Perspective
A 2020 Vision for Healthy People
N Engl J Med 2010; 362:1653-1656May 6, 2010
- Article
How can we best advance the collective health of the United States, while monitoring our progress? This year offers another opportunity to revisit this fundamental yet profound question through the lens of the Healthy People initiative. In setting the country's health-promotion and disease-prevention agenda for the past three decades, Healthy People has articulated overarching goals and tracked movement toward established targets. As we prepare for the next decade, the initiative aims to unify national dialogue about health, motivate action, and encourage new directions in health promotion, providing a public health roadmap and compass for the country.
The initiative, launched by the Department of Health and Human Services in 1979 as a systematic approach to health improvement, encompasses the mutually reinforcing tasks of setting goals, identifying baseline data and 10-year targets, monitoring outcomes, and evaluating the collective effects of health-improvement activities nationwide. Since the first iteration, the successive plans of Healthy People 2000 (released in 1990) and Healthy People 2010 (released in 2000) have identified emerging public health priorities and helped to align health-promotion resources, strategies, and research. Each decade, the program has set objectives that were deemed important, understandable, prevention-oriented, actionable, measurable with available high-quality data, and comparable to those in previous versions. Over the years, the responsibility of developing and implementing these objectives has engaged a growing network of professional and public partners, and the priority-setting process includes sifting through thousands of public comments that are routinely submitted through open community meetings and over the Web.
Wrapping up the activities of Healthy People 2010 permits an assessment of the status of the country's health in relation to targets set a decade ago. The 2010 plan focused on two overarching goals: increasing the quality of life (including years of healthy life) for Americans and eliminating health disparities. Preliminary analyses show that life expectancy has in fact increased (during the period from 2000 to 2006) by 1.2% when measured at birth and by 5.1% when measured at age 65. However, the goal of eliminating disparities remains unmet.1
Digging deeper, one can analyze movement in 28 focus areas (see Leading Health Indicators and Focus Areas for the Healthy People 2010 Initiative), encompassing 467 measurable objectives. Although the definitive report won't be released until the spring of 2011, preliminary analyses indicate that for 71% of the objectives and subobjectives for which we have at least two data points over the course of the decade, the country has either progressed toward (52%) or met (19%) the target. These figures, similar to results from previous decades, reflect broad movement on a host of diseases, conditions, risk factors, and behaviors.
Outcomes for some objectives have already surpassed the 2010 targets. By 2007, for example, the age-adjusted death rate from coronary heart disease had already dropped well below the target of 162 deaths per 100,000 population — down from 203 per 100,000 in 1999 to 135 per 100,000 (see Figure 1Figure 1
Age-Adjusted Rates of Death from Coronary Heart Disease, 1999–2007.). Reductions in major risk factors (e.g., total cholesterol levels, systolic blood pressure, and smoking) as well as evidence-based medical therapies (e.g., secondary preventive therapies after myocardial infarction or revascularization and treatments for acute myocardial infarction, unstable angina, and heart failure) have contributed equally to this 33% decrease.2 However, death rates among men still exceed those among women, and heart disease (of which coronary heart disease remains the largest component) is still the leading cause of death in the United States.On other objectives, despite demonstrated progress, the country has fallen far short of the targets. For example, the age-adjusted rate of cigarette smoking among adults 18 years of age or older decreased from a baseline of 24% in 1998 to 21% in 2008, with statistically significant decreases in all age groups: a 23.3% decrease among adults 18 to 24 years of age, 13.8% among those 25 to 44 years of age, 10.0% among those 45 to 64 years of age, and 14.7% among those 65 years of age or older. But smoking remains the leading cause of preventable death worldwide, and the prevalence among adults remains well above the 2010 target of 12% (see Figure 2Figure 2
Rates of Cigarette Smoking among Adults, 1998–2008, According to Sex and Race or Ethnic Group.). Comprehensive, population-based tobacco-control strategies that combine increased tobacco prices, media counteradvertising, smoking-cessation services, and smoke-free policies have resulted in accelerated decreases in consumption in a number of states, but substantial funding problems have made it difficult to sustain such progress.3 In other areas, the country has also moved steadily away from Healthy People targets. In a critical example, about one third of U.S. adults 20 years of age or older are now obese (see Figure 3Figure 3
Obesity Rates among Adults, 1988–2008, According to Sex and Race or Ethnic Group.). Obesity rates significantly increased between 1988–1994 and 2005–2008 — by 69.3% among adults 20 to 39 years of age, 36.9% among those 40 to 59 years of age, and 44.7% among those 60 years of age or older. Such trends have undoubtedly helped to drive the age-adjusted prevalence of clinically diagnosed diabetes to 59 cases per 1000 population (in 2008), far above the baseline of 40 cases per 1000 (in 1997) and the Healthy People 2010 target of 25 cases per 1000. This rising prevalence means that even greater attention must be paid over the next decade to scaling up evidence-based diabetes-prevention interventions in high-risk populations.As part of Healthy People 2010, 10 leading health indicators were selected with input from the Institute of Medicine as high-priority areas for motivating societal action (see Leading Health Indicators and Focus Areas for the Healthy People 2010 Initiative). These indicators provide both a concise summary of major, preventable health threats and a gateway into the broader framework; preliminary data show progress for about half of the indicator objectives. For example, on the one hand, the first half of the decade saw little change in the proportion of adults who reported having used illicit drugs in the previous 30 days (7.9% in 2002 and 8.1% in 2006) or in the proportion who reported having engaged in binge drinking during the previous month (24.3% in 2002 and 24.5% in 2006). On the other hand, the data show significantly improved immunization rates among children 19 to 35 months of age, from 72.7% in 1998 to 80.6% in 2006, with great progress in shrinking racial and ethnic disparities.1 The completion of Healthy People 2010 will permit further analysis of these and other areas.
The fourth-generation plan, Healthy People 2020, to be released this fall, builds on past achievements and addresses unfinished business.4 It reaffirms the two overarching goals from the past decade but adds two more: promoting quality of life, healthy development, and healthy behaviors across life stages; and creating social and physical environments that promote good health. The social-determinants approach that is captured in the latter goal reflects the Healthy People theme that “the health of the individual is almost inseparable from the health of the larger community and that the health of every community in every State and territory determines the overall health status of the Nation.”5 Public health for 2020 and beyond should continue to stretch beyond traditional health sectors. Doing so will require reinvigorated public health leadership that engages nontraditional partners to create healthier choices that are easier for all people to make.
Maximizing the initiative's public health impact will require expanding interactive Web-based capability to improve data accessibility, refining the target-setting process to better balance the aspirational with the achievable, linking goals with proven strategies for action, focusing more on quality measures in population health, and adding an explicit emphasis on global health. The recently passed health care reform law offers opportunities for disease prevention and health promotion, establishing a national prevention, health promotion, and public health council; a new prevention and public health fund; and a broad array of health-promotion activities affecting individuals, insurance plans, and communities.
Healthy People can prompt Americans to consider better ways of advancing the quantity and quality of life, healthy places and environments, health equity, and disease prevention. By nurturing a unity of purpose and a vision that can mobilize communities, Healthy People captures both our legacy and promise for a healthier nation.
Leading Health Indicators and Focus Areas for the Healthy People 2010 Initiative.*
Leading health indicators
Physical activity
Tobacco use
Responsible sexual behavior
Injury and violence
Immunization
Overweight and obesity
Substance abuse
Mental health
Environmental quality
Access to health care
Focus areas
Access to quality health services
Cancer
Diabetes
Educational and community-based programs
Family planning
Health communication
Human immunodeficiency virus
Injury and violence prevention
Medical product safety
Nutrition and overweight
Oral health
Public health infrastructure
Sexually transmitted diseases
Tobacco use
Arthritis, osteoporosis, and chronic back conditions
Chronic kidney disease
Disability and secondary conditions
Environmental health
Food safety
Heart disease and stroke
Immunization and infectious diseases
Maternal, infant, and child health
Mental health and mental disorders
Occupational safety and health
Physical activity and fitness
Respiratory diseases
Substance abuse
Vision and hearing
* Data are from the Department of Health and Human Services.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org.
Source Information
Dr. Koh is the Assistant Secretary for Health, Department of Health and Human Services, Washington, DC.
- References
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Healthy People 2010. 2nd ed. Washington, DC: Department of Health and Human Services, 2000.
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