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Healthy People 2020 tackling social determinants of health: input sought from health work force.

In the late 1990s, newly sworn-in U.S. Surgeon General David Satcher traveled the country, lending his ear to stories of prosperity, perseverance and sometimes sorrow. His mission, like those before him, was to help develop another decade of national health goals and objectives--to picture an ideal set of destinations on the road to better health.

Ten years later, work continues on reaching the overarching goals of Healthy People 2010, the document Satcher helped develop, while at the same time public health leaders begin looking toward 2020. Indeed, work on Healthy People 2020 is well under way, with leaders proposing new frameworks and vehicles for moving Healthy People into the new decade as well as new indicators -or road signs--to illuminate the distance to Healthy People's final destinations. State and local public health professionals have been busy bringing their input and experiences to the Healthy People table via regional meetings and the Internet, with excitement brewing about Healthy People 2020's newly emerging focus on the social determinants of health and the prospects of an interactive Healthy People document that not only sets destinations, but provides roadmaps.


"Every public health professional should keep apprised of (the Healthy People 2020 process) and offer comments as they see fit," said Jonathan Fielding, MD, MPH, MA, MBA, chair of the Secretary's Advisory Committee on Health Promotion and Disease Objectives for 2020, which advises on Healthy People 2020. "Unless we in public health work together ... we have little chance of achieving the objectives."

Recently submitted to U.S. Health and Human Services Secretary Michael Leavitt for consideration, the committee's first independently developed report includes recommendations for Healthy People 2020's vision, mission and overarching goals. The committee's vision calls for a "society in which all people live long, healthy lives." As for its mission, the committee recommends Healthy People 2020 improve health by strengthening policy and practice, identify nationwide health improvement priorities, and increase public health awareness of the determinants of health, disease and disability. The committee also recommends that Healthy People 2020 provide measurable objectives and goals that can be used at national, state and local levels; encourage actions that are driven by the best available evidence and knowledge; and identify research and data collection needs.

Unlike Healthy People 2010, which had two main goals, Fielding and his colleagues have recommended four goals for 2020: eliminate preventable disease, disability, injury and premature death; achieve health equity, eliminate health disparities and improve health for all groups; create social and physical environments that promote good health for all; and promote healthy development and healthy behaviors at every stage of life. The committee's efforts to elevate the social determinants of health as critical factors not only shifts Healthy People away from its traditionally disease-specific focuses, but helps engage sectors not commonly linked to public health work, said Fielding, who is also director of public health and health officer for Los Angeles County. Health leaders must focus on the trajectory of a person's life course and what can be done at each stage of life to point that trajectory toward good health, said Fielding, who called for taking an "ecological approach to health promotion."

"We want to point out the intersectional nature of what affects health," said Fielding, an APHA member. "We can't achieve what we want without looking at education, jobs, public health infrastructure, recognizing that poverty is a can't just be left to public health. We need to have elected leaders think about the health implications of what they do--tax policy, mass transit, agricultural subsidies--we need people in all sectors to be thinking about health implications."

Another forward-looking recommendation is making Healthy People 2020 into a Web-accessible database that is searchable, interactive and will allow users to tailor the document to their needs--a feature Fielding said he hopes will make Healthy People 2020 more appealing to those without public health backgrounds. Such a tool can also help public health workers lure nontraditional partners to the discussion, said advisory committee Vice Chair Shiriki Kumanyika, PhD, MPH, professor of epidemiology and associate dean for health promotion and disease prevention in the University of Pennsylvania's School of Medicine.

Kumanyika noted that the committee's focus on social determinants represents a "deliberate shift away from the perception that access to health care services will ever solve all of our health care problems."


"My message for public health people: Convince other stakeholders that they have a stake in health, that they're influencing health," said Kumanyika, an APHA member. "We have to learn how to articulate that message so that they come to our table and understand how they fit in."

Officials within HHS' Office of Disease Prevention and Health Promotion are busy gathering and encouraging input as well as preparing for Healthy People 2020's new Web-based debut, while always staying mindful of those without Internet access, said Carter Blakey, senior advisor and lead of the office's community strategies team. Blakey said there are hopes to add resources on best practices and strategies for achieving Healthy People 2020 objectives. Such a feature would differ from past Healthy People documents, in which "we've handed to our users huge objectives and we've never really told them how to do it," noted Blakey, an APHA member.

"Healthy People represents a national effort, not a federal effort," Blakey told The Nation's Health. "We really need it to be representative of all the users and stakeholders."

An organizing framework for Healthy People 2020, including its vision, mission and goals, is scheduled to be released in January by HHS, with a complete set of 2020 goals and objectives to be released in January 2010. Until then, though, development work continues, and state and local public health workers are highly encouraged to take part, said Penelope Slade-Sawyer, MSW, director of the Office of Disease Prevention and Health Promotion and deputy assistant secretary for health. As part of that process, Slade-Sawyer called on workers to seek out and meet with HHS' regional administrators, attend regional meetings that the agency hopes to organize this spring, submit comments via the Healthy People 2020 Web site, and spread the word about joining the Healthy People Consortium, a diverse group of organizations dedicated to achieving Healthy People goals.

"Without state and local health officials participating, Healthy People is just an academic exercise," Slade-Sawyer said. "This is an action plan, it's something that is living. And in order to have life, we have to have input and assistance from people on the ground."

States look forward to new decade

Since 1979, and every 10 years thereafter, Healthy People documents have helped shape the nation's journey to good health and set the standards by which progress is measured. About a year from now, Healthy People will enter a new decade, riding in on the coattails of Healthy People 2010's successes and shortcomings.

With 467 specific objectives on issues ranging from immunizations to tobacco use to vision care, Healthy People 2010 has two overarching goals: to help people of all ages increase the quality and years of healthy life, and eliminate health disparities. In a mid-course review of Healthy People 2010 released by HHS in 2005, researchers found that among objectives for which data was available, 29 had met their targets, 138 had moved toward the target, 17 showed no change and 57 had moved away from the intended target. In regard to the two overall goals, the review found that life expectancy increased, though years free of certain chronic diseases declined slightly. In the disparities arena, there was progress among some objectives, but such progress was offset by disparity increases among other objectives. Overall, the review reported "little evidence of systematic reductions in disparity."

"The last seven or eight years have been difficult ones," said former U.S. Surgeon General Satcher, MD, PhD, who spearheaded the Healthy People 2010 development efforts and is currently director of the Satcher Health Leadership Institute at Atlanta's Morehouse School of Medicine.

Millions more uninsured, higher unemployment and shifting national priorities have made it much more challenging to close the health gap, Satcher told The Nation's Health, though progress has been made in reducing disparities in quality of care. Satcher said the new focus on the social determinants of health will put the nation in a "position to make more progress."

State health workers are echoing Satcher's sentiments and looking forward to Healthy People 2020's new approach and framework. In California, Bonnie Sorensen, MD, MBA, chief deputy director of the state's Department of Public Health, noted that "we've already picked the low-hanging fruit ... if we really want to make a difference in the next decade, we have to address the environmental, social and economic determinants of health." With workers drafting a Healthy California 2020 document, Sorensen said the new emphasis will require public health to do business differently, to address issues not as disease-specific ones, but as they relate to issues such as crime, poverty or community planning.

A large and hugely diverse state, California took its lead from the national document but customized many of the indicators for its Healthy California 2010 document. For example, Sorensen said, the state tracks many more tobacco indicators than Healthy People 2010, and has reaped its greatest successes in its anti-tobacco work, with reductions in smoking prevalence and deaths due to lung cancer, heart disease and stroke. Other successes include rising rates of mammograms and colorectal cancer screenings as well as increased helmet laws for teens, while adult and adolescent obesity remains the most challenging, Sorensen said. Like Healthy People 2020, Sorensen said Healthy California 2020 will emphasis risk factors more than diseases.


To the east in Iowa, Louise Lex, PhD, Healthy Iowans 2010 coordinator for the Iowa Department of Public Health, said she is excited to welcome an interactive Healthy People 2020 that highlights successful interventions and policies. Like California's effort, Healthy Iowans 2010 was tailored to meet Iowa-specific health issues, such as farm injury and problem gambling, while at the same time conforming to the national focus areas. Starting in 2000 with 23 chapters, Healthy Iowans 2010 is a "living document," Lex told The Nation's Health, with chapters added and updated as annual tracking discovers new roadblocks and successes. Among the state's many Healthy Iowans 2010 successes are the enactment of a $1 increase in the tobacco tax and the passage of legislation that restricts smoking in public places, Lex reported, with obesity and binge drinking examples of areas that need more work.

"We've been darn lucky here in (Iowa) because we've had exceptional leadership at the state level," said Lex, who is an APHA member. "You can't do it without it."

While Lex coordinates efforts, she said Healthy Iowans 2010 isn't considered a public health department-only plan. About 200 state organizations are actively involved in developing goals and agreeing to take action. The collaboration is going "way beyond state government... it's not an in-house effort," she said, adding that Iowa's collaborative experience leaves it well-poised to tackle a Healthy People decade in which the social determinants of health take center stage.

"We're part of a huge onion and each of the layers has an impact on our health," Lex said.

For more information on Healthy People 2020 and how to get involved, submit comments or to stay informed, visit

Companion documents broadening reach of healthy people goals

A BEVY of special interest groups involved in authoring Healthy People 2010 companion documents are readying themselves for Healthy People 2020, offering their unique perspectives to the national process while continuing work in communities struggling with health gaps.

Since 2000, a variety of organizations have created Healthy People 2010 companion documents, focusing in on particular health goals, such as Healthy Vision 2010, or highlighting a specific community, such as Rural Healthy People 2010.

APHA member Jane Bolin, PhD, JD, RN, director of the Southwest Rural Health Research Center at Texas A&M University and an author of the rural document, said 2020's focus on the social determinants of health is especially relevant to rural communities, which face hurdles from little access to fresh foods to a lack of public sewage systems. Unlike the national 2010 document, Rural Healthy People 2010 offers Web users a database of successful strategies.

Strengthening federal data collection is key to closing disparities among lesbian, gay, bisexual and transgender communities, according to Rebecca Fox, director of the National Coalition for LGBT Health. Unfortunately, Fox said, because federal agencies do not always collect specific data on such communities, "it's hard to know how much progress has been made ... we're really far behind in having the knowledge to improve our community's health." A call for better data collection was included in the 2010 companion document, and the coalition is working toward broader inclusion in Healthy People 2020.

The Healthy People movement not only brings different U.S. communities together, but has forged new international collaborations as well. Supported by the U.S.-Mexico Border Health Commission, Healthy Border 2010 engages both U.S. and Mexico health workers on health priorities in the 2,000-mile border region. For the Paso del Norte Health Foundation in El Paso, Texas, Healthy Border 2010 has served as a guide for setting standards and as a common platform for discussing health problems and solutions, said APHA member Michael Kelly, PhD, a senior program officer with the foundation. Kelly said the foundation has offered input on Healthy People 2020, particularly related to tobacco use. A new focus on health's social determinants "validates what many of us already know: poverty correlates with poor health," he said.

For more information on Healthy People 2010 companion documents, visit

--Kim Krisberg
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Author:Krisberg, Kim
Publication:The Nation's Health
Date:Dec 1, 2008
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