SECTION I - TOWARD A HEALTHIER AMERICA CHAPTER I INTRODUCTION AND SUMMARY The health of the American people has never been better. In this century we have witnessed a remarkable reduction in the life-threatening infectious and communicable diseases. Today, seventy-five percent of all deaths in this country are due to degenerative diseases such as heart disease, stroke and cancer (Figure 1-A). Accidents rank as the most frequent cause of death from age one until the early forties. Environmental hazards and behavioral factors also exact an unnec- essarily high toll on the health of our people. But we have gained important insights into the preven- tion of these problems as well. It is the thesis of this report that further im- provements in the health of the American people can and will be achieved--not alone through increased medical care and greater health expenditures--but through a renewed national commitment to efforts designed to prevent disease and to promote health. This report is presented as a guide to insure even greater health for the American people and an improved quality of life for themselves, their children and their children's children. Americans Today are Healthier Than Ever Since 1900, the death rate in the United States has been reduced from 17 per 1,000 persons per year to less than nine per 1,000 (Figure 1-B). If mortality rates for certain diseases prevailed today as they did at the turn of the century, almost 400,000 Americans would lose their lives this year to tuberculosis, almost 300,000 to gastroenteritis, 80,000 to diphtheria, and 55,000 to poliomyelitis. Instead, the toll of-all four diseases will be less than 10,000 lives. - - 1-3 FIGURE 1-A DEATHS FOR SELECTED CAUSES AS A PERCENT OF ALL DEATH& UNITED STATES, SELECTED YEARS, 190&1877 Influenza and weumonia 100 90 60 70 60 I- f 0 60 f 40 I- 30 I- 2c I- ia l- 0 m Major cardiovascular diseases 0 All other causes 1900 1920 1940 1960 1970 1977 NOTE: 1977 data are pro”,mnal. ata ‘or #I Other year5 are flrldl. Source: National Center for Health Statistics, Division of Vital Statistics l-2 FIGURE 16 FIGURE 16 DEATH BATES BY AGE: UNeTED STATES, DEATH BATES BY AGE: UNeTED STATES, SELECTED YEARS lsoOl977 SELECTED YEARS lsoOl977 170- 65 years and over 65 years and over 60 - 50 - 40 - 30 - 20 -
1524 v-* 0.8 - 0.7 - 0.6 - 0.5 - z.:: 1900 1910 1920 1930 1940 1950 1960 1970 1960 SOURCE: National Center for Health Statistics, Division of Vital Statistics. 1-3 We status 0 have seen other impressive gains in health in the past few years. In 1977, a record low of 14 infant deaths per 1,000 live births was achieved. Between 1960 and 1975, the difference in infant mortality rates for nonwhites and whites has cut in half. Between 1950 and 1977, the mortality rate for children aged one to 14 was halved. A baby born in this country today can be expected to live more than 73 years on average, while a baby born in 1900 could be expected to live only 47 years. Deaths due to heart disease decreased in the United States by 22 percent between 1968 and 1977. During the past decade the expected life span for Americans has increased by- 2.7 years. In the previous decade it increased by only one year. For this, much of the credit must go to earlier efforts at prevention, based on new knowledge which we have obtained through research. Nearly all the gains against the once-great killers--which also included typhoid fever, smallpox, and plague--have come as the result of improvements in sanitation, housing, nutrition, and immunization. These are all important to disease prevention. Rut some of the recent gains are due to measures people have taken to help themselves--changes in lifestyles resulting from a growing awareness of the impact of certain habits on health. Can We Do Better? To be sure, as a Nation we have been expending large amounts of money for health care. l-4 0 From 1960 to 1978 our total spending as a Nation for health care mushroomed from $27 billion to $192 billion. 0 In 1960 we spent less than six percent of our GNP on health care. Today, the total is about nine percent. Almost 11 cents of every federal dollar goes to health expenditures. 0 In the years from 1960 to 1978 annual health expenditures increased over 700 percent. Yet, our 700 percent increase in health spending has not yielded the striking improvements over the last 20 years that we might have hoped for. To a great extent these increased expenditures have been directed to treatment of disease and disability, rather than prevention. Though, particularly in recent years, we have made strides in prevention, much is yet to be accomplished. For example, recent figures indicate that we still lag behind several other industrial nations in the health status of our citizens: 0 12 others do better in preventing deaths from cancer; l 26 others have a lower death rate from circulatory disease; 0 11 others do a better job of keeping babies alive in the first year of life; and 0 14 others have a higher level of life expectancy for men and six others have a higher level for women. Prevention - An Idea Whose Time Has Come Clearly, the American people are deeply inter- ested in improving their health. The increased l-5 attention now being paid to exercise, nutrition, environmental health and occupational safety testify to their interest and concern with health promotion and disease prevention. The linked concepts of disease prevention and health promotion are certainly not novel. Ancient Chinese texts discussed ways of life to maintain good health--and in classical Greece, the followers of the gods of medicine associated the healing arts not only with the god Aesculapius but with his two daughters, Panacea and Hygeia. While Panacea was involved with medication of the sick, her sister Hygeia was concerned with living wisely and pre- serving health. In the modern era, there have been periodic surges of interest leading to major advances in pre- vention. The sanitary reforms of the latter half of the 19th century and the introduction of effective vaccines in the middle of the 20th century are two examples. But, during the 1950s and 196Os, concern with the treatment of chronic diseases and lack of knowledge about their causes resulted in a decline in emphasis on prevention. Now, however, with the growing understanding of causes and risk factors for chronic diseases, the 1980s present new opportunities for major gains. Prevention is an i 'ea whose time has come. We have the scientific knowledge to begin to formulate recommendations for improved health. And, although the degenerative diseases differ from their infec- tious disease predecessors in having more--and more complex--causes, it is now clear that many are preventable. Challenges for Prevention We are now able to identify some of the major risk factors responsible for most of the premature morbidity and mortality in this country. l-6 Cigarette Smoking Cigarette smoking is the single most preventable cause of death. It is clear that cigarette smoking causes most cases of lung cancer--and that fact is underscored by a consistent decline in death rates from lung cancer for former male cigarette smokers who have abstained for 10 years or more. Cigarette smoking is now also identified as a major factor increasing risk for heart attacks. Even in the absence of other important risk factors for heart disease--such as high blood pressure and elevated serum cholesterol--smoking nearly doubles the risk of heart attack for men. Though the actual cause of the unprecedented decline in heart disease in the last ten years is not entirely understood, it is noteworthy that the prevalence of these three risk factors also declined nationally during this same period. Alcohol and Drugs Misuse of alcohol and drugs exacts a substantial toll of premature death, illness, and disability. Alcohol is a factor in more than 10 percent of all deaths in the United States. The proportion of heavy drinkers in the population grew substantially in the 196Os, to reach the highest recorded level since 1850. Of particular concern is the growth in use of both alcohol and drugs among the Nation's youth. Problems resulting from these trends are sub- stantial--but preventable. Our ability to deal with them depends, in many ways, more on our skills in mobilizing individuals and groups working together in the schools and communities, than on the efforts of the health care system. l-7 Occupational Risks Also more widely recognized as threats to health are certain occupational hazards. In fact, it is now estimated that up to 20 percent of total cancer mortality may be associated with these hazards. The true dimensions of the asbestos hazard, for example, have become manifest only after a latency period of perhaps 30 years. And rubber and plastic workers, as well as workers in some coke oven jobs, are exhibiting significantly higher cancer rates than the general population. Yet, once these occupational hazards are de- fined, they can be controlled. Safer materials may be substituted; manufacturing processes may be changed to prevent release of offending agents; hazardous materials can be isolated in enclosures; exhaust methods and other engineering techniques may be used to control the source; special clothing and other protective devices may be used; and efforts can be made to educate and motivate workers and managers to comply with safety procedures. Injuries Injuries represent still another area in which the toll of human life is great. Accidents account for roughly 50 percent of the fatalities for individuals between the ages of 15 to 24. But the highest death rate for accidents occurs among the elderly, whose risk of fatal injury is nearly double that of adolescents and young adults. In 1977, highway accidents killed 49,000 people and led to 1,800,OOO disabling injuries. In 1977, firearms claimed 32,000 lives, and were second only to motor vehicles as a cause of fatal injury. Falls, burns, poisoning, adverse drug reactions and recreational accidents all accounted for a significant share of accident-related deaths. l-8 Again, the potential to reduce these tragic and avoidable deaths lies less with improved medical care than with better Federal, State, and local actions to foster more careful behavior, and provide safer environments. Smoking, occupational hazards, alcohol and drug abuse, and injuries are examples of the prominent challenges to prevention, and there are many others. But the clear message is that much of today's premature death and disability can be avoided. And the effort need not require vast expend- itures of dollars. In fact, modest expenditures can yield high dividends in terms of both lives saved and improvement in the quality of life for our citizens. A Reordering of our Health Priorities In 1974. the Government of Canada published A New Perspective on the Health of Canadians. It introduced a useful concept which views all causes of death and disease as' having four contributing elements: a inadequacies in the existing health care system; 0 behavioral factors or unhealthy lifestyles; 0 environmental hazards; and 0 human biological factors. Using that framework, a group of American ex- perts developed a method for assessing the relative contributions of each of the elements to many health probl s. Analysis in which the method was applied to the 10 leading causes of death in 1976 suggests that perhaps as much as half of U.S. mortality in 1976 was due to unhealthy behavior or lifestyle; 20 percent to environmental factors; 20 percent to human biological factors; and only 10 percent to inadequacies in health care. l-9 Even though these data are approximations, the implications are important. Lifestyle factors should be amenable to change by individuals who understand and are given support in their attempts to change. Many environmental factors can be altered at rela- tively low costs. Inadequacies in disease treatment should be correctable within the limits of tech- nology and resources as they are identified. Even some biological factors (e.g., genetic disorders) currently beyond effective influence may ultimately yield to scientific discovery. There is cause to believe that further gains can be anticipated. The larger implication of this analysis is that we need to re-examine our priorities for national health spending. Currently only four percent of the Federal health dollar is specifically identified for pre- vention related activities. Yet, it is clear that improvement i'n the health status of our citizens will not be made predominately through the treatment of disease but rather through its prevention. This is recognized in the growing consensus about the need for, and value of, disease prevention and health promotion. Several recent conferences at the national level have been devoted to exploring the opportunities in prevention. Professional organizations in the health sector are re-evaluating the role of preven- tion in their work. The President and the Secretary of Health, Education, and Welfare have made strong public endorsements of prevention. And a rapidly growing interest has emerged in the Congress. The Federal interest is paralleled by great interest in the State health agencies. There are three overwhelming reasons why a new, strong emphasis on prevention-- at all levels of governments and by all our citizens--is essential. l- 10 First,, prevention saves lives. Second, prevention improves the quality of life. Finally, it can save dollars in the long run. In an era of runaway health costs, preventive action for health is cost-effective. Prevention - A Renewed Conxnitment In 1964, a Surgeon's General's Report on Smoking and Health was issued. This report pointed to the critical link between cigarette smoking and several fatal or disabling diseases. In 1979, another re- port was issued based on the knowledge gained from over' 24,000 new scientific studies--studies which revealed that smoking is even more dangerous than initially supposed. In recent years, our knowledge of important pre- vention measures in other critical areas of health and disease has also increased manyfold. This, the first Surgeon General's Report on Health Promotion and Disease Prevention, is far broader in scope than the earlier Surgeon General's reports. It is the product of a comprehensive review of prevention activities by participants from both the public and private sectors. The process has in- volved scientists, educators, public officials, business and labor representatives, voluntary organizations, and many others. Preparation of the report was a cooperative effort of the health agencies of the Department of Health, Education, and Welfare, aided by papers from the National Academy of Sciences' Institute of Medicine and the 1978 Departmental Task Force on Disease Prevention and Health Promotion. Core papers from both documents are available separately as background papers to this report. l-11 The report's central theme is that the health of this Nation's citizens can be significantly improved through actions individuals can take themselves, and through actions decision makers in the public and private sector can take to promote a safer and healthier environment for all Americans at home, at work and at play. For the individual often only modest lifestyle changes are needed to substantially reduce risk for several diseases. And many of the personal deci- sions required to reduce risk for one disease can reduce it for others. Within the practical grasp of most Americans are simple measures to enhance the prospects of good health, including: 0 elimination of cigarette smoking; 0 reduction of alcohol misuse; 0 moderate dietary changes to reduce intake of excess calories, fat, salt and sugar; 0 moderate exercise; 0 periodic screening (at intervals determined by age and sex) for major disorders such as high blood pressure and certain cancers; and 0 adherence to speed laws and use of seat belts. Widespread adoption of these practices could go far to improve the health of our citizens. Additionally, it is important to emphasize that physical health and mental health are often linked. Both are enhanced through the maintenance of strong family ties, the assistance of supportive friends, and the use of cotwnunity support systems. For decision makers in the public and private sector, a recognition of the relationship between 1-12 health and the physical environment can lead to actions that can greatly reduce the morbidity and mortality caused by accidents, air, water and food contamination, radiation exposure, excessive noise, occupational hazards, dangerous consumer products and unsafe highway design. The opportunities are, therefore, great. But if those opportunities are to be captured we must be focused in our efforts. An important purpose of this report is to en- hance both individual and national perspective on prevention through identification of priorities and specification of measurable goals. Americans have a deep interest in improving their health. This report is offered to help them achieve that goal. l-13 CHAPTER 2 RISKS TO GOOD HEALTH Disease and disability are not inevitable events to be experienced equally by all. Each of us at birth--because of heredity, socioeconomic background of parents, or prenatal exposure--may have some chance of developing a health problem. But, throughout life, probabilities depending upon individual change experience with risk factors--the environmental and behavioral influences capable of provoking ill health with or without previous predisposition. Most serious illnesses--such as heart disease and cancer --are related to several factors. And some risk factors--among them, cigarette smoking, poor dietary habits, severe emotional stress-- increase probabilities for several illnesses. Moreover, synergism operates. The combined po- tential for harm of many risk factors is more than the sum of their individual potentials. They interact, reinforce, even multiply each other. Asbestos workers, for example, have increased lung cancer risk. Asbestos workers who smoke have 30 times more risk than co-workers who do not smoke--and 90 times more than people who neither smoke nor work with asbestos. It is the controllability of many risks--and, often, the significance of controlling even only a few--that lies at the heart of disease prevention and health promotion. 2-l Major Risk Categories Inherited Biological Heredity determines basic biological charac- teristics and these may be of a nature to increase risk for certain diseases. Heredity plays a part in susceptibility to some mental disorders, infectious diseases, and common chronic diseases such as certain cancers, heart disease, lung disease, and diabetes--in addition to disorders more generally recognized as inherited, such as hemophilia and sickle cell anemia. Actually, however, disease usually results from an interaction between genetic endowment and the individual's total environment. And although the relative contributions vary from disease to disease, major risk factors for the common chronic diseases are environmental and behavioral--and, therefore, amenable to change. Even familial tendencies toward disease may be explained in part by similarities of environmental and behavioral factors within a family. Environmental Evidence is increasing that onset of ill health is strongly linked to influences in physical, social, economic and family environments. Influences in the physical environment that increase risk include contamination of air, water, and food; workplace hazards; radiation exposure; excessive noise; dangerous consumer products; and unsafe highway design. Over the past 100 years, man has markedly al- tered the physical environment. While many changes reflect important progress, rew health hazards have come in their wake. The environment has become host to many thousands of synthetic chemicals, with new ones being introduced at an annual rate of about l,OOO--and to byproducts of transportation, manufac- turing, agriculture and energy production processes. 2-2 Factors in the socioeconomic environment which affect health include income level, housing, and employment status. For many reasons, the poor face more and different health risks than people in higher income groups: inadequate medical care with too few preventive services; more hazardous physical environment; greater stress; less education; more unemployment or unsatisfying job frustration; and income inadequate for good nutrition, safe housing, and other basic needs. Family relationships also constitute an impor- tant environmental component for health. Drastic alterations may occur in family circum- stances as spouses die or separate, children leave home, or an elderly parent moves in. An abrupt major change in social dynamics can create emotional stress severe enough to trigger serious physical illness or even death. On the other hand, loving family support can contribute to mental and physical well-being and provide a stable, nurturing atmosphere within which children can grow and develop in a healthy manner. Behavioral Personal habits play critical roles in the development of many serious diseases and in injuries from violence and automobile accidents. Many of today's most pressing health problems are related to excesses--of smoking, drinking, faulty nutrition, overuse of medications, fast driving, and relentless pressure to achieve. In fact, of the 10 leading causes of death in the United States (Figure 2-A), at least seven could be substantially reduced if persons at risk improved just five habits: diet, smoking, lack of exercise, alcohol abuse, and use of antihypertensive medication. Risk Variability Because risk factors interact in different ways, population groups which differ because of geographic 2-3 Figure 2-A Causes of Death by Life Stages, 1977 PROBLEM Chronic Dlseaser AGE QROUPS Infants (Under 1) Rank Rate’ Adolescents/ Older Total Children Yourq Adults Adults Adults Adults Population (1-14) (15-24) (25-44) (45-64) (Over 65) (all ages) Rank Rate’ Rank Rate’ Rank Rate’ Rank Rater Rank Rate’ Rank Rater Heart Disease 7 1.1 6 2.5 2 25.5 1 351 .o 1 2334.1 1 332.3 Stroke 8 .6 9 1.2 8 6.1 3 52.4 3 656.2’ 3 04.1 Arteriosclerosis 5 116.5’ 9 13.3 Sronchitls. Emphysema, (L Asthma 10 12.2 6 69.3 Cancer 3 4.9 5 6.5 1 29.7 2 302.7 2 966.5 2 170.7 Diabetes Mellitus 10 .4 10 2.4 8 i 7.8 6 io9.5 7 15.2 Cirrhosis of the Liver 7 6.6 4 39.2 9 36.7 a 14.5 Influenza and Pneumonia Menlngltls Septicemia Trauma 5 50.6 6 1.5 a 1.3 9 3.0 9 15.3 4 169.7 5 23.i 8 .6 6 32.7 Accidents Motor vehicle accidents All other accidents Suicide Homicide Dwetapmental Probkmr 2 9.0 1 44.1 3 23.1 7 10.3 1 0 24.5 6 22.5 7 27.7 1 10.6 2 16.4 4 16.5 5 25.5 7 78.1 4 24.E 10 .4 3 13.6 5 17.3 6 19.1 9 13.3 5 1.6 4 12.7 6 15.6 Immaturity associated 1 467.7 Sirth+ssociated 2 294.4 Congenital birth defects 3 253.1 4 3.6 7 1.6 Sudden Infant deaths 4 142.0 All eeusee 1412.1 43.1 117.1 182.5 l,wo.o 5266.1 070.1 ‘Rate per 100.000 live blrths.
location, we, and/or socioeconomic strata can experience substantial variability in disease incidence. And investigations of the variability can provide important clues about the extent to which major causes of disease and death may be preventable. Contrasts between different groups within the United States will be discussed throughout Section II. Here, it is interesting to note some of the striking influences which international variations in habits and environs can have. For example, an American man, compared to a Japanese man of the same age, is at 1.5 times higher risk of death from all causes, five times higher for death from heart disease, and four times higher for death from lung cancer. And for breast cancer, the death rate for American women is four times as great as for Japanese women. On the other hand, a Japanese man is eight times as likely to die from stomach cancer as his American counterpart. Other Western countries such as England and Wales, Sweden, and Canada have experiences generally paralleling our own although rates vary somewhat from country to country. The importance of environment and cultural habits, rather than heredity alone, is suggested by studies of Japanese citizens who have moved to the United States. They indicate that, with respect to cardiovascular disease and cancer, families who migrate tend to assume the disease patterns of their adopted country. Age-Related Risks From infancy to old age, staying healthy is an ever-changing task. The diseases that affect young children are not, for the most part, major problems for adolescents. From adolescence through early adulthood, accidents and violence take the largest toll. And these are superseded a few decades later by chronic illness--heart disease, stroke and can- cer. Figure 2-A depicts major causes of death by life stages. In one respect, this age orientation is mis- leading. Although heart disease, stroke, and cancer are commonly regarded as adult health problems, their roots--and, indeed, the roots of many adult chronic diseases--may be found in early life. Early eating patterns, exercise habits, and exposure to cancer-causing substances all can affect the likeli- hood of developing disease many years later. Some studies have found high blood pressure and high blood levels of cholesterol in many American chil- dren. The presence of two such potent risk factors for heart disease and stroke at early ages point to the need to regard health promotion and disease prevention as lifelong concerns. At each stage of life, different steps can be taken to maximize well-being--and the health goals described in the next section deal with the major health problems of each group.* Assessing Risk Risk estimates are derived by comparing the fre- quency of deaths, illnesses or injuries from a spe- cific cause in a group having some specific trait or risk factor, with the frequency in another group not having that trait, or in the population as a whole. Some diseases may occur more frequently in a small population group--for example, a rare type of liver cancer among workers handling vinyl chloride. Such a high risk group, of course, is not difficult to identify although many deaths may occur before the disease cause is clearly established.
those which cause death. Other significant condi- tions--such as mental illness, arthritis, learning disorders, and childhood infectious diseases--pro- voke considerable sickness, disability, suffering, and economic loss. These problems are considered in this report--but, for overview purposes, the leading causes of death provide useful indications of some of the prominent risk factors faced by each age group. 2-6 But increases in more common diseases not con- fined to isolated population groups may be much more difficult to attribute to a specific cause. For example, after cigarette smoking was widely adopted, lung cancer rates began to increase dramatically, not immediately but after about a ZO-year interval. Because of the large numbers of diverse people and the long interval involved, many theories had to be considered before the direct link between cigarette smoking and lung cancer was firmly established. The presence of a risk factor need not inevita- bly presage disease or death. But those events can arise from the cumulative effect of adverse impacts on health. The chain of events may be short, as in a highway accident, or long and complex, as in the development of coronary artery disease and the heart attack which may follow. Some diseases may involve a single significant risk, such as lack of immunization. Others involve many contributing factors. Those associated with coronary artery disease, for example, include hered- ity, diet, smoking, uncontrolled hypertension, over- weight, lack of exercise, stress, and possibly other unknown factors. The Role of the Individual Because there are limits to what medical care can presently do for those already sick or injured, people clearly need to make a greater effort to reduce their risk of incurring avoidable diseases and injuries. This is not to suggest that individuals have complete control and are totally responsible for their own health status. For example, although socioeconomic factors are powerful determinants, in- dividuals have limited control over them. Nor can they readily decrease many environmental risks. The role of the individual in bringing about environ- mental change is usually restricted to that of the concerned citizen applying pressure at key points in the system or process. But the individual must rely 2-7 in large part on the efforts of public health offi- cials and others to reduce hazards. People must make personal lifestyle choices, too, in the context of a society that glamorizes many hazardous behaviors through advertising and the mass media. Moreover, our society continues to support industries producing unhealthful products, enacts and enforces unevenly laws against behaviors such as driving while intoxicated, and offers ambig- uous messages about the kinds of behavior that are advisable. Finally, although people can take many actions to reduce risk of disease and injury through changes in personal behavior, the health consequences are seldom visible in the short run. Even when the in- dividual knows that a habit such as eating excessive amounts of high-calorie, fatty food is not good, available options may be limited. And some habits such as alcohol abuse and smoking may have become addictive. To imply, therefore, that personal behavior choices are entirely within the power of the indi- vidual is misleading. Yet, even awareness of risk factors difficult or impossible to change may prompt people to make an extra effort to reduce risks more directly under their control and thus lessen overall risk of disease and injury. Healthy behavior, including judicious use of preventive health care services, is a significant area of individual re- sponsibility for both personal and family health. The following sections of this report will clarify the role of various risk factors in disease and disability. 2-8 SECTION II - HEALTH GOALS FIVE NATIONAL GOALS What should--and reasonably can--be our national goals for health promotion and disease prevention? They must be concerned with the major health problems and the associated--and preventable--risks for them at each of the principal stages of life: infancy . . childhood . . adolescence and young adulthood . . adulthood . . and older adulthood. This section examines those problems and risks and presents specific, quantified objectives for each stage. They are realistic objectives--based upon our own recent mortality trends for each age group, the rates achieved in other countries with resources similar to our own, and the very great likelihood that a reasonable, affordable effort can make the goals achievable.
