BMJ 1998;317:1513-1517 ( 28 November )

Education and debate

"Healthy People 2010": national health objectives for the United States

Ronald M Davis, director. 

Center for Health Promotion and Disease Prevention, Henry Ford Health System, One Ford Place, 5C, Detroit, MI 48202-3450, USA

rdavis1{at}hfhs.org

Establishing health objectives for a population is an important component of programmes aimed at improving and protecting public health. At whatever level it is used---community, state, country, or continent---a system to develop and attain health objectives serves several useful purposes (see box below). Adoption of health objectives at the national (or international) level can encourage the adoption of health objectives in smaller jurisdictions, tailored to local needs and circumstances.

Summary points

Establishing national health objectives is an important strategy to improve and protect public health
The US Department of Health and Human Services's recent draft objectives, Healthy People 2010, are impressive in their scope, detail, and insight---but there are too many objectives, and too many of them are unmeasurable
Inconsistency and lack of balance exist across the 26 priority areas, and the role of the federal government is undefined
Federal politics has tainted the process of setting national health objectives; new approaches need to be considered


    Examples of action (and inaction)

Despite the clear benefits of establishing health objectives for populations, their use is still not universal. The United States, the United Kingdom, and Australia, for example, have promulgated broad national health objectives, but Canada has not. Europe has distinguished itself among continents by establishing regional health objectives.

Purposes of establishing health objectives

  • To provide a baseline assessment of the population's health
  • To establish a tracking system for monitoring change in the population's health
  • To facilitate evaluation of the impact of health improvement activities
  • To increase the breadth and intensity of health improvement activities (through ambitious goal setting)
  • To improve the efficiency and effectiveness of health improvement activities by defining priority strategies to reach the goals that have been set
  • To foster a unity of purpose, organisational participation and partnerships, and a spirit of cooperation (by defining goals and strategies through a consensus process)
  • To help build awareness of, and support for, health programmes among policymakers and the public
  • To guide decisions on allocation of funding

In February 1998 the British government put forward a consultative green paper, Our Healthier Nation.1 It laid out four broad targets for the year 2010: reducing the incidence of injuries ("accidents") and mortality from heart disease and stroke, cancer, and suicide. After public comments are taken into account, the government will publish a white paper laying out a strategy for action. Our Healthier Nation builds on the health strategy put out in 1992, Health of the Nation,2 which was criticised for underplaying the need for healthy public policies and strong local community action, for its reluctance to address the determinants of health, and for "an excessive emphasis on targets that became ends in themselves."3

In Australia, national health objectives were first published in 1988 and 1993. 4 5 These were refined in 1994 in Better Health Outcomes for Australians,6 which focused on four specific areas: cardiovascular health, cancer control, injury prevention and control, and mental health. Diabetes was added later as a fifth priority area.7 Reports in 1997 and 1998 assessed progress towards meeting the goals and targets. 7 8 Biennial progress reports are to be published for each priority area,8 and two have already been issued. 9 10 In addition, most states in Australia now have their own health goals and targets, notably Western Australia and South Australia. 11 12

Canada has adopted national goals in a few specific areas---for example, immunisation13 and sexually transmitted disease14---but it has not yet developed comprehensive national health objectives. A few Canadian provinces, notably British Columbia, have adopted their own health objectives.15

The World Health Organisation's European region, in its Health for All programme, adopted 38 regional targets in 198416 and updated them in 1991.17 Progress towards achieving these targets, which were aimed at the year 2000, was reviewed in 1994.18 In September 1998, the targets were reduced in number to 21: two are aimed at the year 2005, five at 2010, four at 2015, and 10 at 2020. There are two targets on solidarity and equity, three on life transitions and health (infants and preschool children, young people, and elderly people), four on preventing and controlling disease and injury, two on healthy lifestyles, four on health services (access, staffing, funding, and management), and six on other topics.19 The European Health for All programme shows that health objectives can be defined for a large population despite differences in culture, language, political structure, and stage of development across subpopulations.


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  		Fig 1.   The website for Healthy People 2000, which includes links to Healthy People 2010 documents, receives more than 8000 hits a month


    History of national health objectives in the United States

The effort to establish national health objectives in the United States has been longstanding. In 1979 the surgeon general's first report on health promotion and disease prevention, Healthy People, established broad national goals for improving the health of Americans at five major life stages (infants, children, 15-24 years, 25-64 years, and 65 and older) and identified 15 priority areas for public health action.20 A year later the US Department of Health and Human Services released Promoting Health/Preventing Disease: Objectives for the Nation, which laid out 226 objectives in 15 priority areas "for 1990 or earlier." The 15 areas were categorised into preventive health services, health protection, and health promotion.21

In 1991 the department released Healthy People 2000.22 It added several priority areas within the three categories used in Promoting Health/Preventing Disease and added another category, "surveillance and data systems." In its first iteration, Healthy People 2000 offered a total of 332 objectives in 22 priority areas in the four categories. In 1995 it was revised and 19 new objectives were added.23

After publishing Healthy People 2000 the department carried out an extensive programme to chronicle progress towards achieving the objectives and to stimulate supportive action at the state and local levels (fig 1). Comprehensive progress reports have been published annually since 1993, 23 24 together with reviews for specific priority areas and population subgroups (http://odphp.osophs.dhhs.gov/pubs/hp2000/prog_rvw.htm). Over 100 000 copies of Healthy People 2000 documents have been distributed, and the website (http://odphp.osophs.dhhs.gov/pubs/hp2000) receives over 8000 hits a month.25 A 1997 survey showed that all 46 responding states reported using Healthy People 2000 in setting their own health objectives; 33 reported using it "substantially," and 22 indicated that most or all of their published health objectives use the same measure as in Healthy People 2000.26

    Draft objectives for the year 2010

On 15 September 1998 the department released draft Healthy People 2010 objectives.27 The objectives were drafted by work groups with broad input from the Healthy People 2000 consortium, which now includes more than 340 national membership organisations.25 The department is soliciting public comments on the draft objectives up to 15 December and is posting those comments on the web (http://web.health.gov/healthypeople/1998.htm).

The draft document has ballooned in size to include 521 objectives in 26 priority areas (fig 2). There are two overarching goals: to increase quality and years of healthy life (to be tracked by 10 measures) and to eliminate health disparities (described as "a bold step forward from the goal of Healthy People 2000, which was to reduce disparities in health").


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  		Fig 2.   Growth in the number of national health objectives and priority areas in the United States

The priority areas are organised differently in Healthy People 2010, into: promoting healthy behaviours, promoting healthy and safe communities, improving systems for personal and public health, and preventing and reducing diseases and disorders. Several new priority areas (renamed focus areas in Healthy People 2010) represent important advances, including access to quality health services, safety of medical products, public health infrastructure, and health communication. Respiratory diseases and arthritis, osteoporosis, and chronic back conditions have been added as two new focus areas in the disease category.

The Healthy People 2010 draft is impressive in its scope, detail, and insight. Nevertheless, there are several major concerns.

Unwieldy size
The sheer size of the draft makes it unwieldy. Additional time, work, and money will be needed for tracking objectives, and the resources allocated for achieving them will be splintered further. Those in charge of Healthy People 2010 would do well to heed the UK Department of Health's reason for setting a small number of targets in Our Healthier Nation: "If everything is to be a priority, then nothing will be a priority."1

In the early stage of developing the Healthy People 2010 objectives, participants expressed divergent views about size. Some felt that "the encyclopedic nature of the [Healthy People 2000] document provides something for everyone to use." Others, however, questioned how so many areas could be priorities and recommended more focus.25

A major contributor to the size of Healthy People 2010 is the inclusion of "developmental objectives"---objectives for which current surveillance systems do not provide data. The purpose of the developmental objectives is "to identify areas that are important and to drive the development of data systems to measure them."27 As sensible as that rationale might seem, the inclusion of developmental objectives directly contradicts one of the seven criteria for Healthy People 2010 objectives: that objectives should be measurable.27

A modest number of developmental objectives might be allowed---but they account for 45% of the 521 objectives listed in the draft. Thus they are likely to divert substantial attention and resources away from objectives that can be measured. Growth in the number of objectives has got so out of hand that there are even objectives tracking the tracking of the objectives: "Increase to 100 percent the proportion of Healthy People 2010 objectives that are tracked at least every 3 years and to 70 [per cent] the proportion of objectives that are tracked annually."

Lack of balance
Inordinate size creates other problems: difficulty in maintaining balance and consistency across sections. The number of objectives per focus area ranges from seven (health communication) to 39 (maternal, infant, and child health). Is it appropriate to have 16 objectives for heart disease and stroke (the first and third leading causes of death in the United States) and more than twice that number (34) for environmental health? Greater effort is needed to control the number of objectives within each focus area, and to balance the number across areas.

Inconsistency
The format of objectives has been standardised across focus areas, but the content has not. This is not particularly surprising given that each focus area has its own work group responsible for drafting objectives, and that oversight of the work groups is divided among several federal agencies.

As an example of inconsistency, one objective is to "increase to 6 hours the average number of hours that medical school curricula devoted to training medical students in sleep medicine." Another objective calls for inclusion of a health communication/media technology curriculum in schools for health professionals. No other objective relates specifically to the education of medical students. Are medical students adequately educated regarding all areas covered in Healthy People 2010 except sleep medicine and media technology? Wouldn't it make more sense to consult with medical educators about deficiencies in medical school curriculums across all the focus areas, and then build in targets for improvement throughout the document? A more parsimonious approach might be to distil into a single objective a reasonable number of high priority areas for improvement in medical school curriculums.

Two examples in the section on sexually transmitted diseases are illustrative. One objective is to increase the use of contracting through the Medicaid programme (providing health care for poor people) to ensure coverage of and provider payment for counselling, screening, and treatment for sexually transmitted diseases. Another objective calls for an increase in the number of television networks that include positive messages about responsible sexual behaviour in their programming. No other objectives relate to Medicaid or television. Are there no other important Medicaid issues for the topics considered in Healthy People 2010? In regard to television, what about increasing positive messages (and reducing negative messages) about violence, or about use of tobacco and alcohol?

A systematic approach needs to be used to consider each type of strategy (professional education, counselling, screening, legislation, etc) across all the focus areas.

Undefined federal role
The draft objectives explicitly target many diverse sectors of society, including worksites and employees, students and educational institutions, states and communities, state and local public health agencies, restaurants, and the media, as well as healthcare providers, hospitals, managed care organisations, medical group practices, and health education centres. One target that is noticeably absent is the federal government.

Several objectives in environmental health (for example, monitor exposure of the US population to selected chemicals, provide technical assistance to other countries to strengthen their capacity to reduce environmental lead exposure, establish a tracking system for the exportation of pesticides) would seem to have the federal government as the primary target, yet its role is not mentioned in the draft objectives. Moreover, accompanying text is silent or ambiguous about the federal role, typically referring to the country's role.

Another objective is to "establish a single toll free telephone number for access to Poison Control Centers on a 24-hour basis throughout the United States." The supporting text notes that "the viability of many [centres] is threatened by reduced financial support from State and local governments and community hospitals." But the narrative fails to indicate or to suggest who should take responsibility for implementation. Who could facilitate attainment of this objective, and provide ongoing funding for it, besides the federal government? If no one is made accountable for it, there is less likelihood that anyone will feel compelled to do it.

One objective is to "extend to 50 States laws requiring helmet use for all motorcyclists." Accompanying text indicates that fewer than half of the states require all riders to use helmets, but the narrative neglects to mention the critical role of federal policy in leading us to this sorry state of affairs. In 1967 the federal government began requiring the states to enact motorcycle helmet laws in order to receive federal highway funds. Thirty seven states enacted helmet laws during the next three years and by 1975, 47 states had laws requiring all motorcyclists to use helmets. In 1976 Congress revoked the Department of Transportation's authority to penalise states without helmet laws. As a result, by 1978 seven states had repealed their laws and 19 states had weakened them to apply only to young riders (usually under age 18). Again in the 1990s Congress adopted, and then repealed, financial incentives for states to adopt helmet use laws.28 Thus federal policy has probably had the greatest impact on use of motorcycle helmets. Healthy People 2010 should have an objective for Congress to reinstate and maintain strong financial incentives for states to adopt motorcycle helmet legislation. And for those who might argue that a strong federal role in this area goes against the country's traditions of decentralised governance, it is worth noting that federal legislation signed into law in 1984 by President Ronald Reagan (and still in force) requires states to have laws prohibiting the "purchase and public possession" of alcoholic beverages by persons under age 21, in order to receive federal highway funds.

Another illustrative example is the objective to "increase the number of State and local public health agencies that provide continuing education and training to their employees to improve performance of the essential public health services." Essential public health services are defined: "monitor health status; diagnose and investigate health problems; inform, educate, and empower people; mobilise community partnerships; develop policies and plans; enforce laws and regulations; link people to needed services; conduct evaluations; and conduct research." Most of those roles apply to federal health agencies as well as to state and local agencies. Thus the draft objective raises the question of whether federal health agencies are doing all they should to provide training opportunities for their employees. The exclusion of federal agencies from an objective on training is presumptuous, potentially misguided, and likely to offend some state and local officials.

    Encroachment of politics

Healthy People 2010 may be skirting the role of the federal government because it is following the pattern set by its predecessor. Healthy People 2000 was put together during the Reagan and Bush administrations, when carving out new roles and responsibilities for the federal government and new reasons for federal legislation was frowned on. I had a close up view of the effect of that ideology on Healthy People 2000. As director of the federal office on smoking and health in the late 1980s, I served as joint coordinator of the tobacco working group for Healthy People 2000. One of the draft tobacco objectives (which were based on expert opinion, broad outside input, and extensive deliberations by the working group) was to "ensure that all tobacco product packages and advertisements provide information on all major health effects of tobacco use, including addiction, and identify product ingredients and harmful tobacco smoke constituents."29 That draft objective was dropped before the objectives were finalised22 because it would have required federal legislation and regulation. An objective to increase tobacco taxes, perhaps the most effective strategy to deter tobacco use, was not allowed, as tax increases were a matter of extraordinary political sensitivity at the time. Instead, five paragraphs of text about the value of raising taxes on tobacco were inserted into the narrative that accompanies an unrelated objective (that of increasing to 50 the number of states with plans to reduce tobacco use).22

When the objectives were revised in 1995 (by which time President Bill Clinton was in office), an objective was added: "to increase the average (State and Federal combined) tobacco excise tax to at least 50 percent of the average retail price of all cigarettes and smokeless tobacco."23 This addition was helpful, but the failure to include a specific target directed at the federal government reduced its accountability in meeting this objective. The federal government should be the primary target, because federal taxes cover the whole nation, and because states are often wary of raising their own taxes on tobacco due to concern that price disparities among states will lead to interstate smuggling.

The draft objectives on tobacco in Healthy People 2010 continue the dance around the federal role by proposing an objective to increase the price of (rather than the tax on) tobacco products. This not only spreads accountability among three levels of government (federal, state, and local) but also adds as a target the tobacco companies. It might be argued (cynically) that tobacco companies should be a target, because historically in the United States manufacturers' price increases have affected the retail price of their products to a much greater degree than have government taxes.30 But tobacco companies are unlikely to have any interest in helping the nation to achieve Healthy People objectives, and they have other motives to raise the price of their products.

The encroachment of federal politics in the Healthy People process is objectionable in its own right. But it is especially grating when one reads statements by federal officials that Healthy People 2000 "can truly be labelled a national, not just a Federal, initiative" and that "the Department [of Health and Human Services] has had the honor of serving as a convener and facilitator in developing these goals, but they truly belong to the Nation."22

Many or most federal reports must go through a "clearance" process, including review by the Office of Management and Budget and the White House, before they can be released to the public. Among the purposes of clearance is to ensure that these documents conform to the current administration's policy and ideology. That process is understandable, except for documents that are intended to represent national---as opposed to federal---policy. If the Healthy People 2010 objectives are intended to "belong to the nation" they should not be subjected to traditional political clearance in the executive branch of the federal government. They should be based on the consensus views of nationally representative participants, without the threat of tampering by federal officials. Otherwise, they should be called "federal objectives for the nation."

    Conclusions

The draft objectives in Healthy People 2010 represent the latest milestone in an impressive history of establishing national health objectives for the United States. However, the programme is expanding in scope and losing focus, whereas it should be narrowing its focus on the highest priorities. The important role of the federal government in enhancing and protecting public health is ill defined, and federal politics is tainting what is meant to be a consensus based health agenda for the nation.

A new approach is needed. Stoto et al have proposed a thoughtful alternative to the approach used in Healthy People (MA Stoto, B Berkowitz, JS Durch, unpublished manuscript).31 They recommend an abbreviated list of targets for health status and risk reduction that would serve as national health objectives. These would be supplemented by a longer list of performance measures that would be "actionable"---that is, they would allow specific entities to be held accountable for their actions to help achieve the national objectives. Unlike in Healthy People, these entities would include the federal government. For example, a performance indicator for Congress could be passage of federal legislation that provides incentives for the states to adopt strong motorcycle helmet laws, as noted above.

The Healthy People process may have gone too far down the road towards "national objectives for all by the year 2000" to allow a wholesale change in the direction of Healthy People 2010. If this is the case, then we will have to wait another decade---until planning for the 2020 objectives begins---for significant change in the process. In the meantime, health officials in countries initiating this process would be well advised to consider the different approaches used in the United States, the United Kingdom, Australia, and elsewhere, as well as that recommended by Stoto,31 so that they can learn from the experiences and mistakes of others.

    Acknowledgments

Ron Davis is the BMJ's new North American editor.

Competing interests: None declared.

    References

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(Accepted 7 November 1998)

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