HEALTHY PEOPLE The Surgeon General's Report On Health Promotion And Disease Prevention HEALTHY PEOPLE The Surgeon General's Report On Health Promotion And Disease Prevention 1979 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Office of the Assistant Secretary for Health and Surgeon General DHEW (PHS) Publication No. 79-55071 For sale by the Superintendent of Documents. U.S. Government Printing Office Washington, D.C. 20.102 Stock Xumber 017-001-00416-2 DEPARTMENT OF HEALTH. EDUCATION. AND WELFARE W*SHINCTON. D c. -1 SURGEON GENERAL OF THE PUBLIC HEALTH SERVICE The Honorable Joseph A. Califano, Jr. Secretary of Health, Education, and Welfare Dear Mr. Secretary: I am pleased to transmit herewith the manuscript of the Surgeon General's Report on Health Promotion and Disease Prevention. I believe this will be an important document for the American people. Many people and institutions, too numerous to acknowledge, have provided valuable assistance in preparing this report. I would particularly like to express appreciation to Dr. J. Michael McGinnis, Acting Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion) and his staff, and to Dr. David Hamburg, President of the Institute of Medicine, of the National Academy of Sciences, for his leadership in mobilizing the resources of the Institute to provide the accompanying papers which present documentation for the report. Sincerely yours, ssistant Secreta for Health and Surgeon General July 1979 TABLE OF CONTENTS SECRETARY'S FOREWORD SECTION I - TOWARD A HEALTHIER AMERICA . . . . . I- 1 CHAPTER 1: INTRODUCTION AND SUMMARY. . . . l- 1 CHAPTER 2: RISKS TO GOOD HEALTH. . . . . . 2- 1 Major Risk Categories . . . . . 2- 2 Risk Variability. . . . . . . . 2- 3 Age-Related Risks . . . . . . . 2- 5 Assessing Risk. . . . . . . . . 2- 6 The Role of the Individual. . . 2- 7 SECTION II - HEALTH GOALS. . . . . . . . . . . .II- 1 CHAPTER 3: CHAPTER 4: CHAPTER 5: CHAPTER 6: HEALTHY INFANTS . . . . . . . . Subgoal: Reducing the Number of Low Birth Weight Infants . Subgoal: Reducing the Number of Birth Defects. . . . . . . HEALTHY CHILDREN. . . . . . . . Subgoal: Enhancing Childhood Growth and Development. . . . Subgoal: Reducing Childhood Accidents and Injuries. . . . HEALTHY ADOLESCENTS AND YOUNG ADULTS. . . . . . . . . Subgoal: Reducing Fatal Motor Vehicle Accidents . . . . . . Subgoal: Reducing Alcohol and Drug Misuse . . . . . . . . . HEALTH ADULTS . . . . . . . . . Subgoal: Reducing Heart Attacks and Strokes . . . . . Subgoal: Reducing Death from Cancer . . . . . . . . . 3- 1 3- 5 3- 8 4- 1 4- 6 4-10 5- 1 5- 6 5- 7 6- 1 6- 6 6-12 CHAPTER 7: HEALTHY OLDER ADULTS. . . . . . 7- 1 Subgoal: Increasing the Number of Older Adults Who Can Function Independently. . . . 7- 5 Subgoal: Reducing Premature Death from Influenza and Pneumonia . . . . . . . . . . 7-12 SECTION III - ACTIONS FOR HEALTH . . . . . . . .III- 1 CHAPTER 8: CHAPTER 9: CHAPTER 10: PREVENTIVE HEALTH SERVICES. .. 8- 1 Family Planning ........ 8- 2 Pregnancy and Infant Care ... 8- 6 Immunizations ......... 8-16 Sexually Transmissible Diseases Services. .......... 8-20 High Blood Pressure Control . . 8-23 HEALTH PROTECTION ....... 9- 1 Toxic Agent Control ...... 9- 2 Occupational Safety and Health. ........... 9-11 Accidental Injury Control ... 9-17 Fluoridation of Comnunity Water Supplies. ....... 9-26 Infectious Agent Control. ... 9-28 HEALTH PROMOTION. ....... lo- 1 Smoking Cessation ....... lo- 5 Reducing Misuse of Alcohol and Drugs .......... lo-11 Improved Nutrition. ...... lo-17 Exercise and Fitness. ..... lo-24 Stress Control. ........ lo-28 SECTION IV - CHALLENGE TO THE NATION . . . . . . IV- 1 CHAPTER 11: CHALLENGE TO THE NATION . . . . ll- 1 The Obstacles . . . . . . . . . ll- 1 Opportunities for Action. . . . ll- 3 APPENDIX I - MEASURES FOR BETTER HEALTH - A SUMMARY. . . . . . . . . . . . . AI- 1 APPENDIX II - SOURCES OF ADDITIONAL INFORMATION. . . . . . . . . . . . AII- 1 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . AIII- 1 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; o 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. *Rate per 100.000 emulation In swcitied orour). 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. * The Nation's leading health problems are not only 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. II-I CHAPTER 3 HEALTHY INFANTS Goal: To continue to improve infant health, and, by 1990, to reduce infant mortality by at least 35 percent, to fewer than nine deaths per 1,000 live births. Much has happened in recent years to make life safer for babies. The infant mortality rate now is only about one-eighth of what it was during the first two decades of the century (Figure 3-A) thanks to better nutrition and housing, and improved pre- natal, obstetrical, and pediatric care. In 1977, a record low of 14 infant deaths per 1,000 live births was achieved, a seven percent decrease from the pre- vious year. Yet, despite the progress, the first year of life remains the most hazardous period until age 65, and black infants are nearly twice as likely to die before their first birthdays as white infants. The death rate in 1977 for black infants (24 per 1,000 live births) is about the same as that for white infants 25 years ago. Additional gains are clearly attainable. Sweden, which has the lowest rate of infant deaths, averages nine per 1,000 live births (Figure 3-B). If present trends in the United States continue, our rate should drop below 12 in 1982, and new preven- tive efforts could allow us to reach the goal of nine by 1990. The two principal threats to infant survival and good health are low birth weight and congenital dis- orders including birth defects (Figure 3-C). Ac- cordingly, the two achievements which would most significantly improve the health record of infants 3-1 FIGURE 3-A INFANT MORTALITY RATES: UNITED STATES, 3-2 FIGURE 3-B INFANT MORTALITY RATES: SELECTED COUNTRIES, 1975 60 50 - 40 - 30 - 20 - 10 - 0 United Sweden States me mart recent year 01 ata tar mile II ,971 England and Wales Japan Chile Sources: United States. National Center for Health Statistics, D~vts~on of Vital Statistics; other Countries. United Nations. 3-3 FIGURE 3-C MAJOR CAUSES OF INFANT MORTALITY: UNITED STATES, 1976 0 White All other 800 r Hirth- congenital Sudden Influenza Septlcemla All other arsoc~ated birth infant and accldents defects deaths p"e"monla Source Bared on data from the Nattonal Center for Health Statlstlcs, Division of VItaI Statista 3-4 would be a reduction in the number of low weight infants and a reduction in the number with birth defects. birth born Other significant health problems include injuries, accidents, and the sudden infant birth death syndrome which may be the leading cause of death of infants older than one month. But not all health problems are reflected in mortality and morbidity figures. It is also impor- tant to foster early detection of developmental disorders during the first year of life to maximize the benefits of care. And the first year is a sig- nificant period for laying the foundation for sound mental health through the promotion of loving rela- tionships between parents and child. Subgoal: Reducing the Number of Low Birth Weight Infants Low birth weight is the greatest single hazard for infants, increasing vulnerability to develop- mental problems--and to death. Of all infant deaths, two-thirds occur in those weighing less than 5.5 pounds (2500 grams) at birth. Infants below this weight are more than 20 times as likely to die within the first year. tow birth weight is sometimes associated with increased occurence of mental retardation, birth defects, growth and development problems, blindness, autism, cerebral palsy and epilepsy. In the United States in 1976, about seven per- cent of all newborns weighed less than 5.5 pounds. In Sweden, however, the figure was four percent. The difference probably explains Sweden's more fa- vorable infant mortality experience. Because sub- stantial reductions in infant mortality and child- hood illness could be expected to follow any signi- ficant reductions in the number of infants of low birth weight in this country, that should be a major public health goal. 3-5 Many maternal factors are associated with low infant birth weight: lack of prenatal care, poor nutrition, smoking, alcohol and drug abuse, age (especially youth of the mother), social and eco- nomic background, and marital status. Given no prenatal care, an expectant mother is three times as likely to have a low birth weight child. And many women least likely to receive adequate prenatal care are those most likely to have other risk factors working against them. Women from certain minority groups are half as likely as white women to receive the minimum of pre- natal care recommended by the American College of Obstetrics and Gynecology. About 70 percent of ex- pectant mothers under age 15 receive no care during the first months of pregnancy, the period most im- portant to fetal development; 25 percent of their babies are premature, a rate three times that for older mothers. The lower risk with regular prenatal care may result from the benefits of medical and obstetrical services --and from accompanying social and family support services. Infants born to women experiencing complications of pregnancy such as toxemia* and infections of the uterus have a four to five times higher mortality rate than others. For mothers with such medical conditions as diabetes, hypertension, or kidney and heart disease, there is a higher risk of bearing babies who will not survive their first year--a risk which competent early medical care can reduce. * Toxemia--present in two percent of pregnancies-- is characterized by high blood pressure, tissue swelling, headaches, and protein in the urine. It can provoke convulsions and coma in the mother, death for the fetus. 3-6 Maternal nutrition is a critical factor for infant health. Pregnant women lacking proper nutri- tion have a greater chance of bearing either a low birth weight infant or a stillborn. Diet supplemen- tation programs--especially those providing suitable proteins and calories--materially increase the like- lihood of a normal delivery and a healthy child, and attention to sound nutrition for the mother is a very important aspect of early, continuing prenatal care. Also hazardous for the child are maternal ciga- rette smoking and alcohol consumption. Smoking slows fetal growth, doubles the chance of low birth weight, and increases the risk of stillbirth. Re- cent studies suggest that smoking may be a signifi- cant contributing factor in 20 to 40 percent of low weight infants born in the United States and Canada. Studies also indicate that infants of mothers regu- larly consuming large amounts of alcohol may suffer from low birth weight, birth defects, and/or mental retardation. Clearly, both previously developed habits need careful attention during pregnancy. Maternal age is another determinant of infant health. Infants of mothers aged 35 and older have greater risk of birth defects. Those of teenage mothers are twice as likely as others to be of low birth weight. And subsequent pregnancies during adolescence are at even higher risk for complica- tions. Family planning services, therefore, are important--and, for pregnant adolescents, good pre- natal care, which can improve the outcome, is receiving increased emphasis in many communities. Racial and socioeconomic groups show great dis- parity in low birth weight frequency. Not only is infant mortality nearly twice as high for blacks as for whites, prematurity and low birth weight are also twice as common for blacks and some other minorities. Evidence indicates that the racial differential is associated with corresponding socioeconomic differences. Analyses of birth weight distribution according to socioeconomic status among homogeneous 3-7 ethnic populations reveal a clear relationship between birth weight and social class; the birth weight of black infants of higher socioeconomic status is comparable to that of whites. Marital status is another important factor. In 1975, the risk of having a low birth weight infant was twice as great for unmarried as for married women--at least partly because the unmarried are less likely to receive adequate prenatal care. Although further research can help define more precisely the relationship between all these factors and low birth weight and infant mortality, we have clear indications of measures which can be taken now to reduce the risks. Chapter 8 is devoted to those measures. Subgoal: Reducing the Number of Birth Defects Birth defects include congenital physical anom- alies, mental retardation, and genetic diseases. Many present immediate serious hazards to infants. Many others, if not diagnosed and treated immedi- ately after birth or during the first year of life, can affect health and well-being in later years. Birth defects are responsible for one-sixth of all infant deaths. They are the second leading cause of death for children one to four years old, and the third leading cause for those five to 14 years old. Nearly one-third of all hospitalized children are admitted because of genetically determined or influenced disorders which often result in long-term economic and social strains for affected families. Approximately two to three percent of infants have a serious birth defect identified within the first weeks of life--and five to 10 percent of these are fatal. Those most likely to be lethal include malformations of brain and spine, congenital heart defects, and combinations of several malformations. 3-8 In about one-fourth of birth defects, the cause is thought to be purely genetic; in one-tenth, purely environmental. In the remaining two-thirds, the cause is unknown. Interaction between genetic and environmental factors is an important concept guiding substantial research in this area. Given current knowledge, many birth defects cannot be prevented. But many can be. Identifiable environmental hazards can be reduced. Carrier iden- tification, amniocentesis, and neonatal screening procedures (Chapter 8) can aid in detecting some ge- netic disorders before, during, and after pregnancy. Inherited Factors Although some 2,000 genetic disorders are known, fewer than 20 are responsible for most genetic di- sease in this country. Five types cause most of the illness and death: presence of an extra chromosome, and occurs in about one of every 1,000 births. It causes physical de- fects which require lifelong care, and is respon- sible for 15 to 30 percent of the severe mental retardation in children living to age 10. The risk of having a Down syndrome child in- creases with maternal age, especially after 35; at least one-fourth of the 3,000 infants with the syn- drome born each year are those of women 35 or older. Recent research has shown that the father, rather than mother, contributes the extra chromosome in about one-fourth of all cases. Down syndrome can be detected by sampling intra- uterine fluid through amniocentesis but the proce- dure currently is being performed for only about 10 percent of the 150,000 women aged 35 and older who become pregnant in any one year. The advisability of having amniocentesis depends upon individual cir- cumstances and should be discussed with a physician. 3-9 Severe brain and spinal cord (neural tube) defects. Neural tube defects not only occur more frequently than Down syndrome but also result in more deaths within the first month of life. Characterized by lack of development of parts of the central nervous system or its skeletal protec- tion, neural tube defects include spina bifida (a vertebral column defect) and anencephaly (very small head and brain). The defects occur in about two of every 1,000 infants, half of whom die in the newborn period. In addition to amniocentesis, a maternal blood screening test for a substance called alpha- fetoprotein can detect pregnancies at risk for neural tube defects. Risk for neural tube defects is 2.5 times great- er for whites than other racial groups. At greatest risk are families with previous history of the de- fects or with an affected child; genetic counseling is recommended for them. Defects related to particular ethnic groups. These include Tay-Sachs disease, sickle cell anemia, and cystic fibrosis. Tay-Sachs disease is 100 times more frequent among Jewish families of Ashkenazi (Eastern European) descent than in the general population. Although children with the disease appear normal at birth, they die by age five as a result of severe mental retardation and progressive neurologic de- terioration. The disease is caused by accumulation of a fatty substance in the brain. Because the responsible gene is recessive, Tay-Sachs disease occurs only when both parents carry the gene. Each prospective child then has a 25 percent chance of developing the disease. Fortunately, a carrier de- tection screening test is available to identify an at-risk couple before pregnancy. Sickle cell anemia is the most common serious genetic disease among blacks. About 1,000 infants each year are born with sickle cell disease in which 3-10 red blood cells are damaged because of altered sta- bility of their hemoglobin content. Although no mental retardation is associated with sickle cell disease, it is a serious condition leading to years of pain, discomfort, and even death from complica- tions. Specific treatment has yet to be found. Cystic fibrosis occurs primarily among whites in about one of every 2,000 births, affecting 1,500 infants a year. In the disease, abnormal production of mucus leads to chronic lung obstruction and dis- ability during childhood and early adult life. The disease can also affect the pancreas, liver, and intestines. In 1976, it caused the death of twice as many infants as tetanus, whooping cough, syphilis and rubella combined. Although there is no specific cure, there have been many advances in caring for patients so that, if they survive through infancy, many now reach adult life. Sex-linked defects. These congenital disorders affect the sons of mothers who carry an abnormal X chromosome. Hemophilia and muscular dystrophy are two prominent examples. The bleeding disorder, hemophilia, is due to deficiencies in the clotting mechanism of the blood. In muscular dystrophy, muscle is replaced by fat, leading to gradual muscular weakness and wasting. Metabolic disorders. The most widely known of this group--and the one for which infants are most frequently tested--is PKU (phenylketonuria). It involves a genetic liver enzyme deficiency which allows an amino acid to accumulate abnormally, impairing brain function and leading to increasingly severe mental retardation later in childhood. PKU, which occurs in one of every 15,000 births, can be treated with special diet that compensates for the enz_vme deficiency. Cogenital hypothyroidism (cretinism) is a more common metabolic disorder capable of causing mental retardation. Some cases result from genetic pre- disposition but others may be the result of circum- stances (e.g. maternal iodine deficiency) occurring 3-I! during fetal development. About 600 infants a year--one per 5,000 births--are affected, but early detection and prompt treatment with thyroid medi- cation in the first weeks of life can prevent the retardation. The availability of specific tests for both PKU and congenital hypothyroidism has prompted States to consider requiring both for each newborn. Even though the number of affected babies detected will be small, the benefits of early diagnosis and treat- ment for the affected babies can be profound. External Factors Birth defects can result from exposure of the fetus to infectious or toxic agents during preg- nancy, especially during the first three months (first trimester). Infections. Rubella (German measles), when it affects a mother during the first trimester, can lead to congenital malformations as well as still- birth and miscarriage. The greatest risk occurs when most women may not even be aware of being pregnant. The likelihood of rubella-induced malformations is approximately 25 percent during the first three months, after which it begins to decline substantially. The most seri- ous problems for the fetus include blood disorders, heart defects, cataracts or other eye defects, deaf- ness, and mild to profound mental retardation. For prospective mothers who have not been ex- posed to rubella, vaccination prior to pregnancy can help prevent all of the problems for the fetus. Radiation and chemicals in the workplace. These environmental factors have their qreatest potential for harm during the early weeks of fetal .develop- ment--again, often before a woman realizes that she is pregnant. And they remain hazards throughout pregnancy. High doses of ionizing radiation in - 3-12 utero not only can increase risk of fetal malforma- tion; there is suggestive evidence of increased risk of subsequent leukemia and other childhood cancers. To reduce risks, protective measures should be taken to help pregnant women avoid unnecessary exposure. Drugs. A broad range of medications, including some seemingly innocuous over-the-counter prepara- tions, may harm the fetus. A now-classic example of drug hazard is the epi- demic several years ago of birth defects caused by maternal use of thalidomide. Taken as a mild seda- tive and sleeping aid, thalidomide led to devel- opmental defects, particularly of the limbs, in approximately 35 percent of infants of mothers using it. Throughout the world, an estimated 10,000 de- formed infants were born. Thalidomide was on the European market approximately five years before the problem was identified and the product removed, but it was never approved for use in the United States. Other drugs known to cause birth defects include some hormones such as DES (diethylstilbestrol), as well as certain anti-cancer and anticonvulsant agents. DES taken by mothers during pregnancy has been linked to vaginal cancer development in daugh- ters during adolescence and early adulthood. Among drugs currently under study for possible birth defect potential are warfarin, diphenylhy- dantoin, trimethadione, and lithium. Some women need these drugs for serious problems such as post- rheumatic heart disease, seizures, and severe mental disturbances. Also under investigation are some drugs used during childbirth which may have detri- mental effects on the child's central nervous system. It must be emphasized to the public--and perhaps to some physicians-- that exposure to any drug should be avoided at any time during pregnancy, but espe- cially during the first trimester, unless there are overriding medical considerations to use a drug for the mother's health. 3-13 Alcohol. The incidence of alcohol-induced birth defects is now estimated to be one for every 100 women consuming more than one ounce of alcohol daily in early pregnancy. The fetal alcohol syndrome therefore accounts for the occurrence of approxi- mately one birth defect in every 5,000 births in the United States. Affected infants are often of low birth weight, mentally retarded, and may have behavioral, facial, limb, genital, cardiac and neurological abnormalities. The risk and degree of abnormality increases with increased alcohol consumption. According to a Boston City Hospital study of infants born to heavy drinkers (average 10 drinks a day), 29 percent had congenital defects compared to 14 percent for moderate drinkers and only eight percent among non- drinkers. Furthermore, 71 percent of infants born to women who consumed more than 10 drinks daily had detectable physical and developmental abnormalities. Safe alcohol consumption levels during pregnancy have yet to be determined. But, in view of the as- sociation between high levels and fetal abnormali- ties, women who are pregnant or think they might be should be encouraged to use caution. And women alcoholics, until treated effectively for their addiction, should be encouraged by public informa- tion programs and by direct counseling to avoid conception. Other Important Problems Several other problems with major impact on infant health are noted in Figure 3-C. Injuries at Birth Birth injuries, difficult labor, and other con- ditions causing lack of adequate oxygen for the infant are among the leading reasons for newborn deaths. 3-14 Although most pregnant women experience normal childbirth, complications may occur during labor and delivery. Some--such as small pelvic cavity--can be detected in advance, during prenatal care. Others unidentifiable beforehand require prompt management. They include hemorrhaging from the site of attachment of the placenta (afterbirth); abnormal placental location; abnormal fetal position; pre- mature membrane rupture; multiple births; sudden appearance or exacerbation of toxemia; and sudden intensification of a known medical problem such as heart disease or diabetes. Sudden Infant Death Certain babies, without apparent cause or warn- ing, suddenly stop breathing and die, even after apparently uncomplicated pregnancy and birth. This unexplained event, called the sudden infant death syndrome, is believed by some authorities to be the leading cause of death for babies older than one month. Recently evidence has been accumulating that ab- normal sleep patterns with increased risk of breath- ing interruptions (apnea) may be associated with the unexpected deaths. A variety of factors, such as prematurity and maternal smoking, are emerging as possible contributors to increased risk for sudden infant death, but there is a need to learn more. Extensive research now under way should refine our ability to identify high risk infants and effec- tively prevent their deaths. Accidents More than 1,100 infants died in accidents in 1977. The principal causes were suffocation from inhalation and ingestion of food or other objects, motor vehicle accidents, and fires. Many deaths reflect failure to anticipate and protect against situations hazardous for developing infants. Child abuse may also account for some deaths. 3-15 Inadequate Diets and Parental Inadequacy Although they are not major causes of death, problems related to infant care have significant impact on infant health. Even in a society of considerable affluence, many infants are not receiving appropriate diets and suffer from deficiencies of nutrients needed for development. Frequently, it is overnutrition rather than undernutrition which is the problem setting the stage for obesity later in life. Recognition of the extent to which parental attitudes are important to a child's development-- and, with it, the need to bring parents and babies together psychologically--is receiving increasing attention. Even when an infant must be kept in the hospital because of low birth weight, early contact between parents and child may be helpful to a good start in life and sound emotional development. Breast feed- ing is to be encouraged not only for its nutritional benefits but also for the contribution it can make to psychological development. The fact is that growth of a "sense of trust" has been identified as a significant aspect of healthy infancy. Intimate, enjoyable care for babies fosters that growth and the building of sound emotional and mental health. Moreover, recently, there has been growing recognition that certain disorders occur when there is neglect or inappropriate care for an infant. One is "failure to thrive" or developmental attrition-- with the child losing abiJity to progress normally to more complex activities such as standing, walk- ing, talking, and learning. Other disorders linked to neglect or inappropriate care include abnor- malities in eating and digestive functions, sleep disorders, and disturbances in other activities. 3-16 All of these problems underscore the need for regular medical care during the prenatal period and early months of infancy. Such care should be sensi- tively designed to enhance the relationship between parents and child as well as to ensure sound nutri- tion, appropriate immunizations, and early detection and treatment of any developmental problems. As programs have expanded to provide better services to pregnant women and newborn babies, the health of American infants has steadily improved. These recent gains to infant health are indeed heartening. Moreover, more can be done to a greater extent than ever before, we have a clearer understanding of the factors important to ensuring healthy infants. Section III discusses in greater detail the actions we can take. 3-17 CHAPTER 4 HEALTHY CHILDREN I Goal: To improve child health, foster optimal childhood development, and, by 1990, reduce deaths among children ages one to 14 years by at least 20 percent, to fewer than 34 per 100,000. The health of American children is better than ever before. The childhood mortality rate now is far below what it was in 1900 when 870 of every 100,000 children ages one to 14 years died annually (Figure 4-A). Then, the principal causes of death were infectious diseases--and, although they still are responsible for some illness and death, their threat has been greatly reduced through improved sanitation, nutrition and housing, as well as use of vaccines and antibiotics. By 1925, the death rate for children had fallen to 330 per 100,000; by 1950, to 90; and by 1977, to 43. Yet, there is cause for concern. 0 Black American children have a 30 percent higher mortality rate. 0 For all our children at ages one to 14 the death rate is still slightly higher than for those in some other countries (Figure 4-B). 0 And our rate of mortality decline has slowed in recent years. All preventable deaths and injuries are tragic--those for children, especially so. 4-l FIGURE 4-A DEATH RATES FOR AGES 1-14 YEARS: UNITED STATES, SELECTED YEARS 1900-1977 10 8 8 7 6 5 4 3 2 1 0.9 0.8 0.7 06 0.5 0.4 0.3 I I I I I 1900 1910 1920 1930 1940 1950 1960 1970 198, 4-2 FIGURE 4-B DEATH RATES FOR AGES 1-14 YEARS: SELECTED COUNTRIES, 1975 UnIted states SWden England and Wales Japan Chile NOTE ine most recent year Of ata 10, Chlk I5 1971 Sources: United States, National Center for Health Statistics, Division of Vital Statistss, other countries, United Nations. 4-3 Cancer, birth defects, and influenza and pneu- monia cause childhood deaths--all at relatively low rates (Figure 4-C). No other preventable cause poses such a major threat as accidents which account for 45 percent of total childhood mortality. By itself, a 50 percent reduction in fatal accidents would be enough to achieve the goal of fewer than 34 deaths per 100,000 by 1990. And this is not an unrealistic target, since a number of actions can be taken. It is a fact, for instance, that mandatory seat belt laws scrupulously imple- mented in some countries have reduced traffic accident deaths by 30 percent. It should also be entirely feasible to reduce deaths due to fires, falls, and other comnon childhood accidents. In addition to disease and injury, children face other problems--of behavioral, emotional and intel- lectual development. They include learning diffi- culties, school troubles, behavioral disturbances, and speech and vision problems. A generation ago, such problems did not seem as prominent as they do today and they are now sometimes called the "new morbidity." We must face the fact, too, that characteristics developed during childhood can lead to adult disease and disability--and as many as 40 percent of our youngsters aged 11 to 14, for example, are now estimated to have, already present, one or more of the risk factors associated with heart disease: overweight, high blood pressure, high blood choles- terol, cigarette smoking, lack of exercise, or diabetes. Because they are of such importance for well- being all through life, this chapter begins with a special focus on childhood growth and development issues. There follows an analysis of childhood accidental injuries and two other significant, yet preventable, problems. 4-4 FIGURE 4-C MAJOR CAUSES OF DEATH FOR AGES 1-14 YEARS: UNITED STATES, 1978 l- >- I- I_ All other accidents I MObX vehicle accidents n Whute m All other cancer Brth defects Influenza and pne"mo"la Homicide Sources Based on data from the National Center for Health Statistics. Diwsion of Vital Statstics. 4-5 Subgoal: Enhancing Childhood Growth and Development Perhaps the most critical characteristic of childhood is rapid, dramatic change--physical, emo- tional, and behavorial. During the early years of development, a child is especially vulnerable not only to infection and injury but also to problems stenxning from social or interpersonal causes. If special risks-- such as poor nutrition, child abuse or neglect, and insufficient stimulus to intellectual and psychological development--are not identified and dealt with early, growth may be profoundly affected. And the consequences of physical and psychological illness early in life, even if not apparent then, may become so later. Is there in fact a "new morbidity?" Actually, learning disorders, inadequate school functioning, behavioral problems, and speech and vision diffi- culties are not new. Rather, successful control of many life-threatening childhood diseases of the past has permitted a new awareness of and sensitivity to these problems. We have come to realize that threats to a child's physical growth and development also threaten optimal mental growth and development--and that, too, a stimulating and safe environment is essential to optimum mental growth and development. Important sociologic trends need to be taken into account. In 1977, 18 percent of all children-- up from 12 percent in 1970--were living in families headed by single parents. And almost 50 percent of all children today have mothers who work. As a result, early childhood development pro- grams, such as Head Start, which include an array of health, educational, nutritional, and social serv- ices are increasingly needed. 4-6 Several recent studies have shown that children, especially those from low-income families, derive many positive benefits from preschool programs. A 1979 General Accounting Office report indicates that children participating in an early development program subsequently require less reme- dial special education. Participants are held back in grade less often, and demonstrate superior so- cial, emotional and language development after entering school than comparable non-participating children. Learning Disorders As many as 20 percent of school age children have reading or learning disabilities which can have lifelong consequences if not overcome. They are a major cause of school dropout and can also lead to serious emotional and behavioral disturbances, some of which may be manifested as symptoms of physical illness. Although there is little agreement on precise etiology, the consensus is that learning disabili- ties have multiple causes including central nervous system disorders, emotional factors, and environ- mental and cultural influences. Can such disabled children be helped? Research indicates that fully 80 percent whose problems are identified early and who receive remedial education can function within normal range for their age. Vision problems, if uncorrected, can impair learning ability--and an estimated 20 percent of all children have them. Two-thirds are nearsighted; one third, farsighted. As much as an additional three percent have hearing difficulties, often caused by complications from middle ear infections. Impaired hearing from recurrent middle ear infections during the critical 4-7 years of language development can interfere with learning ability. Early diagnosis and treatment of the infections--among the most cornnon ailments of early childhood--could prevent many cases of temporary and some of permanent hearing damage as well as contribute to prevention of learning and behavioral problems later in childhood. Mental Retardation An estimated six million Americans suffer from mild to severe retardation, and each year about 100,000 children are identified as mentally retarded. In only a small percentage of cases is retarda- tion detectable at birth. Usually, diagnosis is made at school age. In about 90 percent of cases, the retardation is defined as mild (IQs 50 to 70). Much mild retardation is now believed to be the result of a deprived sociocultural environment often associated with poverty. The likely mechanism: inadequate stimulation or improper nutrition. Since poor nutrition has been associated with slow mental development, it is important to ensure good nutri- tional habits for children. Child Abuse and Neglect Abuse and neglect are serious--and, unfortun- ately, not rare--threats to both physical and emotional development. They account not only for many injuries, burns and other seeming accidents in children but also for brain damage, emotional scars, and even deaths. There are also children who are victims of sexual abuse, incest, and rape. . The inherently intimate aspect and difficulties in identifying and reporting instances of abuse and neglect have led to widely varying estimates of their extent. Estimates of the actual number of cases of child abuse, which is generally acknowledged to be greatly 4-8 under-reported, range from 200,000 to four million a year. Child neglect is probably more common than direct physical abuse. Abuse and neglect often appear to be manifes- tations of severe family instability. Stress can contribute to the instability and poverty may contribute to the stress. Alcohol is implicated in many cases. Physically or mentally handicapped children can be targets of abuse by parents frus- trated by the handicaps. Parental immaturity can be critical but many otherwise stable, intelligent parents have been known to abuse their children in stressful situations. High risk families range from the obviously deeply troubled and chronically disorganized--many already known in some way to the police or other community resources-- to families temporarily under stress. Also at high risk are children of teenage mothers and those in families with closely spaced children. Abusing parents are often imnature, dependent, unable to handle responsibility. They have low self-esteem, strong beliefs about the value of phy- sical punishment, and misconceptions about chil- dren's competence to understand and perform accord- ing to their expectations. They frequently make unreasonable demands and, during time of crisis, may direct their anger and frustration at a child. They often are isolated socially and have difficulty seeking help. Efforts to reduce and ultimately eliminate child abuse will have to be multifaceted. Some promising approaches involve parent education, enhancement of community and social support systems, assistance to abusing parents through collaborative efforts of public and private sector, and projects designed to create an integrated health and social service delivery system. Such programs help ensure that families at risk for child abuse have continuing contact and follow-up care from a health or social services agency from the prenatal period through the school years. 4-9 Nutrition The nutritional habits developed in childhood can profoundly affect health throughout life. No longer are overt nutritional deficiencies as common as they once were, particularly among the poor and uneducated, although iron deficiency still exists among disadvantaged children and may show up during screening examinations. To some extent, the needs of children who would otherwise be undernour- ished have been met by school programs which provide nutritious breakfasts and lunches, and by food stamps or income supplements. Improvements in these programs, however, are required to more adequately meet needs. Today's most prevalent nutritional problems are overeating and illadvised food choices. Obesity--a risk factor for hypertension, heart disease and diabetes--frequently begins during childhood. About one-third of today's obese adults were overweight as children. An obese child is at least three times more likely than another to be an obese adult. Be- cause obesity is more difficult to correct in adult- hood, major preventive efforts are best directed toward children and adolescents. Another cause of concern is the diet of a large proportion of today's children--containing con- siderably more fat and sugar than a reasonable diet should have. Underscoring the seriousness of that concern: evidence of oronary arteriosclerosis in seemingly healthy young people in their late teens. Limiting fat consumption by children may reduce blood fat levels, and, thus, a risk factor for heart disease. Subgoal: Reducing Childhood Accidents and Injuries Almost 10,000 American children aged one to 14 were killed in accidents in 1977, more than three times as many as died from the next leading cause of death, cancer. 4-10 Motor vehicle accidents are responsible for more than 20 percent of childhood deaths, drowning for eight percent, and fires for six percent. Although these problems fall under the rubric of health, they are the results primarily of environ- mental and social factors--and thus not amenable to usual medical intervention. Prevention requires changes in the behavioral patterns of many parents as well as children. Fre- quently, accidents result from the poor judgment of parents who, for example, speed or drive after drinking-- and from failure to teach proper precau- tionary measures to children. But attention to other factors, such as motor vehicle and highway design, can reduce motor vehicle accident risk--and safety measures can cut the toll of accidental deaths from drownings and fires. Most accidents among older children are accounted for by recreational activities and equip- ment. Among leading causes of the 498,000 recorded emergency room visits made by children aged six to 11 in 1976, were bicycle, swing, and skateboard accidents. For those 12 to 17, the leading causes included football, basketball, and bicycle riding. Contact sport injuries, it should be noted, often involve the mouth and teeth--and the aftereffects and treatment may be long and costly. Toxic substances in the home--drugs, cleaning agents, pesticides, and other items--pose a special hazard to younger children. Although childhood poi- soning deaths have been reduced in the past decade through changes in the formulation and packaging of poisonous agents, poisoning still accounts for five percent of non-motor vehicle accidental deaths among children under five. Lead poisoning is a particularly striking example of an environmental hazard with severe con- sequences for children. Each year, ingestion or inhalation of lead leads to central nervous system 4-11 damage or mental retardation in 6,000 children as well as death for another 300 to 400. Although it is a potential hazard for all chil- dren, lead poisoning is especially threatening for inner city children who may be more vulnerable be- cause of lead ingested in paint chips from peeling, dilapidated walls as well as lead inhaled from auto- mobile exhausts. Elevated lead levels have been detected in the blood and teeth of as many as 25 percent of children aged one to six living in neigh- borhoods with deteriorating housing. Research has been revealing an association between high blood or body lead levels and learning disabilities. Other Important Problems Still prominent threats to the good health of children include two other areas susceptible to preventive interventions: vaccine-preventable dis- eases and dental health. Vaccine-Preventable Diseases We have come tantalizingly close but have yet to reach a feasible goal: to protect all American children from the many serious diseases and the per- manent physical and mental handicaps they may cause for which effective immunization is available. That the goal of virtually eliminating such diseases is feasible and that intensive systematic immunization can achieve it is perhaps most drama- tically demonstrated by the worldwide elimination of smallpox. Another prominent example: the decline in paralytic polio, since vaccine introduction in 1955, from as many as 20,000 cases a year in the 1940s and early 1950s to seven cases in 1978. Today, measles is considered the most threat- ening of the childhood contagious diseases which remain both prevalent and preventable. Its frequent complications include pneumonia, ear infections and deafness. Brain inflammation (encephalitis) occurs in about one of every 1,000 cases, often producing 4-12 permanent brain damage and mental retardation. About one of every 10,000 children afflicted with measles dies as a result of complications. In 1962, there were nearly five million cases of measles (of which about 500,000 were officially reported). After the introduction of the measles vaccine in 1963, reported measles incidence was reduced by more than 90 percent. In recent years the number of cases reported has ranged from 22,000 in 1974 to 57,000 in 1977. But, as a result of the recent National Immunization Initiative, the incidence of measles has experienced a remarkable decline to the lowest levels ever recorded. Rubella (German measles) remains a problem of importance, with 20,000 reported cases in 1977 (actual cases are estimated to be as much as 20 times the reported number). The most dangerous con- sequence of rubella is damage to the fetus when a woman becomes infected early in pregnancy (see Chap- ter 3). A vaccine is available and immunization of children--and of young women before pregnancy--is vital. Mumps, although usually not a serious disease in childhood, nevertheless can sometimes involve the central nervous system, with nerve deafness as one of the most severe complications. Approximately one case of deafness occurs for every 15,000 cases of mumps in the United States. In adults, mumps can affect the reproductive organs and in males this occasionally results in sterility. A combined vac- cine--for mumps, measles and rubella--makes immuni- zation against mumps practical. Still, more than 16,000 cases occurred in 1978. For diphtheria, pertussis (whooping cough) and tetanus (lockjaw), vaccines are readily available. Yet, while incidence has dropped to low levels, many children remain unprotected and vulnerable to the respiratory, cardiovascular, and nervous system complications which may occur with these diseases. 4-13 Pertussis was once a leading cause of death for children at the turn of the century. Today it is fatal to one of every 100 afflicted children, but only 2,000 cases were reported in 1977. Diphtheria and tetanus occur less frequently (under 100 re- ported cases of each in 1977). Still, all three diseases remain threats for children not adequately irrrnunized. Prior to the national childhood immunization effort which began in 1977, one-quarter to one-half of pre-school and school-age children remained in- completely immunized. Ironically, the great success of previous immunization programs created a compla- cency and was one reason why many children were not being immunized. The gains of the past two years demonstrated that national and local campaigns are needed on a sustained basis to increase parental awareness of the need for immunization and maintain immunization at an acceptable level. Contagious diseases for which immunizations are available are not the only childhood infectious diseases of concern. Rheumatic fever--caused by streptococcal infection-- ranked 40 years ago as the leading cause of death for children aged five to 15. Today, with early diagnosis and adequate treatment for streptococcal infections, complications such as rheumatic fever can be prevented. Dental Health Tooth decay affects most children soon after age three when the primary teeth have appeared. BY age 11, the average American child has three permanent teeth damaged by decay. By age 17, eight or nine permanent teeth have decayed, been filled, or are missing. Tooth decay is irreversible. Once begun, decay that is left untreated usually destroys the tooth. Although treatment generally consists of removing the decay and filling the tooth, the problem is compounded by frequent recurrence within relatively brief periods of time. Follow-up and continuing detection and treatment are needed. 4-14 Even though decay primarily occurs in childhood, it may lead to misalignment or loss later of perma- nent teeth. It can also affect appearance and lead to nutrition and speech problems, and difficulties in normal emotional development. Decay has three requisites: a susceptible tooth, a population of certain bacteria in the mouth, and certain foods, particularly sugars, to encourage the bacteria. Prevention efforts, therefore, must be aimed at making teeth less susceptible, minimizing bacterial growth, and altering the diet. The biggest problems are sweets, particularly sticky sweets and hard candies. Sugary materials that are eaten frequently, or that remain in the mouth for extended periods, encourage bacteria in the mouth to form acids that destroy tooth enamel, and subsequently, underlying tooth structures. The practice of giving an infant or small child a bed- time bottle filled with milk or sweet liquid also is conducive to decay. That reduction of sugar intake can avoid much decay was demonstrated by the significant decline in European countries during the two World Wars when sugar was in short supply. Many children also experience disease of the supporting tissues (periodontal disease). Usually beginning in childhood, periodontal disease pro- gresses slowly and, unless checked, can cause serious problems later in life, including complete loss of teeth. Fluoridation has demonstrated over the past 30 years that it is one of the most effective measures in preventing tooth decay and is addressed in Chapter 9. ********** Many factors affect a child's development-- genetics, the home environment, the quality of 4-15 interactions with parents, teachers, health profes- sionals, other adults, peers. With so many influ- ences, no single course of action will protect the future mental, emotional, and physical health of every child and assure realization of full develop- mental potential. Section III will detail needed actions. But the special importance of the school should be emphasized here. Many hours of a child's life are spent in the classroom. Providing health services through school programs can be of great value. So could effective health education. Our children could benefit greatly from a basic understanding of the human body and its functioning, needs, and potential-- and from an understanding of what really is involved in health and disease. There are a number of school systems which have developed good models for health education. For other schools to really take on what could be their highly significant role in health education and health promotion will require a commitment by school leadership at local, State and national levels to apply these models. 4-16 CHAPTER 5 HEALTHY ADOLESCENTS AND YOUNG ADULTS Goal: To improve the health and health habits of adolescents and young adults, and, by 1990, to reduce deaths among people ages 15 to 24 by at least 20 percent, to fewer than 93 per 100,000. Obviously enough, adolescence is a period of complex changes-- in physical growth and maturation and in transition from childhood dependency to adult autonomy. In health, it is--relatively--a good period as measured by the usual morbidity and mortality indicators. Although the death rate for the 40 million young Americans in the 15 to 24 year age group is 2.5 times the rate for children, it is substantially below that for other age groups. Yet, while health for this age group, as for others, is considerably better than 75 years ago (Figure 5-A), there is one startling difference: for adolescents and young adults, recent progress has not been sustained, as it has been for other age groups. Americans aged 15 to 24 now have a higher death rate than 20 years ago. In 1960, the adolescent/young adult mortality rate was 106 deaths per 100,000. By 1970, the rate was up to 128. By 1976, it had dropped to 113--but 1977 statistics show an increase again to 117. This represents nearly 48,000 deaths in 1977 alone. Americans aged 15 to 24 have a higher death rate than their counterparts in other countries such as Sweden, England and Wales, and Japan (Figure 5-B). 5-l FIGURE 5A DEATH RATES FOR AGES 1524 YEARS: UNITED STATES, SELECTED YEARS lBBB-1977 1900 1910 1920 1930 1940 1950 1960 1970 1980 5-2 FIGURE 58 DEATH RATES FOR AGES 1524 YEARS: SELECTED COUNTRIES, 1975 United states Sweden England and W.3kS NOTE me most recent year Of data lo. Chlk