Healthy People 2020: National agenda shifts to risks, roots of disease

When Robert E. Harrington, director of the Casper-Natrona County Health Dept. in Wyoming, started working in 2000 to steer his community toward meeting Healthy People 2010 goals, he knew he would have to pick and choose key priorities if any progress were to be achieved. Otherwise, the document -- a version of which has been issued by the Dept. of Health and Human Services at the beginning of each decade since 1980 to set national health objectives -- was just too overwhelming.

"We tried to use Healthy People 2010, but it was just too big of an elephant to swallow," he said.

The first edition of Healthy People laid out 226 objectives. Healthy People 2000 had 312. By the time Healthy People 2010 was issued, it attempted to tackle 467 objectives, with some items having as many as 28 parts. Subjects ranged from diabetes and mental health to health care access, along with myriad others. But, in recognition that the marching orders have become unwieldy, Healthy People 2020 is expected to be trimmed down.

"As the nation was developing the obesity epidemic, so was Healthy People. ... We need to be more focused to allocate our resources better," said Carter R. Blakey, HHS senior adviser and leader of the community strategies team. She spoke at an April 30 regional meeting in Chicago -- one of six across the country. The events are designed to gain input for the now-under-construction Healthy People 2020 from various health organizations as well as the general public. Comments also are being taken online (link).

Officials say the push to streamline the document likely will be achieved by shifting away from disease-specific goals to those that affect risks for several medical conditions. For example, goals in Healthy People 2010 included reducing the rates of diabetes, end-stage renal disease and cardiovascular death, although some specific strategies overlapped.

Nonetheless, experts recognize that, because of how public health works, it will not be possible to pay attention exclusively to risk.

"Focusing on risk is a great idea, but we're not organized like that," said Blakey. "We're organized categorically. We're going to move in that direction, but at the same time we still recognize the need to pay attention to specific conditions."

Those involved in the revamp want to go beyond eliminating health disparities to achieving health equity and addressing environmental factors that may be interfering with the realization of some goals. Healthy People 2020 also is expected to establish objectives that take into account how the definition of health and wellness changes over a person's lifespan.

"My experience is that people often pay attention to specific populations -- children or adolescents or the elderly. We need to think about health across the life stages," said Patrick Remington, MD, MPH, professor of population health sciences at the University of Wisconsin School of Medicine and Public Health in Madison.

Gathering input

Officials are seeking input from more diverse sources than in previous editions. An interagency work group includes representatives from federal agencies both in and out of HHS.

While past editions have taken public comment into account, for the first time outside experts, including Dr. Remington and several other physicians, have been selected to form the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020.

"We have to do a better job of breaking down our silos, and, if we want people to work with us after the objectives are released, we need to work with them now," said Blakey.

At the Chicago meeting, those weighing in on the process expressed concern about impediments to achieving the initiative's goals. For example, an AMA representative testified about barriers to having physicians more involved in prevention.

"We need to look at a lot of the obstacles and how we can overcome them," said Richard A. Yoast, PhD, director of the AMA's Office of Alcohol and Other Drug Abuse.

For Healthy People 2010, the AMA had in place a memorandum of understanding with HHS to disseminate the document to physicians and to work toward implementation of interventions in the health care setting that would help achieve its goals.

Significant focus also surrounded the idea that a lack of access to care is hindering progress.

"Healthy People has set up some lofty goals, but they have no chance of being met unless we increase access," said Julia Olsta, a registered nurse and the health services community liaison for School District U-46 in suburban Chicago. In her 90-square-mile geographic area, for instance, no facilities were willing to provide eyeglasses to children who were unable to pay for them out of pocket or with private insurance. Also, only two dentists were willing to accept children on any form of public health insurance.

Minority health experts expressed an interest in developing goals specific to various races and ethnicities and not based on those set for Caucasians. They also wanted to better define the concept of health equity and to take into account genetic differences, such as the African-American predisposition for sickle cell anemia.

In addition, gay health advocates lobbied for the addition of questions about sexual orientation in the various survey tools public health officials use to assess progress. Questions about age, gender, race and ethnicity already are standard, and Healthy People 2010 was accompanied by the "Companion Document for Lesbian, Gay, Bisexual and Transgender Health." Those proposing this change say the information gleaned will increase the visibility of disparities associated with sexual orientation.

The framework and overarching goals for 2020 will be released by the beginning of next year. The full Healthy People 2020 will be published in 2010.