Remarks by

JULIUS B. RICHMOND, M.D.

"Building the Next Generation of Healthy People"

National Healthy People Consortium Meeting and Public Hearing
Washington, DC
Friday, November 12, 1998
11:30 a.m.

- A. Lincoln

INTRODUCTION

WHERE WE ARE

As we turn our attention to the next century and frame our overarching health goal for the year 2010 as "health for all-healthy people in healthy communities," it is well that we step back and review how we came to the process of setting these ten year goals.

I became Surgeon-General as we were three-quarters of the way through the twentieth century. It struck me that we had witnessed a remarkable transformation in the health of our people:

* We observed a striking decline in morbidity and mortality of childhood. (Figure 1)

This was largely the result of the decline in the infectious diseases. Parenthetically I would comment that medical students in this country today will not see children with the acute infectious diseases who consumed more than fifty percent of my time in training as a pediatric resident!

Most significantly we witnessed the successful completion of the WHO campaign to eradicate smallpox from the world. (Figure 2) I had the privilege of leading the US. Delegation to the World Health Assembly of 1980 which announced the world-wide eradication of this devastating disease, - one of the greatest achievements in the history of mankind.

But we cannot be complacent about our progress in controlling the infectious diseases, for HIV infections have emerged as a formidable challenge along with other emerging infections.

* We observed a significant decline in our infant mortality rate. (Figure 3)

Although our trend is in the right direction, we have not made progress comparable to other developed nations. (Figure 3A) I hasten to add that some of our states compare favorably to other countries. Our task remains, therefore, as our Surgeon-General reminds us, to eliminate the disparities among the states as well as the disparities among ethnic groups. We have the knowledge; what we have lacked is the political will.

*We noted a significant increase in longevity. (Figure 4) While much of this easily could be attributed to the saving of life in infancy and childhood, we also began to see a saving of lives in the later years. (Figure 5)

Many demographers didn't think we would see an increase in length of life beyond sixty-five years. But they have been proven wrong; the most rapidly increasing age group is that beyond eighty!

* Most surprising of all has been the decline in recent years in mortality from heart disease and stroke. (Figures 6, 7) Many physicians had despaired of reducing mortality from diseases that were multifactorial in origin. Yet the public began to act on the knowledge that we had generated about the roles of diet, smoking, exercise, hypertension detection and treatment, and stress. The progress we have observed came as a result of education and behavior change - not because of medical care (although I don't minimize its importance). This has truly been a great advance in the public's health and it should make us optimistic about the power of our expanding knowledge base in health promotion and disease prevention.

WHITHER WE ARE TENDING

A STRATEGY

It became apparent to us in the late 1970's that a transformation in public health had taken place. We were through the first public health revolution and we were embarking on a second. We reasoned that new strategies needed to be developed. These would require dealing with multiple factors; we would need to think of the long term.

Therefore we decided to set goals for the next ten years. We recognized that, in spite of the revolution in biology subsequent to World War II, that the great advances in the public's health was largely the consequence of our progress in health promotion and disease prevention. The report we presented was titled, Healthy People and the subtitle was the Surgeon-Generals' Report on Health Promotion and Disease Prevention. (Figures 8, 9)

We are now into the third iteration of the report. The Public Health Service has institutionalized the process as one which has a strategy of goals, an analysis of potentialities, and programs for the achievement of the goals.

The transformation of public health requires new ways of thinking about health and disease. (Einstein said, "The unleashed power of the atom has changed everything save our modes of thinking, and we thus drift toward unparalleled catastrophes.") This approach involves our moving beyond diagnosis and treatment (important as they are) and beyond our well-developed efforts at disease prevention to an emphasis on health promotion or improvement in the quality of life.

Our health expenditures go beyond those of other countries. (Figure 10) but these expenditures have not produced a health record that is better than other developed countries. But it has become clear that we can lead longer lives of better quality. (Figure 11) And if health professionals do not lead the way, others will. The considerable interest in alternative medicine certainly suggests that we are not meeting the public's expectations.

To deal with the complex interactions for health promotion, we have developed a model for shaping health policy. This model illustrates the interdependence of our knowledge base, our political will, and our social strategy. (Figure 12)

WHAT TO DO AND HOW TO DO IT

For the year 2010, the Surgeon-General has already indicated a strategy - (Figure 13) that of eliminating disparities in health and increasing the years of quality and healthy life. We clearly have disparities among population groups, by geography, by income and by ethnic groups. For example,

* The disparity between the state with the best record in infant mortality rate and the worst is threefold. Certainly we should eliminate the disparities. (Figure 14)

* The disparity in infant mortality rate between whites and Afro-Americans is twofold. (Figure 15)

* The disparity in rates of prostatic cancer between Afro-Americans and Caucasians is unacceptable. (Figure 16)

* The trends in heart disease among ethnic groups and rich and poor should be reduced. (Figure 17)

* An unfortunate trend which we predicted in 1979 - but didn't reverse is the cross-over of lung cancer over breast cancer as the leading cause of death among women. We told women that if they smoked like men they would die like men. (Figure 18)

To increase the quality of life we need to think boldly about reducing poverty and its health consequences. Poverty is a pervasive factor in accentuating all aspects of poor health. We despair too lightly at doing something about this basic inequity. (Figure 19) Even though it seems an impossible task, the UN's development program has proposed a "decade for the eradication of poverty. " (Figure 20)

Let me suggest a consequence of poverty which is devastating: its impact on the development of young children. Years ago in observing the development of children being reared in poverty we observed what we called developmental attrition. (Figure 21) We also showed that this could be prevented. (Figure 22) These observations formed the basis for the Head Start program which I had the privilege of directing. All children should be entitled to be raised in an environment which permits them to be ready for school.

To pursue the Surgeon-General's strategy further we need to focus on:

1) Promoting Healthy Behaviors (Figure 23)

Many of today's major health problems are related to behavioral issues. Thus, smoking, diet, physical activity, alcohol consumption, substance abuse, and violence are issues which are of basic importance to the morbidity and mortality rates. These are issues which are multifactorial in nature and therefore have no instant or magic bullets. Programs to enhance healthy behaviors will require long-term strategies. Particularly for children we must have long-term strategies, appropriate for their age, to help them learn to make healthy choices.

The Surgeon General's report on mental health , now in preparation, important in many ways, should help us to develop better strategies for dealing with behavioral issues.

We must keep in mind that smoking is the single most preventable cause of death. Peto has emphasized "that over the next 20 years, 100 million people worldwide will die from tobacco-related diseases, and in the US, tobacco is the cause of one-third of all deaths in people under the age of 70."

This suggests that we have not been really effective in developing our preventive efforts. The recent rise in teen-age smoking reflects our ineffectiveness (Figure 24). The conclusion we can draw is that the tobacco industry is effective. They have good research (which of course they don't share with us) and the resources (about six billion dollars per year) to enhance their programs for youth addition.

This provides the opportunity to indicate that in the public health community we have not yet learned to use modern communication technologies effectively. Perhaps we need a Surgeon General's task force on modernizing public health education.

2) Prevention and Reduction of Diseases and Disorders (Figure 25)

We need to make personal health services more available and more responsive to our needs for health promotion and disease prevention. We have had an excellent Public Health Service report by the Task Force on Clinical Prevention Services to Guide Practitioners. The revolution taking place in the financing and organization of health services should not become an excuse for minimizing preventive services. We certainly cannot complete our agenda without developing a universal health service system which is all inclusive and fully utilized by those in need.

Throughout the life span we must develop health information programs which will have personal meaning - which will be internalized by each individual. This will become our best immunizing tool for the prevention of eating disorders and substance abuse while at the same time instilling sound nutritional, exercise and mental health practices.

3) Promotion of Healthy Communities (Figure 26)

Healthy behaviors are most effectively promoted in healthy communities. More emphasis has been placed recently on the need for comprehensive programs in communities. For example, in recent years we have seen a decline in violent behavior in many communities across the country. (Figure 27) While many analyses of the reasons for this reversal of a trend have been offered, we have no clear answer, since it probably results from a comprehensive approach in which we have done many things well and kept them in place long enough. (This is analogous to our reduction in mortality from heart disease and stroke. We still can't quantify which of the several approaches had the greatest impact!)

We need better population based efforts to protect the public's health. Agencies such as the FDA and the EPA have an important role to play. In the matter of tobacco use, for example, we have seen the long term effects of the Public Health Service, through its Surgeon-General's reports in the gradual reduction of smoking. The FDA has played a major role in educating the public and in moving toward further constructive regulatory activity. The EPA continues to move us toward smoke-free environments.

But healthy communities are dependent on broad ecological efforts. Our urban and rural areas of poverty have been neglected and permitted to suffer dilapidation. Toxic dumps are too often associated with poor neighborhoods.

Thus as we move toward a new generation of healthy people we will be moving to build healthy communities. None of us is exempt from this effort, for it must be comprehensive and all-inclusive. (Figure 12) We must continue our efforts to assure safe, fluoridated water supplies. I commend the Surgeon General in commissioning a report on oral and craniofacial health.

We have made progress in increasing our knowledge base. The recent proposals of additional support for NIH indicates we will continue these efforts. Our new knowledge coming from the genome project will give us much to contemplate, scientifically, clinically and ethically. We need to continue to generate the political will for our programs to improve the public's health.

And through this effort to generate health goals for the year 2010 we are demonstrating we have the social strategies to enhance our efforts.

We have the resources to achieve the best health record of any country in history. (Figure 13) With the leadership of the Surgeon-General let us proceed to realize that goal.