Healthy People: A Uniquely Enduring Initiative Jason Davidson, Dan Johnson, Russ Wilson Weber State University

Healthy People: A Uniquely Enduring Initiative

The biomass of humanity exists on this planet in numbers which currently exceed 7 billion individuals. Virtually each one of these individuals lives within some kind of unit of society. Such units include: families, villages, towns, metropolises, states, nations, and continents. Within each of these units of societal organization there lie innate histories, governments, and cultures. While there are many aspects of the human condition which affect life in general, none may do so as decidedly as the notion of health. It is the purpose of this paper to examine the concept of health for these individuals and how that health is managed, fostered, and prolonged. More specifically, it will focus on the Healthy People initiative, how such an initiative came to be, how it affects the lives of the people under its authority, and how it operates in fostering the health of its people. Variola major and Variola minor are two virus variants which make up the disease commonly known as small pox. The Great Pox, as it was also known, was credibly evidenced as early as 3000 years ago (1145 BC) in Egyptian royalty, Ramesses V (Hopkins, 1980). This disease, known as one of the great plagues of humanity, is responsible for the deaths of an estimated 300-500 million people. What is the greater meaning of Variola major, and what relation does it share with the Healthy People Initiative? This condition produced the same effect for U.S. health policy makers that a small, round, red stitched

baseball provides for an 11 year old when, with the swing of his bat; he smashes it into the air and beyond the fence. The year was 1979. The month, October. The World Health Organization symbolically stood before the world and proudly announced that, with the exception of a few controlled outlier cases, the dreaded scourge of small pox had been virtually eradicated from the population general. Coincidentally or, at least with unintentional symbolism, on the very same day as the WHO announcement, Julius Richmond, the U.S. Assistant Secretary for Health and Surgeon General released: Healthy People: The Surgeon Generals Report On Health Promotion And Disease Prevention, 1979. It was released as a desire of Joseph Califano who, at the time, was serving as Secretary Department of Health, Education, & Welfare. The report was described at the time as a home grown, made-inAmerica product of a prior decade of federal and collaborating national organizations work on study documents as background to the Surgeon Generals report. (Green & Fielding, 2011) While it was Richmonds name on the front page, there were others who bore major roles in the crafting and development of the Surgeon Generals report. Two such individuals were William Foege and J. Michael McGinnis. What is interesting to note about these two men is their combined experience with the World Health Organization as they both had prominent roles at the international level in the small pox elimination campaign. Along with their new found confidence in the strategic ability of organized effort to eradicate public health

threats, they brought with them newly learned philosophical tools of the trade; namely: management by objectives. With the release of the Surgeon Generals report, and its espousal to the management by objectives paradigm, there came into the world of U.S. health care policy making a new or, at least revised, school of thought. The report signaled the intent to pursue a quantitatively objectives-guided approach. It presented a bold ten-year goal for reduction of mortality in each of four broad age groups and morbidity reductions in the elderly. (Green & Fielding, 2011) Those age groups were outlined as follows: Healthy Infants, Healthy Children, Healthy Adolescents and Young Adults, Healthy Adults, and Healthy Older Adults. In cleaner terms, the release of the report signaled the arrival of a preventative train of thought, instead of the predominantly reactive practices used in decades prior. It was this transition to defensive foresight that was offered as a remedy for the age old health care dilemma of finite resources vs. infinite demand. It was a somewhat radical way of thinking which suggested that, on a large scale, we can control (or at least influence in a positive way) population disease through our own actions, rather than simply being acted upon by the waves and surges of infection, sickness, and their resulting morbidity. Of the report McGinnis stated, It seemed natural to me that one of the potentially unique and distinguishing characteristics ought to be the expression of specific goals. The 10-year time frame was simply logical for the sake of convenience, practicality, and politics. Instead of being fast-pitched into strike-out after strike-

out of infectious disease endemics, they reasoned that through objective based, long-term goal setting, the policy making Louisville Slugger could finally make contact with the red stitched morbidity ball. With any luck, it might even be able to send it over the fence. At least, thats the dream. As time moved through the decade this Surgeon Generals report acted as both a foundation and springboard for a National collaborative effort towards: Eliminating health disparities Addressing social determinants of health Improving access to quality health care Strengthening public health services Improving the availability and dissemination of health related information. Federal agencies such as the Administration on Aging, Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Food and Drug Administration, and Health and Resources and Services Administration, develop and draft objectives. These objectives and goals are then made available for public comment which is then reviewed in Federal Workgroups. Currently the initiative is managed by the Office of Disease Prevention and Health Promotion within the U.S. Department of Health and Human Services. It is through the budgets of these agencies that the program is funded (HHS, 2013). With the arrival of the new millennium the Department of Health and Human Services readied a new set of Healthy People indicators, designed to meet two key goals - to increase quality and years of healthy life and to eliminate

health disparities between social groups. The Healthy People 2010 initiative differed from Healthy People 2000 in a number of ways. First and foremost the number of objectives measured by the initiative increased dramatically, from 312 to 969 (CDC, 2011). This reflected the governments increased attention to how many things in daily life affect health, but raising the number of items to track to such an overwhelming amount (and an even higher number for the 2020 initiative) also increased the bureaucratic load on the National Center for Health Statistics, whose job it is to gather and compile the information on the objectives (Davis, 2000). Second from the number of objectives was a refining in the focus areas of the initiative. The 2000 program gathered statistics on 22 overarching health topics. Healthy People 2010 increased this to 28, both improving on existing areas and adding new ones. Access to Quality Health Services Arthritis, Osteoporosis and Chronic Back Conditions Disability and Secondary Conditions Food Safety Immunizations and Infectious Diseases Mental Health and Mental Disorders Physical Activity and Fitness Substance Abuse Cancer Chronic Kidney Disease

Diabetes

Family Planning HIV

Medical Product Safety Oral Health Sexually Transmitted Diseases

Educational and Community-Based Programs Health Communication Injury and Violence Prevention Nutrition and Overweight Public Health Infrastructure Tobacco Use

Environmental Health Heart Disease and Stroke Maternal, Infant, and Child Health Occupational Safety and Health Respiratory Diseases Vision and Hearing

Even reducing the 969 objectives down to 28 focus areas still left the new initiative seeming incredibly large and unwieldy, so Healthy People 2010 went a step further and developed the concept of Leading Health Indicators. These indicators were intended to act as sentinels for the most important factors influencing the health of American citizens and to make the key objectives of the initiative more accessible to people at all levels, from national to individual. By condensing the most important aspects of Healthy People into more accessible, less bureaucratic components the hope of HHS and NCHS was give the initiative a more motivational factor (CDC, 2011). These leading health indicators are divided into issues that are commonly known to everyone as health concerns. The hope of those developing Healthy People was to have people engage in more physical activity, reduce the proportion of people who are overweight and obese, reduce tobacco use and the number of children exposed to tobacco smoke, reduce substance abuse among all age groups, promote healthy sexual behavior (primarily indicated by the reporting of condom use and the reduction of sex among minors), promote mental health (reducing suicide rates and increasing care for those with mental disorders), reduce injuries and violence, improve the environment by increasing air quality, increasing immunizations, and increasing access to health care for those without insurance (NCHS, 2012). The downside to the Healthy People initiative, in addition to the ever increasing list of health improvement objectives, is that it places most of the responsibility for improvement on state and local agencies such as departments

of health, schools, hospitals, businesses and families while leaving the role of the federal government somewhat nebulous and unclear. This lack of direction from above leaves many of the objectives improving at a slower rate than they otherwise might, but improvements are still being made. With so many objectives listed by HHS any state or local agency can choose a few specific ones to focus on, improving health at a slower pace but with a more concentrated approach that it might not otherwise have taken (Davis, 2000). The sheer amount of data collected by the NCHS for Healthy People is also a powerful tool in itself, providing benchmarks for health organizations to compare their own progress to, and a framework on which to build localized health improvement programs. This position of counterbalancing bureaucracy with detailed statistical data gathering and health guidelines is where Healthy People found itself through the decade following the turn of the century. Mountains of statistical data was gathered to measure the progress of Healthy People 2010, with the final review clocking in at over 550 pages, but in terms of reaching its two primary goals, increasing quality and length of life and reducing the disparities in health between social groups, the initiative did made progress, but at a slow pace (as might be expected for such a massive undertaking). Out of the 733 objectives that had tracking data 48% made at least some progress in the direction of the stated goal, while 23% met or exceeded the targeted value. Some of the picture was negative, however, with 5% of the tracked objectives demonstrating no change, and 24% actually negative and moving away from the goal set out by DHHS. The focus areas that showed the

most positive progress in improving health were those of occupational safety and health, immunizations, and environmental health, while the area with the largest negative progress by far was nutrition and weight management (NCHS, 2012). The conclusion to take away from the health data gathered in the first decade of this century is one in which health programs and preventative medicine are making great strides in improving the health of Americans, but our national struggle with poor nutrition and obesity continues to be one of the largest red marks on our national reputation. The disparities in health quality and access among different ethnic and socioeconomic groups did not show much change at all, so the health initiatives of the new decade will have to provide even more impetus for improvement, and with even more objectives and focus areas Healthy People 2020 is looking to do just that. Healthy People 2020 is a science based 10 year health initiative, also overseen by the U.S. Department of Health and Human Services. It is designed to reduce or eliminate illness, disability, and premature death among individuals and communities, (U.S. Department of Health and Human Services [DHHS], 2013), among several other broader issues. From December 2010 to December 2020 Healthy People encompasses 600 Objectives and 1200 measures covering 42 topic areas. Each objective and measure is aimed to improve the health of all Americans and is set to be fulfilled in all communities through out the United States. All objectives have a reliable data source, a baseline measure, and a target for specific improvements to be achieved by 2020 (DHHS, 2013).

The undertaking of Healthy People 2020 seems almost impossible to attain given the history of America and its limited attention given to health prevention and promotion. The United States cultures primary emphasis has predominantly been tertiary care. Momentum is building from the success and data gathered from previous Healthy People models and the passing of new legislation under the Affordable Care Act. Health promotion and prevention is slowly moving into the mainstream (Cottrell, Girvan, and McKenzie, 2012). So how did these objectives and measures come about? More importantly, are they going to do any good to improve the quality of health of Americans? Both are valid questions that deserve attention. The remainder of this paper will take a closer look at how Healthy People 2020 was developed, the Healthy People 2020 goals, and the expected impact. Prior Healthy People accomplishments provided health based objectives and initiatives that focused on interventions. The successes and defeats that came from prior Healthy People models have helped in the process of developing new initiatives for 2020. In addition to prior experience, 2020 also received input over several years from a diverse group of individuals and organizations. These individuals and organizations were leading federal agencies, a federal interagency workgroup, and the general public. Also involved was the Secretarys Advisory Committee on National Health Promotion and Disease Prevention Objectives (DHHS, 2013). The initial step in the process of developing Healthy People 2020 was to create topic areas. Leading federal agencies, all which have seasoned experts in

their respective fields, developed these topic areas. These agencies included, the Administration on Aging, Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Indian Health Services, National Institutes of Health, Office of Minority Health, Office of Population Affairs, and many others. All of these agencies, and others not listed, contributed substantial work to create these topic areas. After these experts came up with proposed objectives, the Federal Interagency Workgroup then reviewed the objectives. The Federal Interagency Workgroup (FIW) was formed to not only review the topic areas created by the lead federal agencies but to also lead out in the development effort. The U.S. Department of Health and Human Services was just one among 8 agencies that formed the task force, including: the U.S. Department of Agriculture, U.S. Department of Education, U.S. Department of Housing and Urban Development, U.S. Department of Justice, U.S. Department of Interior, U.S. Department of Veterans Affairs, and the Environmental Protection Agency. The FIW used the result of 4 previous Healthy People initiatives which include: 1979 Surgeon Generals Report, Healthy People: The Surgeon Generals Report on Health Promotion and Disease Prevention, Healthy People 1990: Promoting Health/Preventing Disease: Objectives for the Nation, Healthy People 2000: National Health Promotion and Disease Prevention Objectives, and Healthy People 2010: Objectives for Improving Health, to learn from the past efforts. In addition to the topics being reviewed by the Federal Interagency Workgroup, these topics were also available to the public for comments and feedback.

Public comments and feedback were done in several phases of the development process. Phase one entailed contributing a comment regarding the vision, mission, and implementation. The feedback received was then directly implemented into the framework of Healthy People 2020. The second phase encompassed what was then the proposed Healthy People 2020 objective. Thoughtful public comments helped shape the final set of objectives. The third and final public comment phase was to comment on the new objectives to be added in the following topic areas: HIV, health related quality of life and wellbeing, and social determinants of health. The public was also encouraged to suggest additional objectives focused on critical public health issues that might exist within the already determined 42 topic areas. Additionally, the twelve members of the Secretarys Advisory Committee on National Health Promotion and Disease Prevention Objectives also contributed to the development and implementation of healthy People 2020. They produced recommendations on format, framework and guidelines for implementation (DHHS, 2013). The U.S. DHHS sums up the development process by stating that healthy people 2020 is, the product of an extensive stakeholder feedback process that is unparalleled in government and health. It integrates input from public health and prevention experts, a wide range of federal, state and local government officials, a consortium of more than 2,000 organizations, and perhaps most importantly, the public. More than 8,000 comments were considered in drafting a comprehensive set of Healthy People 2020 objectives (DHHS, 2013).

The painstaking process to develop the 2020 model appears to have left no stone unturned, with a much broader vision, mission, and goals than ever before (see appendix for a concise list of vision, mission, and goals). The goal is to be a resource for all Americans and serve as a guide for health education professionals. The website, www.healthypeople.gov, is full of information and resources free to the public including web seminars, lessons, discussions, and continuing education. It also has contact information on how to get involved in ones own community. Every topic has objectives and goals that correspond to the overall mission and goals of Healthy People 2020. Because there is so much information, it can be difficult and overwhelming to know where to get started. Healthy People has created Leading Health Indicators which are the top 12 priorities and include what people can do to get involved (DHHS, 2013). Involvement by individuals, organizations and professionals is key to the success desired by 2020. Databases are provided to do research to find what interventions would best fit a particular community. Also, unlike previous Healthy People models, 2020 felt that implementing an action model known as MAP-IT (Mobilize, Assess, Plan, Implement, Track) would help achieve the Healthy People goals (Cottrell, Girvan, and McKenzie, 2012). Arguably, the most difficult task in the whole process, as in prior models, is to accurately track and measure data pertaining to each objective (Schneider, 2014). Healthy People is currently using various data systems such as vital statics systems, surveys, and data from safety institutes to accomplish this task. The public and health professionals are able to access current data regarding

any objective or measure to see how it is progressing. As a whole the American people are healthier now than in the past. The Institute of Medicine commented in 2002 by every measure we are healthier, live longer, and enjoy lives that are less likely to be marked by injuries, ill health, or premature death (Institute of Medicine [IOM], 2002). Healthy People has had an impact on the overall health of Americans and it appears to be the model the nation will follow for the foreseeable future. Although the nation has been slowly moving in the direction of health promotion over the past 50 years the Patient Protection and Affordable Care Act will speed up the process to a much faster pace with both political and financial support. The Affordable Care Act has a wellness and prevention provision dedicating funds to prevention and public health, receiving up to 1.25 billion dollars and school health receiving another 50 million in 2013. In 2014 benefits will be given to individuals participating in wellness programs and meeting certain health standards. Prevention and public health will receive another 1.25 billion dollars and school health another 50 million in 2014 as well. The law allocates the same 1.25 billion and 50 million in 2015 and beyond (Cottrell, Girvan, and McKenzie, 2012). Health promotion breaking into the mainstream will create more excitement and generate more support, shifting the emphasis from tertiary care to prevention. The Healthy People goals and objectives have become the defined national health agenda and have helped produce a healthier population in the United States than ever before. It is clear to see that a substantial amount of time, money, and research

was put into the development of healthy people 2020 and that the model is having an impact on overall health. The looming question remains whether 2020s comprehensive and vast goals will all be met. This question will remain unanswered until the arrival of 2020 and the final analysis of the decades achievements. Even so, Healthy Peoples future looks bright with growing support from all sectors. Many, if not all, Americans will feel its impact.

APPENDIX A: Healthy People 2020 Overview Vision A society in which all people live long, healthy lives. Mission Healthy people strives to: -Identify nationwide health improvement priorities. -Increase public awareness and understanding of the determinants of health, disease, and -disability and the opportunities for progress. -Provide measurable objectives and goals that are applicable at the national, State, and local levels. -Engage multiple sectors to take actions to strengthen policies and improve practices that -are driven by the best available evidence and knowledge. -Identify critical research, evaluation, and data collection needs. Overarching Goals -Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death -Achieve health equity, eliminate disparities, and improve the health of all groups. -Create social and physical environments that promote good health for all. -Promote quality of life, healthy development, and healthy behaviors across all life stages.

Sources: CDC. (2011, November 8). Healthy people 2010. Retrieved from http://www.cdc.gov/nchs/healthy_people/hp2010.htm Cottrell, R, Girvan, J, & McKenzie, J. (2012). Principles and Foundations of Health Promotion and Education. San Francisco: Benjamin Cummings. Davis, R. M. (2000, March 25). Healthy People 2010: Objectives for the United States. British Medical Journal. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127182/ Green, L. W., & Fielding, J. (2011). The U.S. Healthy People Initiative: Its Genesis and its Sustainability. Annual Review of Public Health, 32, 451470. http://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth031210-101148 Hopkins, D. R. (1980, May). Ramses V: Earliest Known Victim?. World Health Organization, 22. Retrieved from http://trove.nla.gov.au/work/47660767?q&versionId=60572418 Institute of medicine (IOM). (2000). Brief Report. Promoting health: intervention strategies from social and behavioral research. Retrieved November 10, 2013 from http://www.nap.edu/openbook.php?record_id=9939&page=1 National Center for Health Statistics (NCHS). (2012). Healthy People 2010 Final Review. Hyattsville, MD: U.S. Government Printing Office.

Schneider, M. (2014). Introduction to Public Health. Burlington: Jones & Bartlett Learning. U.S. Department of Health and Human Services (HHS). (2013). HealthyPeople.gov. Retrieved October 23, 2013, from http://www.healthypeople.gov/2020/default.aspx