DEPARTMENT OF HEALTH AND HUMAN SERVICES
Meeting of: Secretary's Council on Health Promotion and Disease Prevention Objectives for
2010
April 23, 1999, Proceedings
DR. MEYERS: Thank you. Before I start, I would like to acknowledge the work of the ODPHP staff on this agenda item, and especially Dr. Dirk Ruwaard from the Netherlands, who has brought his experience on a similar process, especially related to conceptualization, to ODPHP over the last 6 months, and it has been extremely helpful to us. Also, I would like to mention Dr. Linda Bailey, Dr. Mark Smolinski, Debbie Maiese, and Mary Jo Deering, as well as the other ODPHP staff, for this particular development of the framework.
The summary of comments on the framework and goals is in your briefing book at the back of Tab IV. If you have had a chance to look through that, I think you have noticed that there is good support for both goals, especially for changing the goal of reducing disparities to eliminating health disparities.
If you look through the comments, I think you will also come to the same conclusion that we do and that the Healthy People Steering Committee did, that the final version of the document would be significantly strengthened by a conceptual framework that clarifies these complex issues that are addressed in Healthy People. As you know, several different schematics have been proposed as possible frameworks, and after looking at the comments and the very specific suggestions we have received, the ODPHP staff went back to the drawing board, as it were, and developed, with input from the Healthy People Steering Committee, a conceptual framework that builds on the previous one, but also responds to public comments for a structure that better describes our understanding of health.
I have asked Dr. Mark Smolinski, who was the chief person in the office responsible for making this happen, to actually describe the framework to you. He can do it in the most persuasive and enthusiastic manner of any of us. So I will turn it over to Mark.
DR. SMOLINSKI: Good morning.
As Linda was saying, what we really tried to do was be responsive to the public comments about the framework for Healthy People, and we really appreciate all the efforts people put forward, all the different ideas that were submitted. But what we looked at was-the problem with most of them was, we tried to fit the focus areas and the table of contents and everything of Healthy People into sort of an artificial framework. So we sat back and said, "How do we want to communicate our concept of health, and based on that, let's develop a framework to communicate Healthy People that fits into that method."
So our framework is basically consisting of four areas-the goals, the health status, the determinants of health, and then policy. I will go through these one at a time as we build our model.
So, basically, in Healthy People we have our two goals. Moreover, we have an overall goal or vision of Healthy People in Healthy Communities, and what our model is going to try to express is that this encompasses more than just what we can do in the realm of health. Healthy People in Healthy Communities really is an expression of well-being, but in addition to trying to achieve that overall goal, within Healthy People we have two very specific goals that will help us achieve well-being. One of these is to increase the quality and years of healthy life and the other is to eliminate health disparities.
In order to understand how we are going to achieve these goals, we have a lot in Healthy People that focuses on health status, and basically these are the things that we can measure. Within Healthy People, there are basically a lot of outcome measures. The burden of illness includes the majority of very disease-specific measures that are within the 28 focus areas, but we also have more generic measures of health that deal with life expectancy and quality of life. Of course, those measures directly go back into the goals, as does the burden of illness, because most of those are broken down by racial and ethnic groups and other areas where we are trying to eliminate health disparities. Of course, in order to know how we are achieving our goals, we are going to have to look at health status.
A more complicated box of the model is the determinants of health, and I have broken these down into two areas to try to explain them a little more concisely. This is the core component of what we believe disease prevention and health promotion is going to be encompassing, the determinants of health. I think when you look at the next presentation on Leading Health Indicators, it is going to be very obvious from the IOM committee's report that their focus was also on the determinants of health.
What we have done here is, we have tried to show that the individuals in the core center-when we are talking about Healthy People in Healthy Communities, it all boils down to an individual who makes up the composition of the larger groups. What we have done is, we have tried to show that the individual is a composite of both their behaviors and their biology, but that that cannot exist in an independent state, because the environment surrounds the individual. So, for instance, if you look at something like smoking, we always say that smoking is a behavior, but within our model we are going to try to show that it is not only the choice not to smoke, but that smoking can, in fact, change your biology if you end up getting cancer. You can go back and change your behavior, but also your social and your physical environment. Whether you work in a smoke-free environment can influence your choice to smoke. Whether you have the infrastructure, the surrounding social environment, family structure, and so forth-that will impact as well.
So, within the social environment, we are talking about education, income, social networks and, within the physical environment, we are talking about safe homes, schools, work sites. We will build all this together to show that nothing is an independent factor, but it all works together as individual and community interactions.
In addition, the determinants of health also encompass a component that we have chosen to call community interventions, and these include health promotion, health protection, disease prevention, and cure and treatment. This is really a spectrum. What we have tried to show here is-instead of using words like public health, we wanted to try to get more stakeholders involved to show that there are activities that might not be seen in the realm of the health arena that certainly are health promotion and health protection, disease prevention, and possibly even care and treatment. So this encompasses not only your systems of community health care but also any intervention that can impact on the health of the country.
So, again, to flow into the model, the determinants of health is where our main activity is. If you look through Healthy People, most of them really focus within this area, and those are going to lead us to measuring our health status and hopefully help us achieve our goals.
So the final level that we built into our model is basically a level of policy, and we feel this is very important, especially in light of our goals, and the one goal in particular, on eliminating health disparity. We cannot do this alone with health policy. We have to get the other intersectoral policies involved. This involves housing, education, urban development, everything.
So what we tried to show here is that the policy level can have an impact by flowing through the determinants of health to change the health status and achieve our goals. The outside arrows show that there are other agencies and intersectoral policy areas that may not really see themselves as flowing up through our model of health, but certainly their policy can, in fact, influence our goals of eliminating health disparities and increasing the quality and years of healthy life.
So when you first looked at it in this book, it may have looked a little more complicated than I think it really is. We have tried to make this as simple as possible yet really communicate all that we want Healthy People to communicate. I think one of the really nice features of this model is, it helps people understand why we have such a diversity of objectives within the entire document and within every focus area in and of itself, but a given focus area can take all of their objectives and fit them into the model and show that they are really trying to achieve their goals through a variety of different objectives. We hope that this is going to help us engage more stakeholders in the Healthy People process by seeing that we have a foundation of what we are trying to describe through the process.
Lastly, we also think this will be very helpful in getting Healthy People into more curriculums of schools of public health, medical schools, and so forth, because we have based it on a real solid model of health that will help instructors try to bring it into the agenda.
So, basically, that is a quick overview, and I would be happy to answer any questions or take any comments.
DR. MEYERS: We will come back to this discussion of the framework, or you will see the framework again used in Volume I. The intention was to build the more user-friendly version of Healthy People around this model, essentially telling this story.
DR. WINDOM: That is an excellent way to present this on a local level, to have this type of diagram and put it together and let everybody see what the total concept is. You should be commended for that.
DR. SATCHER: Other comments or questions? This is very important.
Julie?
DR. RICHMOND: I think this is a very important contribution to our conceptualization of what all of these issues are as we translate multiple objectives and approaches. They fit very well, and I think this is a very interesting approach, and I think it is a document certainly for teaching purposes, for people in the health professions, as well as other students, I think, that is extremely valuable, because it does explicate the details.
I think for public communication-David, in your introductory comments you focused on the importance of communication to the public-I would just suggest that I think it has more complexity than one can readily communicate, and I think we do need to have a somewhat simpler model that can be used in the large macro sense in terms of communicating with the public. That would be my concern. I do not hold a brief for the one we tried to develop. I am indebted to the staff here for having helped with that after our last meeting, but we did develop a somewhat similar model, and I just want to suggest that for communications to the public we may have to pay some attention to getting this into some simpler form.
DR. SHALALA: I think that is a good point, David. I mean, this has to be translated for an individual family so that they understand how this works for them.
DR. RICHMOND: We could refresh our memories. I just happen to have a slide-
[Laughter.]
Let me just put this up. This is also a little more complicated than I wanted it to be, but nonetheless, it is somewhat simpler.
DR. SATCHER: But I think what we are doing is, we are trying to get closer.
DR. RICHMOND: Here we are talking about healthy behaviors, healthy communities, and disease prevention and health promotion, and these are all interacting. So I think it is a somewhat simpler presentation. Again, I would emphasize that the model that we just had presented is extremely valuable for teaching purposes.
DR. SATCHER: You know, what I think we can do-hope we can do-is, we can develop some focus groups and test some of these models and see which of the models-but also what kind of model-would best communicate to the average American family. But this is a great beginning, I think.
DR. SHALALA: Yes, I actually think you have to have something that they are into, I mean, that takes them through what this means for them, but it does not mean that you cannot have different translations for different people. I mean, it is a translating problem, so people can identify with this, and it certainly can be done. The important thing is to get the fundamental conceptualization right, which you clearly have done.
DR. LURIE: But this is very much akin to the discussion we are going to have in a little while about Leading Health Indicators. As we simplify the model and talk about Leading Health Indicators in a few moments, we also might talk about how the model in that interacts, because that is, again, a communication piece to the American public.
DR. SHALALA: The word may not be simplification; it may be translation. It's different from simplifying, because it gives you a different conceptualization than really translating it in a way in which Dr. Brooks can take to every community.
DR. DUVAL: The Secretary just made one of the two points I wanted to make. I do think you can use both, but I think that the target audiences are different. Each will serve that particular target audience better than the other. I mean that. I can see this, as Julius said, for teaching purposes, for health providers, et cetera. This model that we have been introduced to and the concept as presented a moment ago is really excellent. On the other hand, if the target audience is laypeople and the possible subject, so to speak, of our ultimate objectives-families, et cetera-as the Secretary suggested, I think that Julie's model is a little bit more salable.
I do have a second point, though, and it is only a matter of personal discomfort, and it is not a strong one. Under the concept of community interventions, I am bothered by the fact that health promotion is in that group. I say that for this reason. I regret that my memory is not sufficient to bring you back the name, but approximately 24 or 25 years ago, a faculty member at the University of Wisconsin wrote a brilliant series of papers on the issue of what constitutes health promotion in the sense of the personal responsibility elements, health promotion being for the most part subjective, oriented-to-yourself decisions that you would make about exercise, nutrition, and so forth, and do not call for community intervention beyond education.
The other three in that category are, in fact, interventions. I throw that out only to ask you to think about it. I do not feel sufficiently strongly about it, that it should not be in there, but-
DR. SATCHER: We would disagree with that.
DR. DUVAL: Would you? All right.
DR. SATCHER: I do not particularly like it when I disagree with you.
[Laughter.]
No, we spent a lot of time in terms of, you know, the Surgeon General's Prescription that I showed you this morning. One of the points that we tried to make is that, when it comes to physical activity, good nutrition, avoiding toxins, and responsible sexual behavior, it is more than personal responsibility. If the States do not require physical education in K-12, the children are not going to develop lifetime habits of physical activity. The system has to promote physical activity.
Where is it, St. Louis, where the Boot Hill community has developed walking trails for the elderly because the communities are not safe? They are not just saying it is a personal responsibility to be physically active. They are saying it is a community responsibility to promote that. The same thing with diet. We are meeting with the Department of Agriculture as one of the Secretary's interagency strategies; the Department of Education and Agriculture are talking about school lunches. If we want kids to consume fruits and vegetables, we ought to have models of that in the schools. So we see it as more than personal responsibility.
DR. DUVAL: Well, I still have that reservation.
DR. SATCHER: Well, I would like to follow up with you on that.
DR. SHALALA: But your point is, as I understand it, that where is the individual responsibility in this conceptual framework?
DR. DUVAL: That is the question, plus the fact that I-
DR. SHALALA: If it is not in health promotion, where does it come in?
DR. SATCHER: Well, that is a good point. If we do not show the-
DR. DUVAL: Well, it comes up in the behaviors just above it, but I am not suggesting that I could improve on this. I could not, and I am not even attempting to convey that. What I am attempting to say is that I am a little bothered by the fact that there is a point at which you want to be careful about personal decisions being influenced and so forth by, you know, the heavy hand of government, or whatever it turns out to be. I am not being specific about that. So I have a little reservation about that, even though I accept totally the fact that there is a role for the community, and I am one of those who, incidentally, responds to my community senior trails.
DR. SATCHER: Well, if you look at what has happened to smoking in this country since the Surgeon General's report in 1964 when-what-over 60 percent of physicians were smokers, and now it is down to less than 10 percent. Smoking has settled in adults among low-income people, you know, low-educated people. That is not true in teenagers, but in terms of adults. So the social framework, I think, has a lot to do now with who smokes in this country and who does not.
DR. SHALALA: Phil, are you following this conversation?
DR. LEE: Yes, I am.
DR. SHALALA: Okay, do you have something to say that you might want to say on this?
DR. LEE: Well, the San Francisco Health Department produced a report in December 1998. It was called the San Francisco Burden of Disease and Injury: Mortality Analysis 1990-1995, and they did it not only citywide but by neighborhood, and they used basically a very similar framework. They used a modification of the Evans-Stoddard model, compared why some people are healthy and others are not to determine the health of populations, and used a population health perspective. Then they developed a matrix that looked at specific causes of death, like HIV/AIDS, ischemic heart disease, lung cancer, stroke, drug poisoning, suicide, homicide, et cetera, against things like tobacco, diet and exercise, alcohol, environment, firearms, sexual activity, motor vehicles, and drugs, using basically the Foege-McGinnis Actual Causes of Death 1993 paper as a basis for that matrix, and it proved to be an extraordinarily valuable effort that they used as the basic measure of years of active life lost. Then you realized what a huge impact, for example, AIDS had in San Francisco over, let's say, ischemic heart disease or lung cancer, stroke. Another surprising one was drug poisoning in terms of its major impact.
They used the standard expected years of life lost as the basic measure to determine health status. We will get into that when we get into the next conversation, but it seems to me the framework we used in San Francisco, used in the health department in San Francisco, fits very well with the framework that the department is now proposing and we are proposing in Healthy People. So I think it is very much a move in the right direction.
DR. SMOLINSKI: We did use the Evans-Stoddard model to put this framework together. That is a key basis.
DR. LEE: I realize that.
DR. SMOLINSKI: Just to respond to the health promotion, we did toy with the idea of calling this bottom area individual and community interventions, which would encompass the comment that you are trying to make. It was sort of felt when we went through a bunch of different groups that basically, you know, individuals were part of the community and did we really need to specify that. But please give us comments on things that would help improve the model, and that would be a very simple thing to do. It would also make it more parallel with what we have above about the interactions that we call individual and community.
DR. LEE: It is very important to use the community intervention notion because, for the last 20 years, there has been so much emphasis on personal behavior, and we need to get much more into the engagement of the community broadly. It is not just individual behavior, as David pointed out, with smoking, and whether it is any of these other areas-firearms, drugs, whatever. I like the idea of putting that framework of the community around it, as opposed to the emphasis we have had too much on individual behavior.
DR. SHALALA: But you have to find some balance here, Phil. I mean, we have to find some way, because you do not get there with just community behavior. We know that.
DR. LEE: Individual behavior, no question, but the community has to be engaged in it.
DR. SATCHER: No, we agree that personal behavior is critical. The only thing we are saying is that personal behavior is influenced by the community. Personal behavior is promoted by the community.
DR. DUVAL: In fairness, and vice versa. The smoking thing is a superb example. Communities have responded all over the United States with a change in the collective individual moods about smoking. In other words, it moves in both directions.
DR. SATCHER: It does.
DR. DUVAL: Certainly, in raising this I am not trying to be persuasive or looking for an answer. I am just saying I looked at it and I thought, I do not see the personal-
DR. SATCHER: I think you and the Secretary are making good points. I think if there is any question about the fact that we are not including individuals within the community, we need to do that. So we will.
DR. SHALALA: Yes, I think that, just as they rethink and fine-tune it, there is a question of balance here. I agree.
DR. SATCHER: Yes, I was concerned that he was leaving the community responsibility out.
DR. SHALALA: Right, and he is not at all.
Okay, thank you.
Ed, do you have anything else you want to say about this?
DR. BRANDT: No, I have been listening with interest.
DR. SHALALA: And you can hear everything?
DR. BRANDT: So far.