physical circumstances o f life such as the pre sence of toxic chemicals and microbiologic agents of disease in a ir, water, and food; psychosocial influences on people's health-related behavior, such as education, advertising, and regulations pertaining to alcohol and cigarettes; and access to medical services . Public health must seek to ensure that all such conditions favor the health of people . It may do so in a variety of ways: by encouraging action of others in both public and private sectors; by regulation requiring action; and by providing direct services. Obviously, in the United States, the public health mission must be pursued at the federal, state , and local levels of government. The states, however, constitutionally carry the primary public responsibility for health protection. Their dutie s , according to the 10M committee , should include monitoring of health and conditions affecting health; adoption of legislation governing health-re lated activities; setting objectives for health; delegating authority to local jurisdictions to assist in achieving these objectives and supporting them in fulf illing their local missions (if necessary, by direct action to overcome inadequacies); assuring personal , educational , and environmental health ser vices; and leading in the development of resources and services for health advancement. Although many Americans in recent decades have looked to the federal government for the solution of e ssentially all health problems, the federal public health role is mainly to support the states. Sometimes the states lack the power or otherwise fail to fulfill the public interest in health, for example , in providing access to medical services; in protecting against the interstate spread of communicable disease or environmental pollutants; and in assuring safe food and drugs for shipment among states . Then the federal government must undertake direct responsibility for "assuring conditions in which people can be healthy." In general, however, the federal responsibility in public health is to formulate nation-wide health objectives and to stimulate attention to them; to provide technical and financial assistance to states that will facilitate the development of resources and services aimed at achieving these objectives; and to adopt health-relevant regu lations, e specially concerning interstate commerce . Technical assistance includes federal support of research and education designed to find and disseminate knowledge for dealing effec tively with health problems. Local governmental jurisdictions in the United States vary so much in size , nature , a nd the popUlation served that specifying their public health roles is d ifficult. For the most part they function as arms of the state . No person, however, should be beyond the reach of essential public health protection. Clear delineation of local authority for public health is necessary. For ex-


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ample, there should be no overlapping of responsibilities between countie s and the cities i n them. Jurisdictions with larger populations obviously may be able to offer a fuller array of services. It is often appropriate for rural areas to join in multicounty units in order to ensure that at least minimum services are provided in a practical manner. Whatever the locale, however, the public health system should extend to all residents. State legislative bodies, schools of public health, associations of public health personnel, and others concerned with the future of-public health are now examining the 10M report and its recommendations. For example, the report was a considerable factor in the reestablishment of a separate depart ment of health by the state of Washington. Associations of public health professionals in various states are conducting conferences on the 10M report and its implications for their activities . Schools of public health are consider ing how to strengthen their relationships with state and local health de partments, for example , by offering training to personnel already in the field, giving students greater opportunity for participating in the work of health departments, and encouraging faculty to undertake professional responsibil i ties in public health . It now appears that the 10M report may have a substantial impact o n what happens in public health during the 1990s. TRENDS IN MORTALITY AND MORBIDITY DURING THE LATTER HALF OF THE TWENTIETH CENTURY Whereas pneumonia, tuberculosis, and diarrheal disease topped the list of causes of death in 1 900, five decades later these conditions did not appear in the first rank. Heart disease, cancer, and stroke had taken the leading places, responsible for two thirds of all mortality. Further more, during the second half of the century , the sharp decline of the formerl y leading causes of death-along with diphtheria, typhoid fever, scarlet fever, and other acute communicable diseases-has continued. Im proved sanitation. immunizing agents, and antibiotics have been remarkably effective. One of the most exciting sentences in public health literature could be written, " Smallpox was an acute exanthematous, communicable disease caused by variola virus" ( 14). Poliomyelitis had largely yielded to its vaccine, and eradication of that disease was beginning to appear on the public health agenda. Tuberculosis, which had caused more than 1 0% of all deaths in 1 900, was responsible for less than 0. 1 % before the end of the 1 980s (25). The Centers for Disease Control of the Public Health Service even published "A Strategic Plan for the Elimination of Tuberculosis in the United States" (8) . Paralleling these advances, infant mor tality dropped from more than 1 00 per 1000 births in 1900, to 29 by 1 950, and down to 10 by the l ate 1980s (25) .



5

Maternal mortality was falling even more steeply; it declined 80% in the 1 920s following passage of the Sheppard-Towner Act in 1 92 1 , and further from 83 per 1 00,000 births in 1 950 to 7 in the late 1 980s (24). Another important phenomenon has occurred. Although the principal epidemics of chronic disease rose to peaks during the third quarter of the century, some have already begun to recede. These chronic disease epidemics constituted, after communicable disease control, the most striking feature of health thus far in the twentieth century. The principal severe manifestation of coronary heart disease, coronary thrombosis, was described in the United States only in 1 9 1 2 ( 15). Thereafter, the frequency of that condition rose rapidly. In the early decades of the century it struck particularly more affluent, white men. At mid-century the disease was still quite rare among Black men. Subsequently, however, coro nary heart disease extended through all social classes. At its peak in the 1 960s, that condition accounted for one-third of all mortality in the United States (20). Thereafter, the age-adjusted death rate from coronary heart disease, which had been increasing for several decades, began to decline precipitously . That downturn has continued for more than 20 years at the rate of about 2 .0-2.5% annually. Age-adjusted mortality from cerebrovascular disease, the other major form of cardiovascular disease, had been decreasing for some years; acceleration of the fall started in the 1 960s, and the more rapid decline has continued. So striking was the drop in mortality from such a major cause of death as coronary heart disease that the National Heart, Lung and Blood Institute called a conference in 1 978 to examine the matter (42). Epidemiologists attributed the decline mainly to risk factor modifications, especially lower blood cholesterol, less cigarette smoking, and better blood pressure control . C ardiologists, on the other hand, were inclined to give more of the credit to improved management of patients with the disease . C ancer as a cause of death likewise increased sharply, both absolutely and relative to other diseases, during the first part of the century. Since 1 950 the cancer mortality rate has risen more slowly, but mortality from all other causes combined has been falling. Thus whereas one seventh of the age adjusted death rate in the United States during 1 950 had been due to cancer, the proportion climbed to one fourth by the late 1980s (24). Examination of the ages of people and body sites affected, however, provides insight into the cancer trend. Progressively from the younger ages , cancer mortality has been declining since 1 950. The overall increase in cancer deaths has been due almost entirely to lung cancer. That form of malignancy affects mainly persons over 60 years of age, but it is responsible for more than one fourth of all cancer deaths . By 1 970 even lung cancer mortality began declining among persons up to 44 years of age, and in 1 980 up to 54 years . Thus it appears that


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BRESLOW

the cancer epidemic, like the cardiovascular disease epidemic, is coming under control, though not as rapidly (5). The reversal of the major chronic disease epidemic curves during the third q uarter of the century reflects both changes in the risk factors-particularly the decline in cigarette smoking, improved control of blood pressure, and probably the lower cholesterol levels-and application of improved technolo gy for d iagnosis and treatment. Knowledge of how to m inimize coronary heart disease, lung cancer, a nd other important chronic diseases has come through the "second epidemiologic revolution" (4 1 ) . The latter has d isclosed the causative factors of the current major fatal d iseases and opened the path toward preventing them. The reorientation of health action toward emphasis on chronic d isease prevention has been termed the "second pub lic health revolution" (27). Although the age-adjusted death rate from chronic diseases has b een declin ing, their burden on the population continues to grow because a higher proportion of people are living into the middle and later years of life when card iovascular disease, cancer, and other chronic conditions take their major toll. This phenomenon does not mean, however, that the chronic d iseases are "degenerative," inevitable consequences of an aging population. It merely reflects two circumstances. First, the f actors causing the chronic diseases typically require many years to exert their eff ects, a nd hence these effects lend to appear late in life. Second , more people are now surv iving into the years when the consequences of exposure to the risk factors occur. Thus, for example, people who consume fat excessively must live severa l d ecades before atherosclerosis appears and possibly lead s to card iovascular death. A person who begins smoking cigarettes in early adolescence carries a much increased risk of dying from lung cancer, but that risk shows itself almost entirely after age 40. The chronic conditions that fatally affect people in the f ifth and later d ecades of life hence hav e becom e more prominent because of three phe nomena: (0) the decline of communicable d iseases; (b) wide exposure to tobacco, excessive use of alcohol, excessive f at consumption, and too little physical exertion; and (c) extension of life into the years when the risk factors will have done their damage. High rates of cirrhosis of the liver, d iabetes , and chronic obstructive lung disease as well as cancer a nd the card iovascular d iseases come about largely as a consequence of years of exposure to con ditions beyond the capacity of many humans to withstand. The extent to which life has lengthened is often presented as the proportion of the population above 6 5 years, now more than 12% . Also deserving emphasis in that connection is the increasing life expectancy beginning at age 65. Half the people who reach that age now live beyond age 82. Whereas d uring the f irst six decades of the twentieth century only about 1 0% of the

THE FUTURE OF PUBLIC HEALTH Table 1

7

Life expectancy at birth and at 65 years of age,

United States, selected years, 1900--1985 At birth 1900

47.3

1960

69.7

Gain

At 65 years 11.9 14.3

2.4 years

22.4 years 1985

Gain

16.7

74.7 5 years

2.4 years


Source: Ref. (24).

gain in life expectancy from birth was achieved during the years beyond 65, during the period 1 960- 1985 almost half of the gain occurred after age 65 (Table 1 ) . In fact , the most rapidly growing segment of the population now consists of persons over 85 years of age. Population growth in the upper reaches of life has stimulat ed debate on the potential life-span of man, that is, the highest age that can ever be attained. The highest on record is now 120 years (23) . Debate is also extend ing to average life expectancy, that is the age attained by half the popul ation ; and to the maxim um life expectancy, the age that half the population may ultimately be expected to reach (13). Satisfaction with past achievements in health, especially in reducing mortality, must be restrained . Three elements of the situation continue to be t roublesome: (a) persisting morbidity from non-fatal as well as fatal con d it ions; (b) failure to overcome the gap in hcalth betwecn the morc favored and the less f avored portions of the population; and (c) the emergence of new health problems . Arthritis and other musculoskeletal d isorders, though rarely fatal, are responsible for a substantial amount of d isability and pain , especially d uring the later years of life. Also, many people survive heart disease and stroke but remain incapacitated to a greater or lesser degree . Leading causes of activity limitation from chron ic conditions appear in Table 2 . Although frailty will continue to be a problem in the decades ahead, the outlook is not totally dismal. One analysis, for example, ind icates that "on average, older in d ividuals will be living more comfortable and functional lives as well as simply longer ones" (45). The extreme discrepancy between health of the affluent and health of the poor continues to disgrace America. Blacks with 12% of the population and Hispanics with 7 % constitute the two largest racial/ethnic minorities, and a large proportion of the poorest people, in the United States. In 1 984, 34 % of Black household s were below the poverty level, 15% of Hispanic households, and 12 % of white (30) . The actual extent of poverty in the Hispanic popula-

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BRESLOW Table 2

Limitation from chronic conditions, United States adults, 1979-1980". Conditions 1000 population. Average annual rateb

causing limitation in major or secondary activity, per


Rank

Men 45-64

Women 45-64

J. Diseases of heart, 59.4

Arthritis, 59.0

2. Arthritis, 36.2

Diseases of heart, 38.2

3. High blood pressure, 26.5

High blood pressure, 33.9

4. Def.!orth. impairment-back 25.lc

Def.lorth. impairment-back 22.0c

5. Other musculoskel. disorders, 23.9d

Other musculoskel. disorders, 21.4

6. Def.!orth. impair.-lower extrem., 20.4

Diabetes, 17.2

7. Diabetes, 14.8

Def.lorth. impair.-Iower extrem., 13.9

8. Arteriosclerosis, 14.1

Arteriosclerosis, 9.8

9. Emphysema, 13.4

Malignant neoplasms, 9.6

10. Visual impairment, 8.9

Asthma, 8.4

I I . Other respiratory disease 8.5e

Mental symptoms, 7.9

12. Paralysis, 8.0

Other digestive disease, 6.5

Men 65+

Women 65+

1. Diseases of heart, 135.0

Arthritis, 143.1

2. Arthritis, 82.4

Diseases of the heart, 93.2

pressur e , 65.3

3. High blood pressure, 46.5

High blood

4. Emphysema, 39.0

Diabetes, 30.7

5. Arteriosclerosis, 34.9

Def./orth. imp.-Iower extrem., 29.7

6. Visual impairment, 31.1

Visual impairment, 29.6

7. Diabetes, 27.7

Arteriosclerosis, 25.5

8. Def.!orth. imp-lower extrem., 25.1

Def.lorth. impairment-back, 20.5

9. Cerebrovascular disease, 24.5

Other musculoskel. disorders, 17.2

10. Paralysis, 21.0

Cerebrovascular disease, 15.0

11. Other musculoskel. disorders, 18.4

Paralysis, 12.4

12. Def.!orth. impairment-back, 18.0

Malignant neoplasms, 12.4

Source: unpublished tabulations from the National Health Interview Surveys, a

Ref. (45).

1979-1980.

hThere are 53 disease and impainnent titles that encompass all chronic conditions in the International

Classification of Diseases. Major activity is job or housework; secondary activities are clubs, shopping, church attendance, etc.

For

major activity limitation, men are asked about jubs; women are asked about

their usual activity Gob ur housework) in the past year. All rates shown here have luw sampling errur (relative standard error under 30%).

'Deformity or onhopedic impairment. d

Excludes anhritis.

e

Ex.cludes chronic bronchitis. emphysema. asthma. hay fever without asthma, and chronic sinusitis.

tion , however, is greater than is indicated by these statistics , since the n umber of Hispanic persons per household is substan ti ally larger than among Blacks and whites. Hispanics also had the lowest educational level; less than half had completed high school, compared with 79% among Blacks 25-34 years of age and 87% among white s the same age . Infant mortality in 198 3- 1985 was 9 . 5 among whites but 18 .6 amon g Blacks in the United S tates (24) . Life expectancy in 1986 was 65 years for Black men and 74 years for women, contrasted with 72 and 79 years among



9

white men and women, respectively. Socioeconomic circumstances are pre sumably the major factors in these differences, but cultural factors may also be involved. By 1975 the formerly m ajor communicable di seases were under or coming under control, and some of the important chronic and noncommunicable diseases, especially the cardiovascular diseases, were also coming under control. The next few years , however, were to bring new form s of traditional diseases and even somc new diseases. The emergence of AIDS has been the most disastrous health event in the 1 980s . First recognized in 1 981 , reported cases of that disease totalled 82,764 as of 31 December 1 988 (9, 22) . Of these, 32 ,3 11 were reported in 1 988. It appears that in the United States, the peak of transmission of the human immunodeficiency virus (HIV ) may have been reached. An increasing annual number of deaths m ust be expected for the next few years , however, because of the extremely high fatality rate some years after infection with the causative agent. Estimates of the number of infected persons have ranged as high as 1 .5 million , but these estimates have recently been declining. Concentrated in the southern and coastal states, the disease has affected most severely B lack and Hispanic men . Although most cases thus far have occurred among homosex ual men , the proportion of cases among both male and female intravenous drug users has been increasing while transmission of the infection among male homosexuals has slowed remarkably. A much smaller number of cases has resulted from blood transfusions , and that mode of infection has dropped sharply . More than a thousand cases have been reported among children , most of them presumably infected perinatally from their mothers . Heterosexual transmi ssion of HIV in this country has been low, although in some other countries that appears to be a common mode of infection. From experience throughout the 1980s it appears that AIDS in the 1990s will continue to cause tens of thousands of deaths annually, unless an effec tive means of treatment is discovered . Also of great concern is that although the epidemic spread appears to be declining especially among male homosex uals, endemicity has been established in that group and, perhaps what is even m ore important for the future , among intravenous drug users. Furthermore, the political constituency formed by white m ale homosexuals to combat the epidemic in the 1980s may not continue to be so effective when awareness spreads that B lack and Hispanic intravenous drug users are becoming the m ain victims. A new pneumonic disease appeared in explosive form among persons attending an American Legion convention in Pennsylvania during the summer of 1976 ( 12). Named after its first victim s and caused by a gram-negative bacterium , Legionnai re's Disease has occurred throughout the United States and on four other continents. O utbreaks typically strike people who are

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BRESLOW

resident in certain hotels, hospitals, and other buildings. The causative organ and other apparatus used for cooling buildings, especially in stagnant water. Spread appears to be airborne.

ism can often be recovered from the evaporation

Toxic shock syndrome, characterized by fever, hypotension, myalgia, and a rash, is due to S.

aureus (35). The condition gained notoriety in 1979 when

the use of tampons, especially one brand of tampons, by young menstruating

women was identified as the source of the infection. After the removal of the from the market and the decline in use of tampons general ly, the outbreak receded, though cases have continued to occur, some in Annu. Rev. Public Health 1990.11:1-29. Downloaded from www.annualreviews.org Access provided by 74.15.55.149 on 01/23/15. For personal use only.

particular product

association with cutaneous infections.

Lyme disease is still another infectious condition recognized in recent manifested by fever, arthritis-like symptoms, and an erythema surrounding the tick bite, was first identified in Lyme, Connecticut in 1977 (39). Since that time it has been noted across the United States, including the western states. Infection occurs

years. This spirochaetal disease, spread by ticks and typically

mainly through ticks attaching themselves to people moving through tall grass where the insects abound. Besides several distinctive infectious conditions that have appeared recent ly, a host of new diseases caused by environmental agents is being recog nized. Perhaps the outstanding example is asbestosis (36). This condition, characterized by fibrotic destruction of the lung tissue and air space, arises particularly among men exposed occupationally to asbestos. Generally the disease affects workers many years after exposure, causing dyspnea and

sometimes death. In addition to its toxic effects on the lung, asbestos may also induce malignant change, particularly in the form of highly fatal mesothe lioma. Although first noted during the early part of the century among asbestos miners, the disease also strikes others exposed to the substance, for

example, shipyard workers and those who encounter it in insulation and brake materials. More recently concern has extended to residences, schools, and

other buildings in which asbestos was used during construction. Advances in the chemical industry have brought many workers engaged in the manufacture of organical solvents and other substances into contact with highly toxic materials (19). Use of these materials in workplaces has exposed still more, and the hazard has extended to household and other users of products involving these chemicals. Adverse effects on the liver, kidney,

bone marrow, and nervous system have been well defined. Pesticides con stitute another class of chemicals in widespread use to which serious adverse health effects have been traced. The emergence of new diseases and health conditions again emphasizes the need for a strong core public health capability, prepared to identify quickly new health threats and to formulate effective control strategies.

In summary, tremendous strides have been made during the latter half of


11

the twentieth century against premature mortality, particularly from the com municable diseases. The tide also seems to be turning against the major chronic noncommunicable diseases. Gratification with those advances is mitigated, however, by persisting morbidity, by the continuing gap in health between the affluent and the poor, and by the advent of new diseases.


ISSUES AND PROSPECTS FOR THE 19905 At least five major issues in public health will require attention during the 1990s: 1. Will public health be functionally and structurally reconstituted into a coherent pattern, for example, along the lines proposed in the Institute of Medicine report, or will the drift toward fragmentation continue? 2. How can the start in setting objectives for public health be expanded to reach its full potential? 3 . Has the time arrived for shifting gears from disease control to health promotion? 4. Can the nation be jolted out of tolerating its long-standing gross inequities in health? 5. What are, and what should be done about, the health implications of accelerating developments in technology?

The Reconstitution of Public Health The statutory authority for public health established to deal with the problems of a previous era falls short of current requirements. As those health problems have come under control, state legislative bodies have tended to downplay the role of health departments. In mergers with departments devoted to income maintenance and other aspects of welfare, budgetary and other attention has focussed mainly on the large monetary implications of the welfare side, with increasing disregard for the public health element. Historically, welfare leadership, in meeting the medical care needs of the poor (while public health personnel generally shunned that task), contributed to that situation. Legislative leaders at all governmental levels, however, have not totally overlooked the health problems that have gained prominence in recent years. Indeed, they have created agency after agency to handle the problems, especially in the environmental field. That has led to severe jurisdictional difficulties when a health hazard is suspected. For example, citizen and local medical concern about the health hazards of operating a toxic waste facility near Casmalia, California resulted in appointment of an investigative commis sion. The commission's report noted (34):

12

BRESLOW Multiple governmental agencies have responsibilities for past and present monitoring [of) (a) compliance by the Casmalia Resources facility with several sets of regulations concern ing operations; (b) air pollution from and surrounding the site; (e) contamination of groundwater under and surrounding the site; (d) drinking water in communities near the site; (e) the health of employees of the facility; and !fJ the health consequences of the facility's operations on the residents of nearby communities. These agencies include the Santa Barbara County Department of Health Services; the Central Coast Region; California Regional Water Quality Control Services; the Santa Barbara County Air Pollution Control District; the California Department of Health Services; the California Occupational Safety and Health Administration; the United States Environmental Protection Agency; and the


United States Occupational Safety and Health Administration. The Commission emphasizes, however, that no one of these agencies has the authority and resources to (I) ensure adequate surveillance of any actual or potential damage to health from operation of the Casmalia Resources facility; and (2) to assemble, maintain, and present a composite view of the situation as the basis for public policy and effective control measures.

Avoidance of such situations and assurance that the public's health will be adequately protected depends upon designation of one agency with appropri ate authority and resources . Consistent with the pattern of government in the United States, that one agency should be a state agency, except where

interstate aspects are involved, Whether such ass ignments can be achieved depends upon the willingness of legislative bodies and governors to charge s ingle health agencies with the responsibilit ies involved. Their willingness to do so and to relinquish micro-management of the growing crises in health affairs rests, in turn, to a considerable extent upon the confidence they feel

they can place in health departments . Adequate response to the health implications of complex situations such as the above mentioned Santa Barbara example requires competence in med ical and health educational as well as in their strictly environmental elements . Because the environmental, medical, and educational approaches to solving

public healt h problems are so often intertwined. a health department with strength in all these modalities is highly desirable in the modern, in dustrialized world. That makes the 10M proposal on the matter and the opportunities to implement it during the 1990s so important .

Setting Objectives for Public Health

The health advances achieved during the post World War II period, and the prospects for extending and even accelerating them, emboldened public health leaders to formulate concrete obje ct ives as the basis for action. That was a fundamental shift in strategy. It differed from previous efforts that had

been

toward such ambiguous goals as "reducing the toll" of particular by emphas izing the achievement of quantitative objectives within explicit t ime limits. directed

conditions


13

The World Health Organization's 1966 action establishing the interruption of smallpox transmission throughout the world as an objective by the end of 1976 constituted probably the most striking instance of the new policy (48). A worldwide campaign for eradication of that disease, which had plagued humankind through many centuries, led to the last known cases---on e in Somalia 26 October 1977 and two laboratory infections in England during


1 97 8 . In Canada the 1 974 Lalonde Report proposed, among other things, "a goal-setting strategy for raising the level of health . . . [and] . . . the establishment of specific dates by which reductions in the incidence of major mortality and morbidity are to be achieved" ( 18) . A key 1978 paper in a series on various aspects of the health field sponsored by the Institute of Medicine, National Academy of Sciences, sparked a movement in the United States to set objectives for public health (28). Following a Conference on Health Promotion and Disease Prevention called that same year by the Institute of Medicine, the Surgeon General of the Public Health Service asked the Institute of Medicine to review the state of the art in that field. That endeavor and other studies led to the 1977 Surgeon General's Report on Health Promotion and Disease Prevention, Healthy People, which set goals linked to five periods of life, infancy through adulthood; and detailed priority areas of health to be approached through personal preventive services, health protective measures, and health promo tion (40). In 1 980 these several initiatives culminated in a document, Promoting Health/Preventing Disease: Objectives for the Nation, which formally launched the United States on the course of guiding public health effort through the setting of objectives ( 10). Setting objectives for public health begins with delineation of the popula tion to be servcd and its demographic as well as health characteristics. Projection of trends in the population and in health problems yields an initial approximation of what the situation will be, say ten years hence. Then it is necessary to consider the biological, behavioral, environmental, and medical factors that influence the trends. Next one must estimate the feasibility of turning, or accelerating the turn of, these factors in a favorable direction. With analysis of available knowledge, it is possible, thereafter, to project a course of action and judge what could be accomplished thereby within a given period of time. In this endeavor, account must be taken of the considerable impact on almost any health problem from forces outside the health sector. Finally, practical experience in public health programs helps in setting objec tives by emphasizing both the potential and the pitfalls of organized commu nity effort. The case of tobacco use illustrates this process. Objectives for 1990 that

14

BRESLOW

were set in 1 980 included reducing the proportion of smokers to 25% of the adult population. The decade has marked the first drop in total consumption of cigarettes in the United States. from 640.0 billion in 1 98 1 to 574.0 billion in 1 987 (estimate) due especially to a decline in smoking among adult white males. Overall. the proportion of adults smoking the United States fell from 40.4% in 1965 to 33.3% in 1980, and to 29.1% (provisional) in 1 987 (43). B iologically, addiction to nicotine must be considered and note taken o f the fact that cessation appears to be more difficult among long-time, heavy users ,


than among light users. Definite but limited success in influencing people in various ways never to start or to quit tobacco use indicates what may be

accomplished through behavioral approaches . C hanging the environment the media, the prices , and places for tobacco purchase and consumption--can affect the extent of use . Physicians and other health professionals could play a much larger role than they do in the control of tobacco use among their patients. Although the health sector can influence all of these forces, the power of the tobacco industry in direct marketing and in swaying the nation's

political and other institutions must be heeded and countered. Economic considerations such as how to deploy the use of the land and employment of the people now devoted to tobacco growth also affect the control of tobacco use. Promoting Health/Preventing Disease: Objectives for the Nation outlined 15 target areas: high blood pressure control, family planning, pregnancy and infant health, immunization, and sexually transmitted disease (preventive health services); toxic agent and radiation control, occupational safety and health, injury control, fluoridation, and infectious disease control (health protection); and smoking and health, alcohol and drug abuse, nutrition, physical fitness, and control of stress and violent behavior (health promotion). For example. by 1 990 at least 60% of persons with blood pressure over 1 60/95 should have attained a level of 1 40/90 or below for two or more years, whereas among various states and communities the proportion under such control ranged from 25-60% in the late 1 970s. In the category of accident prevention and injury control, the motor vehicle mortality rate should be reduced to 1 8 per 1 00,000 popUlation or less, whereas in 1 978 it was 24. In regard to misuse of alcohol. the cirrhosis mortality rate should be reduced

from 1 3.5 per 1 00,000 in 1 978 to 12 in 1 990. D uring 1 985, the Public Health Service reviewed progress toward the 1 990 objectives (31) . Overall. 13 .0% of them had already been completely achieved; for example, reported rubella cases had declined to less than 1 000 per year. Decline in the motor vehicle death rate appeared to be on target. Smoking by adults. however. had dropped from 33.5% in 1 979 only to 30.5% in 1 985. whereas the 1 990 objective was 25%. In other cases. such as teenage


15

Progress toward 1990 health promotion goals: 1977-1985

1990 1990 goals

1977

1979

1981

1983

1985

goal

14. 1

13.1

11.9

11.2

10.6

9

42.3

40.1

38.0

35.3

33.8

34

1I4.8

1I4.8

107.1

96.0

95.9

93

532.9

500. 2

482.1

452.8

438.7

400

33.1

30

13.7

12

(Infants under 1 year) To reduce infant mortality rate to fewer than 9 deaths per 1000 live births

(Children 1-14 years)


Reduce deaths among children ages 1-14 years to fewer than 34 per 100,000

(Adolescents and young adults /5-24 years) To reduce deaths among people ages 15-

24 to fewer than 93 per 100,000

(Adults 25-64 years)

To reduce deaths among people ages 2564 to fewer than 400 per 100,000 (Older adults 65 years and over)

To reduce the average annual day s of restricted activity due to acute and chronic conditions to fewer than 30 days per year for people aged

Restricted-activity days per person

36.5

41.9

39.9

32.1

65 or

over" To reduce the average annual number of days of bed disability due to acute and chronic conditions to fewer than 12 days per year for people aged 65 and

Bed-disability days per person

14.5

13.7

14.0

16.7

over" a

Levels of estimates for 1982-1985 may not be comparable to estimates for previous years because the

1982-1985 data are based on a revised questionnaire and field procedures.

SOURCES: Refs. (25a,

40);

data computed by National Center for Health Statistics, Division of Analysis from

data compiled by Division of Vital Statistics and from Table

I; Division of Health Interview Statistics; data from

National Health Interview Survey.

pregnancy, it seemed very unlikely that the objectives would be achieved. For some objectives, data were not available for assessment. Not only had an initial set of objectives been established for 1990, and a mid course review conducted, but data concerning the objectives began to appear in annual health-statistic publications. For example, progress toward certain of the goals was recorded in the 1987 edition of Health United States, as shown in Table 3 (24). That first experience has encouraged the Public Health Service to proceed

the

16

BRESLOW

with another round of setting objectives for public health , this t ime for t he ycar 2000 . The Institute of Medicine of the National Academy of Sciences has jo ined in the current effort . The two agencies have conducted hearings around the country and received te stim ony from hundreds of individuals and orga n izations. More than 300 national professional , voluntary, and governmental health agenc ie s and several hundred experts in the various fields have re


viewed draft statements of objectives. The complete set of draft objectives will be circulated to several thousand people in the field for comment. This extensive part ic ipation should make the health objectives for the year 2000 a

genuine consensus document . It now appears t hat t he objectives for t he year 2000 will be larger in scope t han t he 1990 set, for examp le, including attention to cancer and other chronic disease, the health of older people, and access to preventive health se rvic es . During t he 1990s it seems likely t hat the national health objectives for the year 2000 can be a significant guide to public health action. To maximize their value , however, the states should establish their own objectives , follow ing the national format but adjusting specific objectives to t he ir own c ircum stances. Thus in setting an objective for the infant mortality rate, it would be reasonable for a state to take into account its own position in t he ran ge of infant mortality rates, which in 1983-1988 among the 50 states extended from 8 .5 in North Dakota to 20 .4 in t he District of Columbia (14) . Moreover, states s hould consider t he rates in different segments of the p opulation , suc h as those in urban ghettoes and in suburban , affluent communities. By t akin g t he se kinds of data into account, objective s can be set for t he different areas of the country, guiding local action to reach state and national goals. This seems the way to ut ilize to the fullest the new p ublic health strategy. From Disease Control to Health Promotion

From time immemorial peop le have struggled to avoid premature death and to minimize disease. That task still dominates health work in much of the world where malaria, poliomyelitis, tuberculosis, measles, and high rates of infant mortality prevail. Moreover, even in the United States, some of these con ditions, including premature death, continue to strike far too many individuals

in certain segments of the population . I n such circumstances people tend t o think o f health merely as the absence of disease . To sustain life and avoid serious disease requires t he maximum attention that can be given to the matter of health. The idea of enhancing or promoting health cannot find a place in people's consciousness. During recent decades, however, the situation has changed remarkably for much of the popUlation in the industrialized nations. With the vast c urtailment

of major communicable diseases, along with the sharp decline of cardiovascu lar and other chronic diseases, pe opl e now commonly l ive into the e ighth and



17

ninth decades of life. In addition, they are largely free of serious disease through most of their lives. That contemporary state of affairs is stimulating considerable rethinking of the meaning of health and of the way to achieve and maintain it. No longer required to consider health merely the absence of disease and infirmity, people are beginning to devote attention to its positive aspects, to what some people call wellness. In this expanded sense embracing its positive as well as negative aspects, health can be defined again as it was in classical Greek and Chinese thought, namely, maintaining balance in relation to one's environment (29) . According to this notion, health is a dynamic equilibrium in the face of all forces surrounding life. Closely related to that concept, keeping stability in the human condition (health) requires a certain capacity, reserves, for responding to whatever occurs. Increasing this capacity, this potential for maintaining health, constitutes health promotion. That idea of health and health promotion appeared recently, for example, in the Ottawa Charter for Health Promotion, "Health is a positive concept emphasizing social and personal resources, as well as physical capabilities ... .Health is ...a resource for everyday life, not the objective of living.. .. Health promotion is the process of enabling people to increase control over, and to improve their health" (33). Ancient physicians in both eastern and western worlds recognized health promotion, though with different words. In his work Airs, Waters, and Places, Hippocrates recommended 2500 years ago that physicians give atten tion to "the mode in which the inhabitants live and what are their pursuits, whether they are fond of drinking and eating to excess, and given to in dolence, or are fond of exercise and labor, and not given to excess in eating and drinking" (1). Galen's notion of hygiene was "a correct amount of food, drink, sleep, wakefulness, sexual activity, exercise, massage, etc" (37). About 4000 years ago, a Chinese physician is said to have enunciated a prescription for a healthy diet, "cereals for energy, fruits for accessory, animals for benefit, vegetables for supplement" (49). All of thesc ideas are directed toward bolstering people's capacity for keeping equilibrium in their life situations, that is, health. Although the idea that maintaining health entails more than diagnosis and treatment of specific diseases thus goes back to ancient times, in its current resurgence the meaning of health promotion has not yet been accorded consensus. It still seems to stand for such various concepts as:

1 . Measures designed to influence people individually to make choices, within the framework of their living circumstances, that are favorable to health (educational model).

18

BRESLOW


2. Measures designed to opt imize people' s living circumstances for making choices that are favorable to health (enabling model). 3. All measures t hat enhance the possibility of health (comprehensive mod el). In one example of the comprehensive model , health promotion was defined as "the advancement of well-being and the avoidance of health risks by achieving and maintaining opt ima l levels of behavioral, social, environmental, and biological determina nts of health" (2 1 ) . The first two concepts noted above focus on individual behavior as a factor in hea lth. The first is limited to teaching; the second includes attention also to the circumstances of learning. The third extends beyond measures concerned with individual behavior to embrace much broader efforts to advance health. The first concept of health promotion has come under attack because in assuming that the individual is totally responsible for his own health, it constitutes "blaming the vict im . " If he smokes cigarettes, a ll we should do is teach him not to do so. The second , so-called "enabling" model of health promot ion is more consistent with our understanding that choices by in d ividuals that affect health are not made in a vacuum. Such choices are heavily influenced by the physical a nd social environment in which one lives. That view carries a different notion of individual and social responsibility. The latter was expressed among other places, in a 1952 report , Building America' s Health (32): Recognition of the significance for individual responsibility for health does not discharge the obligation of a society which is interested in the health of its citizenry. Such recogni tion, in fact, increases social responsibility for health . . . it becomes necessary for a society which wishes to advance the health of its citizens to adopt measures which guarantee to the individual an opportunity to make appropriate decisions in behalf of his health . . . [namely]

. . . access to professional services. education concerning personal health

[practices], and a reasonably safe physical environment. Only then can individual responsibility for health exercised through personal action reach its full potential . Comprehensive health promotion thus includes all three modalities: preventive medical services, environmental measures, and influences on behavior that are favorable to health. The goal for all three, separately, and in combination, is not only to avoid specific diseases but also to achieve "physical, mental, and social well-being . "

The scientific base for health promotion in this comprehensive sense consists, in part, of the identification of factors that influence health and effective means for dealing with t hem, either in ind ividuals or in populations (3, 4). One set of these so-called "risk factors" is composed of bod ily characteristics that have been determined to be precursors of disease, for example, physiological changes, such as hypertension; anatomical, such as obesity and cervical dysplasia ; biochemical, such as high serum cholesterol; a nd genet ic , such as trysomy 2 1 . Dealing with these disea se precursors has



19

taken the form o f screening , especially screening focused o n the early stages of abnormality. Pin-pointing of individuals with such conditions and correc tion of the aberrations is an increasingly accepted form of preventive medi cine. The other set of risk factors is comprised of common habits that are known to involve an increased likelihood of poor health, including specific diseases . Such habits include, for example, smoking cigarettes , indulging excessively in alcohol, eating too many calories, and obtaining insufficient exercise. Although several significant risk factors , both bodily characteristics and personal habits , have been well-established, a two-pronged strategy for correcting them most effectively is still under development and evaluation. One approach is to identify individuals who are at high risk, for example, those who smoke cigarettes and have blood pressures exceeding 160/95 , or 140/90; and blood cholesterol levels above 240, or above 200. Concentrating efforts on such individual people constitutes the so-called medical model. The other approach is to focus efforts on an entire population , seeking to reduce health risk in the community by achieving for all people optimum bodily parameters and personal habits for health . That is the public health model. Obviously both thrusts in this strategy will be useful. The community approach in a complete sense includes the medical model, i . e . dealing with selected individuals . A framework for community health promotion appears in Figure 1 . Ad hoc health promotion efforts by various agencies can be valuable for the in dividuals affected and can also assist in creating a favorable milieu for more sustained effort. Institutionalizing health promotion activities in ongoing community organizations seems important, however, to achieve lasting re sults. Not waiting for health promotion to be introduced as a regular service in medical practice, a substantial proportion of companies with large workforces in the United States had initiated by the early I 980s some activity designed to improve health . For example , a random sample of all 1984 worksites in the private sector with 50 or more employees disclosed that two thirds had at least one health promotion activity. More than half of the activities had been initiated in the previous five years . Common activities were health risk assessment (29 .5% of worksites) , smoking cessation (35 .6%), blood pressure control ( 1 6 . 5%), exercise/fitness (22 . 1 %) , stress management (26 .6%) , and back problem prevention (28.5%) ( 1 1 ) . Improved morale and productivity are often cited along with moderating effects on health care costs as reasons for conducting the programs , although little evidence has been available to substantiate that view. Several large American corporations have undertaken extensive health promotion programs for their employees and evaluated them. For example,


Societal

/ supporting /

�

practices

Health promotion builds

Community • organization for

medical measures

and Optimal bodily ___ . � to mI m' mlze parameters disease of health , in order

etean air and water, safe food,

weight, cervical ephhelium, blood pressure, respiratory capacity, blood cholesterol, blood sugar , Immunhy against measles gene structure

_ _ _ _ _ _ _ _ _ __

....,� personal behavior

prices of alCohol and tobacco, opporturities for exercise, gun regulation, air pollution control, ready access to preventive medical services

no cigarette smoking, proper exercise, limited, if any, alcohol use, good diet .

to maximize hemih and health stetus

that foster

Healthful

organized actMty speciflcally for health in a residential, work, school, religious, or any other community

Figure 1

� /

Environmentand

aI

pre-natal care, periodic health exams and follow-up

Framework for health promotion. (Adapted from a model being developed by the Health Promotion/Disease Prevention Center at the

University of California, Los Angeles.)



21

the Johnson & Johnson Live for Life program started i n 1979 with provision of services at certain companies and others observed as controls (46) . Experi ence at Johnson & Johnson showed reductions in smoking and weight as well as improvement in fitness among employees at intervention sites compared with control sites (6). Economic analyses indicated lower hospital utilization and costs for employees at the intervention sites compared with the controls (2). Several American corporations-Johnson & Johnson, Control Data, Dupont, and some Blue Cross/Blue Shield Plans-have not only developed health promotion programs for their own employees, but are beginning to sell these programs to other employers. It seems that major American em ployers-and increasingly, smaller ones too--are becoming committed to a health promotion thrust as a highly significant component of their employee health expenditures . Their concern is focusing on morale , health status, productivity, absenteeism, and disability payments as well as dollar health care costs in the usual sense . Worksite programs necessarily focus on relatively healthy adults . Another significant segment of the population, of course, can be reached through the schools. That is an especially important age-range for health promotion endeavor because habits for lifestyle are being formed at that time. Also certain bodily tendencies of health significance, such as obesity and high blood pressure, may appear among children and young adolescents . Among various recent efforts to introduce health promotion into schools , a notable example is the Know-Your-Body program of the American Health Founda tion (47). Health curricula have been designed and tested for use at each grade level of elementary and secondary schools. Linked with certain bodily measurements, such as height-weight and blood pressure, which are reported to each student, these curricula help students to understand how their bodies function and how their own bodily characteristics and personal behavior, for example , in relation to tobacco, can affect health . This science-based approach to health promotion among school children and youth may be contrasted with previous school health programs that usually reflected other concepts about school health, for example, those based on moralistic ideas , or on the notion that athletic prowess is the aim of school health endeavor. Unfortunately , some years ago a trend of thinking emerged in public health circles that almost denigrated the ideas that personal values or physical exercise could substantially affect health. Now we are beginning to realize that an individual's sense of worth and appropriate physical exertion can indeed influence health. Recent advances in biology, epidemiology, psychol ogy, and other health-related sciences have been laying the groundwork for a renaissance in school health, a transition to a new level and nature of school health activity. Health curricula constitute only one essential in such a pro gram.

BRESLOW

22

A comprehensive school health program includes five elements:

(a) curric

ula for student learning in the classroom, the effectiveness of which depends in considerable part on support by the other four elements; (b) physical exercise, with emphasis on physical fitness for all, not just on competitive sports;

(c) the school food service, which in recent years has usually offered

unhealthful menus sometimes abetted by government dumping of fatty foods such as poor quality cheese onto the schools;

(d) a prevention-oriented health

service with nurses and other health professionals engaged in periodic health


evaluations of students, the results of which are relayed to the individuals concerned in health counseling sessions; and

(e) maintaining a healthful

environment in schools, including both physical safety and security, and psychological influences such as knowing that teachers and other staff avoid tobacco. A truly comprehensive school health promotion program requires attention to all of these five , mutually reinforcing features .

Continuing Social Inequities and Their Impact on Health Among the industrialized nations, the United States has long been known for maintaining extreme poverty in a sizeable proportion of its population, and tolerating the health effects of that situation. For example, being black in the United States has historically carried an increased risk of poverty; in the 1980s one third of the black people were below the poverty level, nearly three times the rate among whites (30). Blacks also had correspondingly poorer health as indicated by a 50% higher overall death rate , six years less life expectancy, and an infant mortality rate twice as high and maternal mortality rate three times as high . Table

4 reveals the continuing gap in health indices between

blacks and whites. Although "race" is commonly cited as the risk for the substandard health record, analysis indicates that the underlying factor is mainly family income. In general, for example, infant mortality "is 1 . 5-3 .0 times higher among the poorest families than among the nonpoor families"

(26) . Kovar found that

"family income is more strongly related to measures of health status than other socioeconomic characteristics such as race and parental education" ( 1 7). Two major waves of hunger associated with poverty have been recognized in the United States during the latter part of the twentieth century . Gross hunger as a concomitant of poverty came to attention in the United States through a report by a group of physicians who testified to the Congress in 1 967, "If you go look you will find America is a shocking place. No other Western country permits such a large proportion of its people to endure the lives we press on our poor. To make four fifths of a nation more affluent than any other people in history, we have degraded one fifth mercilessly"

(44).

During the 1 970s the nation attacked hunger as an element of extreme


23

Black/white discrepancies in health indices Females

Males

Life expectancy

B lack

White

B lack

White

1980 1985

1980 1985

1980 1985

1980 1985

65

71

72

73

74

78

79

1113 1024 327 301 230 232 78 61 23 31 18 18 50 72

745 278 161 42 16 10 II

689 245 159 33 13 9 8

631 201 130 62 14 22 14

589 187 130 50 10 21 11

411 135 108 35 7 9 3

391 122 110 28 6 8 3

64

Age-adjusted


death rates All causes Heart disease Cancer Stroke Cirrhosis Diabetes Homicide

Source: Ref. (24).

poverty through food stamps for poor households; school lunch programs; a supplemental food allocation for women, infants, and children (WIC); and congregate meals for the elderly (38). After a decade of such effort, poverty was still present but not the extensive hunger. A few years into the Reagan administration, however, the problem of severe hunger reappeared. A 1983 report commissioned by the US Depart ment of Agriculture disclosed that hunger in America was growing "at a frenetic pace and the emergency food available for distribution is quickly depleted" (38). Dozens of other studies confirmed the reappearance of hunger as a serious national problem. Hunger in the United States takes the form mainly of "silent undernutri tion," for example, among young children whose weight is several pounds below the normal range on a growth chart (7). Estimates indicate that 20 million Americans are affected. The health impact strikes most severely pregnant women and young children who are biologically most vulnerable to hunger. For centuries poverty has been a major health problem, and it continues to be one in the United States. Other manifestations of social subjugation, closely intertwined with pover ty in this country, are related to health. Segregation in housing and dis crimination in education and employment have long adversely affected the sizeable proportions of American people who are black, Asian, Native Amer ican, or of other minority racial-ethnic origins. Social pressures continue to retard health improvement among many of these people. The second largest minority, Hispanic Americans, comprise about 8% of


24

BRESLOW

the population . Three fifths are of Mexican origin, and another tenth are from Central and South America; these groups are concentrated in the southwestern states (30) . About one fifth of the Hispanic Americans are Puerto Rican or Cuban, located mainly in the New York area and Florida, respectively. The Hispanic American population in the United States has been growing during the 1980s almost five times faster than the population as a whole . In 1 984 one fourth of the Hispanic families in the country were below the poverty level, compared with one eighth of the overall population , and the unemployment rate was twice as high. Whereas 74% of all adults had completed high school, only 48% of the Hispanics (42% of Mexican Americans) had done so . Far fewer health data are available concerning Hispanic Americans than blacks and whites; also there are considerable differences in lifestyle between the two larger groups, Mexican Americans and Puerto Ricans. Evolution of Technology and Behavior: Significance for Health

The accelerating pace and extent of technological innovation and the corre sponding changes in behavior demand increasingly rapid responses to the health implications of these developments . Advances in food management, transportation, communication , energy production , and other aspects of the physical environment during this century have vastly altered the way people live. For the most part the changes have enhanced the possibility of health , but some developments have brought new hazards-notably the creation of nuclear arsenals by the super-powers and the proliferation of that capability in other countries . Although manipulation of nuclear energy has opened up a much needed new source of electricity and other useful forms of power, the dangers to health of managing nuclear energy have become all too evident in the Three Mile Island, Chernobyl , and other incidents. The chemical industry has produced and continues to develop a vast array of new substances, useful in myriads of ways. We now realize, however, that many of these substances carry substantial risk of toxicity and carcinogenesis to human beings . Systematic testing of new chemicals for adverse effects is only beginning to get under way, and investigating the possible untoward consequences of those already being used is still quite limited. Exposure to potential health damage from chemical products can occur in several ways: during their manufacture; in using them, especially improperly; and from waste disposal situations. During the past few years , the release of hazardous chemicals into the air, water, and soil has attracted much attention. During the early years of the industrial revolution, safeguards had to be established against pollution of public water supplies with enteric pathogens. After that source of disease was checked by public health action, the disposal



25

of large amounts of relatively nonhazardous domestic and industrial waste became necessary. For some time, waste disposal did not seem to pose serious health risks, and public health agencies lost touch with the situation. Now that the chemical industry has expanded so greatly, the dangers to health, includ ing hazardous waste disposal , have stimulated a multiplicity of agencies: the Occupational Safety and Health Agency , the Environmental Protection Agen cy, the Food and Drug Administration, and many state and local bodies dealing specifically with air and water pollution problems. Although jurisdic tion has been established for these agencies by statute, federal , state, and local public health departments cannot escape their overall responsibility for pro tecting the public health . Thus in any particular environmental situation, for example, regarding dangers from and complaints about operation of a com mercial waste disposal site where many kinds of possibly hazardous wastes are deposited from several sources, jurisdictional confusion is bound to occur. There is substantial public concern about the dangers of relying on in adequately regulated efforts by chemical and nuclear energy industries to minimize environmental dangers; the history of denying risk is too strong. Several issues are emerging from that bewildering situation that require public health consideration, and possibly action: What criteria and methods shall be used for determining health risk? What level of risk shall be tolerated: zero, sensory annoyance, diagnosable disease , one death per million lifetime ex posures, or other alternative? How can the concept of probability , so impor tant in these situations , be effectively communicated to the general public? How shall the time and cost required to assure health safety be taken into account? What is the most sensible administrative management for protecting the public interest? Resolving these issues will require considerable scientific talent, ethical input, and political skill during the 1990s. New technology , of course, can have a profound effect on health through medical service as well as through the physical environment. Effective vac cines against many diseases have recently become widely available, and the prospects of developing such means of preventing additional diseases appear good. Drugs for controlling depression and other mental disorders are becom ing highly useful. Improvements in mammography are making that technolo gy safer and less costly in the early detection of breast cancer. These and many other technological advances in medicine are increasing the potential for improving health . Of course, possibly adverse side-effects also attend the greater biological power involved . The challenge to public health from this technological progress in medicine is to assure its prompt, efficient, and safe application. For example, can the vaccine against measles (and possibly other effective vaccines) yield the same degree of control over that disease as already achieved against poliomyelitis , or even smallpox? How can the substantial benefits of mammography be


26

BRESLOW

brought to the millions of women in this country now apparently destined to develop breast cancer during their lifetimes? What are the most appropriate ways of using drugs for mental disorder, with maximum benefit to both the individuals involved and society at large? Technological advances are affecting health by inducing changes in be havior as well as by direct environmental or medical influences. For example, the fork-lift and other contrivances for facilitating movement of heavy objects and reducing physical demands on the worker, motor vehicles for transporta tion, and television for recreation have greatly curtailed physical exertion. Simultaneously, the greater availability of meat and dairy products through refrigeration and other methods has encouraged excessive caloric intake. particularly of fat. These twentieth century innovations have profoundly altered the system of human responses to the environment, resulting in fat consumption and diminished physical exertion beyond biological limits for health. These have been substantial factors, along with cigarette smoking and hypertension, in the coronary heart disease epidemic of our time. It is necessary to curtail behaviors that continue to induce the disease, especially in less advantaged members of society, and to help immigrants who have not previously been exposed to such conditions, avoid them. Thus in the 1 990s and into the next century it will be important to keep a sharp eye on how technology changes life circumstances in w ays that affect health. In earlier times human health suffered from encounters with natural conditions: lack of food, cold, heat, injuries, other organisms, and the like. The industrial revolution brought a more healthful state of affairs in some important respects, but it also introduced crowding and exhausting, dangerous work. Experience in the twentieth century has demonstrated repeatedly that a world increasingly transformed by human endeavor, though better for human kind in many w ays, carries new threats to health. These hazards tend to be discerned only dimly at first because their effects are increasingly subtle. The limits of human lifespan are gradually being reached, and impairments caused by the evolving features of life may take decades to become manifest. Environmental, medical, and behavioral factors will continue to influence health. For the protection and advancement of public health it will be neces sary to watch these three avenues, both for newly arising negative influences on health and for means of exerting favorable impact.

CONCLUSIONS The 1990s will bring critical decisions concerning public health. How the nation and the states deal with its extensive fragmentation will determine the structure of public health, probably for years to come. If the movement


27


toward setting concrete objectives for the field flourishes, not only will greater concentration of professional effort but more public support may be generated. The need to consider health promotion as well as disease control is now coming onto the public health agenda. Confronting severe inequities in American health will require joining a long-awaited, broad social attack on poverty and racism, certainly an important venture for public health. A strategy for minimizing the adverse health consequences of technological changes remains to be developed . Literature Cited 1 . Bemarde, M. A. 1973. Our Precious Habitat. New York: Norton 2. Bly, J . L . , Jones, R . C . , Richardson, J. E. 1986. Impact o f work-site health pro motion on health care costs and utiliza tion. J. Am. Med. Assoc. 1 56:3235-40 3. Breslow, L. 1978. Risk factor interven tion for health maintenance. Science 200:908- 1 2 4 . B reslow, L. 1978. Prospects for improv ing heal th through reduci ng risk factors. Prevo Med. 7:449--5 8 5 . Breslow, L . , Cumberland, W. 1988. Progress and objectives in cancer con trol. J. Am. Med. Assoc. 259: 1 690-94 6. Breslow, L . , Fielding, J . , Herrman, A . A . , Wilbur, C. S . 1 990. Worksite health promotion: Its evolution, and the John son & Johnson experience. Prevo Med. In press 7. Brown, L. J . , Allen, D. 1988. Hunger in America. Annu. Rev. Public Health 9:503-26 8 . Centers for Disease Control. 1989. A s trategic plan for the elimination of tuberculosis in the United States. Mor bid. Mortal. Week. Rep. S-38 (Suppl. No. S-3): 1 -25 9. Committee on AIDS Res. and the Be hav . , Social and Statist. Sci. CBSSE, Natl. Res. Council . 1989. AIDS: Sexual Behavior and Intravenous Drug Use. Washington, DC: Natl. Acad. Press 1 0 . Dept. Health and Human Servo Public Health Servo 1 980 . Promoting Health/ Preventing Disease: Objectives for the Nation. Washington, DC: US GPO 1 1 . Fielding, J. E . , Piserchia, P. V. 1989. Health promotion: Frequency of work site activities. Am. J. Public Health 79: 1 6-20 1 2 . Fraser, D. W . , Tsai, T. R . , Orenstein, W . , Parkin, W. E., B eecham, H . G . et al . 1977. Legionnaires disease: Descrip tion of an epidemic of pneumonia. New Eng!. J. Med. 297 : 1 l89-97 1 3 . Fries, J. F . , Schneider, E. L . , Guralnik,

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