DEPARTMENT OF HEALTH AND HUMAN SERVICES
Meeting of: Secretary's Council on National Health Promotion and Disease
Prevention Objectives for 2010
September 12, 2000, Proceedings
Agenda Item: Reflections of Former Assistant Secretaries for Health
James Mason
Julius Richmond
Edward Brandt, Jr.
Robert Windom
Philip Lee
DR. SATCHER: I'd like to stop now and ask for comments from the Assistant Secretaries for Health, including reflections if you would like on your experience with Healthy People.
Jim, why don't we start with you, because you have a lot to reflect on, just joining us after a long period of time. We are delighted to have you and delighted to hear your perspective.
DR. MASON: It is good to be back. It seems to me that, as I reflect on this, the dramatic success that has occurred over the past 21 years since our first meeting in 1979 is really remarkable.
As I read the material for this meeting, I had no idea of the amount of progress that had been made. Between 1979 and the year 2000, mortality rates have fallen -- for infants, 50 percent, children, 40 percent, adolescents and young adults, 20 percent, adults, 31 percent, and, unfortunately, for older adults like me, only six percent. But that is remarkable. I think that's a real tribute to the Healthy People process. Although we have a long way to go, we can be proud of those fantastic achievements.
In reflecting on the past, I think our success is largely due to this being, as you have already mentioned, a non-political, non-partisan activity. It started under the Carter Administration, Julie Richmond, and then it flowed smoothly during the Reagan, Bush, to the present Clinton era, and it has continued unabated by changes and politics or partisanship. I think if we are going to continue to have the success that we have had in the past, it is absolutely imperative that this non-partisan background for Healthy People continues. It doesn't matter which party is in power in Congress or the White House; this has to go on, because continuity is fundamental to this kind of success.
I think we have been successful because each of the people, Assistant Secretaries and others responsible, has believed in bottom-up rather than top-down planning. These are national, not federal, objectives. I think that considerable progress has been made in the last 21 years in developing that bottom-up type of planning.
The Consortium, the reaching out, is much more successfully done. We didn't know how to do it 21 years ago, and I think we have yet a ways to go, but we are doing a far better job now than we ever have in the past. I think our success will depend upon greater involvement of others.
We have to realize that the work doesn't get done at the federal level, at the top level. There's an important role for you and the Secretary and the President, but the work is done at the local level with the coordination at the top. I believe that this success that has been achieved is largely the result of efforts that start at the individual level, the family level, the community level, the state level, and then, finally, what we can do at the federal level. Each of those levels has to be recognized for what it can contribute.
I think we are all concerned about the disparities that you have already talked about. We recognized those disparities early. I think it's marvelous that we have gone from recognition to, then, Healthy People reduction of those disparities, and isn't it wonderful that we have arrived at the point where we think we can eliminate those disparities?
I think this is going to take a lot of work. It's one thing to have a slogan, eliminating those disparities, but those of us around the table, and right down to the individual and family, are really going to have to accomplish a lot. I think we must focus on doing something. This must be our highest priority.
I believe in -- having stressed how important it is that things happen at the grass roots level, I nevertheless want to emphasize how important it is for leadership and coordination at the federal level, at the national level. The further reduction in mortality will not occur if things are left to themselves. That is the greatest impact that can occur, that this coordination and this leadership occur.
I think that leadership occurs through a lot of the things that you have been doing. I think that we have to improve the database; it needs to be improved and expanded. We have to continue to involve people at all levels. I think we have to hold the nation's feet to the fire, and that's part of this accountability.
I hope that, as we look at these statistics, as Bill Foege, the former Director of CDC, always reminded us, we have to see a face behind every statistic. There are faces, and these are people, and they are important to us.
So I just end on the importance -- even though the work doesn't get done here, the leadership and the coordination and the holding people to responsibility does. I just believe that, with the continued focus that you are providing, we can do even more than we have done.
DR. SATCHER: Thank you very much for those insightful and invigorating remarks. We appreciate that. Why don't we continue? We don't have any particular order. Julie, do you want to --
DR. RICHMOND: My name has already been invoked. I guess I'm the culprit that initiated this effort. But let me, perhaps, just take a few moments to look at why we did this, why we initiated this effort in the late '70s, and do it somewhat in historical terms. By historical, I really mean the health record of the nation over the 20th century, to do it in terms of the century.
Since my background has been in pediatrics and in child psychiatry, I had been aware of course of the very sharp reduction that had taken place in the early decades of the century in the acute infectious diseases.
Just anecdotally, I can say that I calculated how I spent my time as a pediatric resident. This is just prior to World War II; that tells you a little bit about my age. I calculated that I spent half of my time taking care of children with diseases that our medical students, if they are trained in this country, will not see. So this was a remarkable transformation that I witnessed.
But concomitant with that transformation in the early decades of the century, a feeling had developed that we have been there, done that, and we're not going to see any really great advances in the future. There was the feeling that the non-infectious diseases, largely multi-factorial in their genesis, really could not be touched. As a matter of fact, some demographers wrote editorials in the American Journal of Public Health saying things like that.
But as one of our late colleagues, who was one of the founders of the IOM, Dr. Walsh McDermott, was fond of saying, while nobody was looking, we began to see a very significant reduction in mortality from heart disease and stroke. This rang a bell. We said, well, if we can do this with these multi-factorial diseases, why can't we do this across the board?
We then began to develop the notion that we ought to set some goals, building on the old Wizard of Oz comment that, if you don't know where you're going, any old road will do. So we decided we ought to try to set 10-year goals and to try to institutionalize that process.
As Jim describes so beautifully, the subsequent Assistant Secretaries followed through on that, and really implemented this process. So we are just through the third iteration of the establishment of health goals for the year 2010, and we are very indebted to David and all of his colleagues in the Public Health Service for having done this.
Now, in order to do this, we drew very, very heavily on, of course, the research base, the knowledge base that is so critical, of the NIH. Ruth Kirschstein, who is here, played a continuing role in that process, in keeping NIH actively involved, and the CDC, and particularly the Center for Health Statistics, which I keep saying is our directional compass that really tells us what directions we ought to be going in.
But we also involved our colleagues in the non-governmental sector, and particularly through the IOM, and they provided the scientific documentation. So in the first iteration, we had two documents. We had the setting of health goals, and we also had the documentation which the IOM provided, and we are very much indebted to them.
Now, the process in terms of numbers of goals -- and I'll just pick up on David's comments for a moment -- we set some macro goals by age groups in our first document. We set out goals for infancy, early childhood, childhood, 12 years, and then the older years. Interestingly enough, since Jim has already indicated that we haven't made quite as much progress for older Americans, we couldn't define really how to put these goals. So we really ended up not thinking of mortality rates as we usually do, but we thought of functional capacity. I think that still remains a pretty good way to set those goals.
But then, as David pointed out, all of our constituencies in the public health and health community broadly descended on us, particularly when Bill Foege, as the CDC Director, convened a conference for us in Atlanta -- people from all around the country and indeed around the world. All of these people descended and said, you can't just stay with those five macro goals, you've got to have all of these others. So we ended up not with 300 and some, David, but with 226.
But I think that David has indicated that this has been one of the problems. Since we are talking about what we have accomplished, we also should talk about the problems. People do have problems in dealing with the multiplicity of health goals.
I think the notion of health indicators that David has described is an excellent way to begin to develop a focus that is clear. We on this Council tried to be helpful a little bit in developing this diagram, which really puts all of the health goals under the three rubrics that David identified as promoting healthy behaviors, promoting healthy communities, and preventing disease and disorders, and doing this through the reduction of disparities -- purveying the notion of reducing disparities, geographically, economically, in all kinds of ways. More recently we have been talking about nutrition and obesity and physical fitness. We have great disparities in our population there.
So I think the notion of reducing disparities is conceptually a very, very effective way to go. But I think, within those targets, my own feeling is, we've got to highlight rather pointedly certain of the very major problems that we have to tackle. I think the recent release of data on the increase in type two diabetes associated with increasing obesity in the nation is one that I think we have to focus on more pointedly.
The other, and this is historically one for our Surgeons General since Surgeon General Luther Terry's first report in 1964, is not alone reducing smoking rates, but also, particularly, targeting teenagers for prevention. I think that that task remains largely undone, and that is another emphasis that I would like to see.
But I think conceptually -- if we can convey to the public health community that there is some order in these 600-odd health goals, and they fall under these rubrics -- that it will be a good service. I'm sorry, I think I've gone on a little too long.
DR. SATCHER: You've got it up to 600 objectives; you started with 400 and something. Thank you very much, Julie. We appreciate all of your work in this area over the years.
Let's continue. First, let me thank you for your support in our efforts with the rotovirus vaccine, and helping us to look critically at what can happen in bringing agencies together.
DR. BRANDT: Julie, you're not off the hook. When I showed up here in 1981, we had the objectives that Julie and his colleagues had developed. He left out one thing; he didn't tell me that we were going to discover AIDS right off the bat. But other than that -- and we set about trying to implement them by making assignments to Public Health Service agencies and trying to encourage states, working with ASTHO and other groups to adopt their own objectives that were important to each state, and hopefully down to the counties and other activities.
I think the fact that we have made a lot of progress is impressive. One of the things that I like about the 2010 objectives is that we are now able to start moving towards morbidity measurements. I think it is one thing to reduce deaths from heart disease, but it is quite another if we can reduce MI's to begin with, which is what I would like to see us do.
I agree with your 10 indicators completely. I think they are right on target, and I think it is high time that we began to address some of the problems that we haven't addressed as well as we certainly could.
I'm impressed, like Jim Mason said, with how much has been accomplished since 1979. It doesn't mean that we can quit; we've got a lot more to do. I also agree that this has got to get down to the local level. I'm pleased to see that you've got business involved and other kinds of organizations involved, because that is very important.
I do think your leadership has been important and will continue to be important, and those of us that are also still working -- Julie, I want you to know -- are trying to make sure that we do accomplish this goal. You have my vote and my assurance to you that at least now in Oklahoma, we want to make it the healthiest state in the union, but we've got a long ways to go, let me tell you.
DR. SATCHER: I was really impressed when I was with you in December with the Healthy Oklahoma project that the Oklahoma Medical Association did. Thank you very much. Next we have Bob Windom, who has really been a force in this effort. He has taken this to the American Medical Association and a lot of different areas of the country, and he continues to write op-ed pieces to keep people aware of their responsibilities. Bob?
DR. WINDOM: Thank you, David. Well, as Ed was saying when he was here, the early part of AIDS was a big issue. I think neither one of us or anybody realized it was going to have such an impact on other infectious diseases for us to deal with.
So as I came on in '86, like Julie said, 50 percent of his early days was with infectious disease. Well, over 50 percent of our time had to be spent with trying to educate the public on this disaster, as far as infection was concerned.
In so doing, we found a great difficulty in getting the people to realize what we were really saying to them. There was a lot of publicity about it in the papers and so forth, but we didn't seem to find that young people were changing greatly when they were supposedly reading these bits of information. That led to our sending out for the first time a mailing to every household in the nation, some 110 million homes, a $20 million effort that the President allowed us to do. Still, with that brochure, somehow we didn't quite reach everybody or, at least, they didn't read it.
So I think today, as we are looking forward to this work in progress that is in its third decade, we still are lacking to really get down to permeate all the way through to reach the real youth of this nation. In Florida, we have a problem with our aquifer, of getting water down to permeate through the sand and soil from the top down. I think we need to look more as to how we can permeate into the youth of this nation.
That leads me to the idea that I think might be helpful, to have us take as our ambassadors people who are looked upon by the youth of our nation. Tiger Woods, Serena Williams are outstanding examples that almost every child today looks to as individuals who are able to be successful, not a team of football players or whatever, individuals who have succeeded so well.
If they could come on board, we'll get together and have some brainstorming, to see where they could participate, as they almost daily are in contact with youth, and say, by the way, did you have your five fruits and vegetables today, or why are you not exercising enough? Exercise is doing good for us, and so forth.
I think the youth will be responsive to things like that. If we don't get the good habits started, everybody in this room knows how difficult it is with every bad habit. We have to break it, once it has been so well established. So I think we need to get these icons in the national arena to help be our spokespersons and to help reach out to that area.
So I think that communication is the name of the game, to get the word out in whatever way we can. Maybe we need to have a major public relations firm be a part of it. It may cost money to some extent, but I think the cost on the topside would certainly be productive and less expensive in the long run by the benefits that might come from this type of association.
So I'm encouraged, the way things are going, though. In Florida, we're speaking out to counties coming together and having meetings, and talking to them about the whole program. Our state health director, Dr. Brooks, has been here at this table before, and he is very concerned about pushing prevention. In fact, he does not make any public appearance, in which, no matter what his subject is, he doesn't end up with personal time devoted to prevention. That is our real message that we've got to get across.
So it is a work in progress, and I think we're going to be successful with better improvement of the parameters of the data that we are looking forward to. But I think in the long run, over the next 20, 30 and 40 years, the young kids today need to have good direction that will make them healthy. Some of us older ones are not going to be covered much from what we do, but we still ought to keep trying, and not give up until the last day.
So anyway, that is what I would like to offer as a suggestion.
DR. SATCHER: Thank you. We will certainly take that suggestion. I think you're right. I think the real challenge that we face now is communicating this message effectively, especially to young people. Your ideas are ones that we will certainly consider. I may have to have you call Tiger and Venus for us, and get them on the phone. But I think it is a great idea, because we need positive role models for our young people, and people that they will in fact listen to.
DR. BRANDT: I saw what Nike does and what American Express does. They have these repeated, repeated things that makes people look at them. They know that they represent some message. It is over and over, repetition.
DR. SATCHER: Dr. Lee?
DR. LEE: David, I want to comment in three areas. I want to follow the advice of President Johnson, who told us, when we were drafting speeches for the White House, to point with pride, view with alarm, and then say what we were going to do.
First of all, I think the goal to eliminate health disparities is a major contribution. It will be a very difficult task, but it is, I think, critically important to have that as a goal.
Second, the conceptual basis for Healthy People 2010 for the first time is based on the health field concept, or the determinants of health. Even though that was implicit in earlier Healthy People goals and objectives, it wasn't specifically articulated, which it has been.
The third contribution is the Leading Health Indicators. I think there, we need to look not only at lifestyle and health systems, but we also need to look at socioeconomic status. The best indicator of health status is socioeconomic status. There is evidence from Marmot's and other studies that, in the last 20 to 30 years, that has become more important than behavior -- behavior both for a long period of time, both on the good side and the bad side, things like smoking and drinking and other behaviors -- very important.
Several other developments are I think very, very encouraging. One is at the community level, the civil engagement process that is going on far beyond public health. We will be dealing with some of that later on in the meeting, the development of collaborations, partnerships. There is a phenomenal amount of activity, and we need to find ways to support that.
Second, on research, molecular biology, the Genome Project, is certainly going to have a huge impact, and we need to look very carefully at where and how that is going to impact on the ethnic health disparities. That is a major factor. When you eliminate socioeconomics, there are still racial/ethnic differences that are significant. The Genome Project as it is currently configured at least may help more the people in the upper socioeconomic stratum, and Caucasians rather than minorities. Actually, you can hardly call them minorities, at least in California, anymore, because Caucasians are no longer in the majority.
DR. SATCHER: That's right.
DR. LEE: The second development, now in technology, and then informatics -- in all of those areas, very, very important developments that will have a positive potential impact.
Then, if we look at, view, with alarm, I did want to cite two reports. First of all, the World Health Organization World Health Report 2000. Despite the progress that we have made, the United States ranks 15th in this overall analysis among about 191 countries, on the overall health system attainment. Japan is the number one system, number two, Norway, number three, Sweden. We're 15th.
And then, when it comes to performance, the health system performance, the United States ranks 37th, and France is number one. Now, that's the gist, that we have a lot of work to do.
A second report is the recent report of the Pew Commission, and they have -- I'll just use one quote; this is their Commission on Environmental Health. They say, as the Commission's earlier reports on birth defects and asthma illustrate, we have lost our focus, commitment and capacity for preventing these diseases, often abdicating to the endless search for miracle cures and costly treatment. Some states and communities have made heroic efforts to put an integrated public health system in place, but the federal government has failed to provide them with the weapons they need to do so. Our next President and Congress have the responsibility to focus on a national agenda on improving public health and protecting the public against environmental threat. Certainly, we have heard none of that from either of the major Presidential candidates or the other candidates as well.
So I think we have very serious structural problems that won't be solved by communication. They won't be solved by people changing their behaviors, but will involve a major effort on the part of the federal government as well as other levels of government and the private sector.
Now, in terms of what can we do about it, it seems to me that we have a framework. The Pew Commission has made some very excellent suggestions. Jo Boufford and I are working on a little project which we call Health Policies of the 21st Century, a little modest effort. My son Paul and one of his colleagues have done a little piece for us on the Internet. It is very impressive, what has been happening, and the opportunities that exist in that area.
I would say that that is one area that perhaps, David, we could have a future meeting focusing on the national health information infrastructure. We have the report from the Advisory Committee for the National Center for Health Statistics, towards a healthy information infrastructure. There, a major contribution is made, in that it focuses not just on the personal or, one would say, consumer perspective and the second provider, but also on the community.
There is also, in the Public Health Service, the National Library of Medicine, the National Center for Health Statistics, CDC and HRSA, all doing very, very important work. The National Research Council Computer Science and Telecommunications Board had a report, Networking for Health, Prescriptions for the Internet. Then your panel on interactive communication in health, Wired for Health and Well-Being: The Emergence of Interactive Health Communications. Finally, the PHS's, or the Department's, Informatics Initiative -- very, very important. Currently we have about 212 data resources in the Department;
75 percent focus on infectious diseases or infectious agents and medical treatments. Thus, three-quarters of the data collection focuses on one-tenth of the determinants of health.
Earl Fox has got a $25 million initiative, and we have got a -- what is it, maybe $40 billion budget -- (Break in recording as tape ends before another commences) --
$25 million as glue money for information systems, trying to glue the various separate pieces together.
But the initiative, the Department initiative on informatics, has three priorities: fund state-level initiatives that apply new informatics and statistical techniques to model population health dynamics; second, link Health and Human Services, housing and non-traditional areas such as criminal justice and transportation; and third, create new informatics methods to assess discrimination in the health field. Very focused.
We need resources to move that forward, because I think there is no area -- I would say the two areas that are going to contribute the most -- one will be, other than the changes and the improvements in the socioeconomic status, if you can continue and have a better distribution of the economic gains that we have made, which of course have been helping the upper class more than the working class. So we need to have some focus there on improving the circumstances for people in middle income, lower income.
But I think, by increasing investments in the informatics infrastructure and using the technologies to apply around chronic disease as a few people have, we can shift the focus. We still have a medical system that focuses on an acute care model to deal with the huge chronic illness burden, and does not focus on prevention.
So those are my thoughts. It's a little bit hair-shirt, but I think we need to really look at some of the areas of opportunity as we go forward, and see how these resources, and how the federal government, can contribute to making this whole thing even more effective.
Thanks.
DR. SATCHER: Thank you very much for those comments. Very helpful. We have debated a lot the whole issue of socioeconomic status and realize that it is really pervasive in all of these things we are discussing and trying to do. I think we still struggle with how to best integrate that.
I was just in China two weeks ago for the World Federation of Public Health Association meetings, in which they asked me to talk about disparities from a global perspective. Clearly, when you look at disparities from a global perspective, the role of socioeconomic status just stands out, as it does in this country even though different racial and ethnic groups tend to line up in a certain way around social and economic disparities.
DR. LEE: Right, right.
DR. SATCHER: So I think your point is very well taken.
DR. LEE: But you have made a tremendous contribution, first of all to make this the priority area, to even get the President to buy into it, so that now, there is a tremendous interest in this, and looking for ways -- okay, how do we deal with these problems.
DR. SATCHER: Very good. Thank you. I am really very impressed by the comments that the former Assistant Secretaries for Health have made. I know we always record these and have them on transcript, but I think this time, what we probably should do is send the comments to them to edit, because I think we really ought to use these comments as we move forward -- very rich and helpful comments.
So I thank all of you for the thoughtful way in which you approached your comments this morning. I think it will be very helpful to us as we move forward.
We are going to take a few minutes break, because we need to do a photograph. Unfortunately, Phil, you won't be able to join us for this, but we're going to take a photograph. Then we're going to come back, and Randy is going to lead our discussion --
DR. RICHMOND: Call it a virtual photograph.
DR. SATCHER: A virtual photograph of Phil.
DR. LEE: Right, right, right.
DR. SATCHER: That's technology you're talking about.
DR. WYKOFF: We'll splice it in later.
DR. SATCHER: Why don't we take a stretch break.
(Brief recess)
DR. SATCHER: -- very important points made by the Assistant Secretaries for Health, which we hope to capture for you. I remember that Dr. Mason pointed out that this is not a federal project, but a national project. It involves federal, state and local government. It involves the private sector.
But I think one of the real challenges that we face is to enlist, effectively enlist the efforts of additional collaborating organizations from outside of government. That is really what we are going to talk about today, for the rest of the day.
When we had the launching of Healthy People 2010, we had the so-called Conference edition of the 2010 document. It's called Partnerships for Health in the New Millennium. That was not the final edition, as we pointed out. That would be superseded by a final edition that will be distributed in November when we have the Consortium meeting in Boston on November 11. We are going to make sure that each of you gets a copy of that final edition.
But also, mark your calendar if you can participate in the November 11 Consortium meeting. By the time of that meeting, we hope also to be fairly far along with a new approach for increasing the contribution of partnering organizations in our joint effort to realize these two goals, improving years and quality of life, and eliminating disparities, and all of the objectives for Healthy People 2010.