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.     - -

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            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.

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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.

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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.

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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.

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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.

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   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.

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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.

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  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 <s ,971

Sources: UnIted States, Natlonal Center for Health Statlstlcs, Dlvlsion of Vital Stat!stics:
     other countries, United Nations.

5-3


  What are the principal threats to health? Vio-
lent death and injury, alcohol and drug abuse,
unwanted pregnancies,  sexually transmissible dis-
eases   are  among the more common health-related
problems for this age group.

  Young men are at particular risk, their death
rate being almost three times that of young women.
And,  although chronic  diseases are not among the
major causes of death at this period of life (Figure
5-C), the lifestyles and behavior patterns which are
shaped during these years may determine later sus-
ceptibility to chronic diseases.

  Accidents, homicides,  and suicides account for
about three-fourths of all deaths in this age group.
Responsibility has been attributed to behavior pat-
terns characterized by judgmental errors, aggres-
siveness,  and,  in some cases,  ambivalence about
wanting to live or die.  Certainly, greater risk-
taking occurs in this period of life.

  The variability of these traumatic deaths by sex
and race is striking.  All types are three to four
times more frequent for males.  While motor vehicle
accident deaths are more likely to occur among white
youths, young blacks of either sex are at least five
times as likely to be murdered; homicide is the
leading cause of death for young blacks, ranking
slightly ahead of total accidents.

  Certainly, injury control must be a clear health
promotion priority for young people but the task
will  not be easy.   Injury rates are linked to
factors--lifestyle and socioeconomic--not usually
addressed by  health programs.   Nevertheless, a
strong effort must be made since this is a major
public health problem.

  An equally difficult task will be to reduce mis-
use of alcohol and drugs.   But it is essential to
strengthen the effort--for the misuse contributes
greatly not only to injuries, homicides and suicides
but also to other problems of young people which
have been growing rapidly.

5-4


             FIGURE 5-C
MAJOR CAUSES OF DEATH FOR AGES 16-24 YEARS:
        UNITED STATES, 1976

50 -







40 -






30-






20 -







10 -






O-

0 White

All other

Motor
vehicle
accidents

All other
accidents

Cancer

Heart
disease

Source Based on data from the Nattonal Center for Health Statlstuzs. D~ws~on of Vital Statinlcs

5-5


Subgoal:  Reducing Fatal Motor Vehicle Accidents

  In 1977 motor vehicle accidents were the leading
cause of mortality in the 15 to 24 year age group,
accounting for 37 percent of all deaths.

  Although a complex interaction--of driver, ve-
hicle and roadway--determines the risk of accidents,
nevertheless a teenage or young adult driver who is
involved in a traffic accident is twice as likely to
die as a driver 25 years old or older.

  Alcohol consumption is clearly implicated in
many of the fatalities.  About half of fatally in-
jured drivers have been found to have blood alcohol
concentrations of more than 100 mg/dl (100 milli-
grams of alcohol per deciliter of blood).   In most
states,  this is considered presumptive evidence of
intoxication.  Blood alcohol levels even lower than
100 mg/dl increase the likelihood of an accident--
especially for teenagers, the elderly,  and others
particularly sensitive to alcohol.  Young people
also place themselves at greater risk by driving
while under the influence of marijuana or other
drugs.

  The attitudes of young people about risk are
significant.  While excessive speed was a factor in
35 to 40 percent of all vehicular fatalities in
1977, it was an influence in almost half of those
involving teenagers 15 to 19.  Although lap and
shoulder belts can help to prevent serious injuries
and fatalities, 80 percent of Americans, including
teenagers and young adults, do not use them.

  Motorcycle  accidents killed more than 4,000
Americans in 1977--30 percent of them under 20 years
of age.  Motorcyclists,  because they have so little
protection,  have a seven times greater chance of
fatal injury for each mile driven than do automobile
drivers.   And,  more frequently than   automobile
accidents,  motorcycle   accidents    cause   severe,
permanent head injuries leading to paralysis.

5-6


  Although  some decline in  vehicular  accidents
resulted from institution of the 55 miles an hour
speed limit,  more can be done.  Greater production
and use of active and passive passenger restraints,
safer cars, and increased use of helmets by motorcy-
clists,  as well as continued enforcement of speed
limits, would lead to further reductions, and these
actions are discussed in Chapter 9.

Subgoal:  Reducing Alcohol and Drug Misuse

  Alcohol and drug abuse are behaviors with major
implications in many areas.  Not only do they in-
crease risk of accidents, suicides, and homicides,
they also contribute to family disruption and poor
school and job performance; and they have a poten-
tial for leading to long-term chronic disease.

  Use of alcohol and drugs has been increasing
among young people.  About 80 percent of 12 to 17
year olds report having had a drink, more than half
drink at least once a month, nearly three percent
drink daily.  Since 1966, the number of high school
students intoxicated at least once a month has more
than doubled, from 10 to over 20 percent. Nearly 80
percent of male high school seniors drink at least
once a month and more than six percent drink daily.

  Although young people may drink less regularly
than older people,  they tend to consume larger
quantities and are more likely to become intoxicated
on  drinking  occasions.   No wonder,  then,   that
alcohol-related accidents are the leading cause of
death in the 15 to 24 age group and 60 percent of
all alcohol-related highway traffic fatalities are
among young people.

  Drug abuse was  virtually unknown among young
people in 1950.  Prior to 1962, lifetime experience
with any illicit drug was limited to less than two
percent of the population, including young people.

  By 1977,  60 percent of 18 to 25 year olds had
tried marijuana; about 20 percent had tried stronger

5-7


substances such as cocaine and hallucinogens; and
about 30 percent had illegally used drugs available
only on medical prescription.  Even among 12 to 17
year olds, nearly 30 percent had tried marijuana.

  Beyond  increasing drug experimentation among
young people, the frequency of use is increasing.
Less than one percent of high school students report
daily use of drugs other than alcohol, tobacco or
marijuana-- but over 20 percent regularly smoke ciga-
rettes and about 10 percent smoke marijuana every
day.    And   stimulants --amphetamines--are   another
category of drugs which young people report taking
most frequently.

The physical and psychological effects are high-
ly variable.  They differ from person to person as
well as from drug to drug.  It is, therefore diffi-
cult to determine precisely how harmful experimenta-
tion is in terms of the drug use to which it leads.

  By any measure, however, drug problems are seri-
ous, have increased greatly--and if the full poten-
tial of our adolescents and young adults is to be
realized,  additional steps  (Chapter 10) must be
taken to reduce the harmful effects from both alco-
hol and drugs.

Other Important Problems

Among other prominent threats to the physical
and mental health of young people are problems of
adolescent pregnancy,  sexually transmissible dis-
eases, mental illness,  suicide and homicide.   To a
great extent, they represent failures to help young
people acquire the skills and information needed to
solve problems and make sound decisions during years
of rapid change.

Teenage Pregnancy

Childbearing during adolescence is a high risk
experience for mother and child alike.

Yet one-fourth of American teenage girls have
had at least one pregnancy by age 19.  Every year

5-8


about one million adolescents under the age of 19
become pregnant,  including perhaps 300,000 under
15--which represents an annual rate of 10 percent of
all teenage girls.   Two-thirds of them are unmar-
ried.  At least three of every 10 elect to terminate
their pregnancies.  Birth rates for teenagers aged
16 to 19 are declining but they are increasing for
girls under 16.

  These young mothers have greater risk of bearing
low birth weight infants--with consequent develop-
mental problems and risk of infant death associated
with low birth weight, as noted in Chapter 3.  And
often they face significant social problems:   dis-
ruption of schooling,  high rates of repeat preg-
nancy, and public dependency.

  A substantial proportion of school districts
still encourage expectant teenage mothers to drop
out of school;  many do not provide for continuing
education; more than 25 percent of the young mothers
become pregnant again within just a year after their
first delivery.

  A major underlying problem that urgently needs
addressing for this age group is the inadequate
knowledge of,  and access to,  information on sexual
behavior and family planning services.  In 1976, an
estimated 40 percent of unmarried teenage girls,
aged 15 to 19 (two-thirds by age 19), had engaged in
sexual intercourse and 25 percent of them never used
any form of contraception.

  Birth control methods currently prevent an esti-
mated 750,000 unwanted pregnancies annually.  If all
sexually active young people who did not want to
become pregnant were to use some effective form of
contraception regularly,  it is estimated that pre-
marital pregnancies would drop by more than 300,000
a year.

  There is growing evidence, too, that for the
pregnant  teenager   and   her  baby,  comprehensive
programs,  which include emphasis on the mother's
continued  schooling,   are  associated  with fewer

5-9


repeat pregnancies.  Many programs have been devel-
oped which demonstrate the value of education for
parenthood  and family planning--and of improved
family support for teenage parents.

  An example of what a medical center-based pro-
gram for teen mothers and their infants can accom-
plish is provided by a program at the Johns Hopkins
Medical Institutions in Baltimore.

  There, staff members provide young mothers with
comprehensive medical and psychological  services,
conduct  classes from the first prenatal   visit
through labor, delivery,  and for three years after
delivery, and,  perhaps most important, form close
supportive relationships with the young women.

  Recent results indicate that 85 percent of
mothers enrolled at the center have returned to
school and only five percent became pregnant again
within a year after delivery.  Of all Baltimore teen
mothers,  only 10 percent return to school and 47
percent become pregnant again within a year.   Teen
mothers in the program also have had fewer obste-
trical complications and fewer premature deliveries,
and have given birth to larger and healthier babies
than Baltimore's teen mothers in general.

Sexually Transmissible Diseases

  Sexually   transmissible   diseases  increasingly
threaten the health and well-being of millions of
adolescents and young adults.

  Although there has been some recent improvement,
overall, in the incidence of gonorrhea and syphilis,
both diseases continue to increase among adolescents.

  Moreover,   other  sexually  transmissible  dis-
eases-- such as herpes virus and nonspecific urethri-
tis--have recently become recognized as major public
health problems.  Along with gonorrhea and syphilis,
they account for an estimated eight to 12 million
cases of sexually transmitted diseases a year.

5-10


  And the greatest risk of acquiring them occurs
among young people age 15 to 24 who account for
about 75 percent of all cases.

  Because infection is often unrecognized for lack
of apparent symptoms, many young people also suffer
serious permanent complications.  Each year, an es-
timated 75,000 women of childbearing age become
sterile as a result of pelvic inflammatory disease
caused by a sexually transmitted infection.  Actions
to control  sexually  transmissible  diseases   are
discussed in Chapter 8.

Mental Health

  That adolescents today are coming of age in a
predominantly urban,  technological society, charac-
terized in part by shifting values and traditions,
may account in no small part for alcohol and drug
abuse problems and others.

  Since individual development does not take place
in a vacuum but is strongly influenced by sociocul-
tural factors,  society's expectations play a large
part in the way young people experience this period
of their lives.   But the turbulence of the last
decade has made it difficult for young people to de-
velop any clear sense of what these expectations are.

  Some observers point to teenage pregnancy, de-
linquency and crime, suicides, and child abuse as
well as drug and alcohol abuse as both evidence and
products of that uncertainty.   Others contend that
these problems  are simply more visible today and
involve only a minority of adolescents.

  In any event,  the transition from childhood to
adulthood may take some toll on an adolescent's emo-
tional stability.  And problems such as 20 percent
unemployment among teenagers (40 percent for minor-
ity youth) create additional stress for young people
trying to develop their identity and their place in
life.

5-11


  While the full degree of impact of broad social
issues and overall social and national stability on
personal development is not clear, there is general
agreement that the family has the most direct influ-
ence on  the expectations of young people.   Yet
family structures have been undergoing significant
changes in recent years.

  Added complexity is faced by the teenage parent,
often single, trying to fulfill the personal growth
needs of an adolescent while simultaneously having
to meet the needs of a dependent, rapidly developing
baby.  Because of the demands of these responsibili-
ties,  support through special programs for teenage
parents,  including some form of day care and other
community and mental health services, is very much
needed.

  The diverse problems of teenagers and young
adults require  a broad range of mental  health
services and the combined efforts of the family,
school, workplace,  and community.  The pressures of
parents and peers, as well as of the media, are all
factors which contribute to these problems--and
which can be employed to help solve them.

  The growth of community mental health services
in recent decades has made resources more available
in local areas and adolescents are gradually begin-
ning to use them.  But mental health programs
tailored to adolescents are not abundantly avail-
able.  The recent report of the President's Com-
mission on Mental Health recommends expansion of
these programs.

Suicide

  Suicide is the third leading cause of death
among teenagers and young adults, some 5,600 of whom
took their own lives in 1977. Of total suicides, 20
percent are committed by people under age 25.

  Among adults, three times as many men as women
commit suicide and adolescent males are more likely
to take their own lives than adolescent females.

5-12


  The most frequent weapons include firearms,
drugs,  and motor vehicle exhaust gases.   Firearms
are used four times as often as poisoning (the
second most frequent method), and firearm suicides
have been increasing at a much faster rate than
suicides by other means.

  Unfortunately the  suicide  rate  among young
people has not plateaued, but is increasing. In
1950, the rate was only about 20 percent of what it
reached in 1977.  In 1976, more than one of every 10
teenagers and young adults who died committed sui-
cide.  Many more suicides were attempted but not
reported as  such or not  identified as suicidal
efforts.

  It is estimated that some five million Americans
have made one or more unsuccessful attempts at sui-
cide and that 10 percent of this group will ulti-
mately succeed.   Some estimates indicate that the
actual suicide rate is three times the reported rate.

  An increased suicide rate is not unique to this
country.  Many other industrialized nations are ex-
periencing  increases,  particularly   among   young
people.  Indeed,  in 1974 several countries exceeded
the United States suicide rate of about 12 deaths
per 100,000.  Japan had 18,  Sweden 20, and Germany
21.

  Most suicidal persons give verbal or behavioral
warnings first,  and 80 percent of those who take
their own lives have made previous attempts. While
predicting suicide with certainty is  impossible,
those at highest risk include people who are severe-
ly depressed and those at odds with themselves and
the people close to them. Mental health workers are
becoming more skillful in early detection and man-
agement of suicidal tendencies.  A prime need is for
hotlines --and prompt referral to sources of profes-
sional help when problems are noted (see Chapter 10).

Homicide

  Murder accounts for over 10 percent of all
deaths among adolescents and young adults--just

5-13


under seven percent for whites but almost 30 percent
for blacks in this age group.

  In 1977, when an estimated 21,000 Americans were
victims of homicide,  about 25 percent were aged 15
to 24, placing that group at greater risk than the
rest of the population.  The deaths of these young
people represent a very large and tragic waste in
terms of the many years of productive life lost with
each death.

  The American homicide rate is very much greater
than for most other industrialized nations.   Our
rate of 10.2 homicides per 100,000 people in 1974
compares with a rate of only 0.9 for France, 1.0 for
Great Britain, 1.1 for Sweden, and 1.3 for Japan.

  In about 20 percent of murders in this country,
victim and offender are relatives or have a close
relationship; in 40 percent, they are acquaintances;
and in the remaining 40 percent, there is no known
relationship.  An estimated 60 to 80 percent of
homicides occur as the result of personal disagree-
ments and conflict, while robbery, sexual assault
and other circumstances account for the rest.

  As with other fatal injuries, homicide is more
common among the poor, more frequent on weekends and
at night,  and often associated with alcohol abuse.
In about 90 percent of murders, both offender and
victim are of the same race.  Men are three to four
times more likely to be victims--and five times as
likely to be offenders--as women.

  Many factors  undoubtedly are  involved in our
high homicide rate.  Economic deprivation, family
breakup, the glamorizing of violence in the media,
and the availability of handguns all are important.
Firearms,  the most frequently used homicide weapon
in the United States, were involved in 63 percent of
the murders occurring in 1977, with handguns used in
half, and cutting or stabbing weapons employed in 18
percent.

  Easy access to firearms appears to be the one
factor with a striking relationship to murder. From

5-14


1960 to 1974, handgun sales quadrupled to more than
six million a year.  During that same period, the
homicide rate increased from 4.7 per 100,000 to 10.2
for the overall population--and from 5.9 to 14.2 for
young people aged 15 to 24.

**********

  Broad  physical,  psychological,  social,   and
family changes all have a powerful impact on young
people.

  Young people are compelled to adjust not only to
rapid individual changes, but simultaneously to meet
the expectations of both family and community.  The
strains which result can have considerable bearing
on the problems of adolescents and young adults.

  Stress is to be expected in life. But for some
adolescents and young adults, it can become over-
whelming.

  At critical junctures, they urgently need as-
sistance in finding ways to cope and make important
decisions   and   constructive   adjustments.    Such
assistance (described in Chapter 10) can contribute
greatly to improving  both their health and the
quality and value of their lives.

5-15


CHAPTER 6
HEALTHY ADULTS

Goal:  To improve the health of adults,
    and,  by 1990,  to reduce deaths
   among people ages 25 to 64 by at
    least 25 percent, to fewer than
    400 per 100,000.

  The contrast is sharp.  For an infant at birth,
life expectancy since 1900 has increased 26 years.
But today for a man at age 45 the expectancy is only
five years greater than it was in 1900.

  On the one hand, preventive measures have been
successful in reducing infant and childhood deaths
from what were the major threats in those years, the
acute  contagious diseases.   On the other hand,
treatment measures, even though increasingly sophis-
ticated, have been far less successful against what
are the prime threats for adults:   the chronic
diseases, often of insidious onset, slowly progres-
sive, ultimately devastating.

  Only recently have we gained significant in-
sights into the causes and many risk factors in-
volved in the chronic diseases--and into tangible,
applicable  preventive measures.   Although   those
measures are different and the results may be less
inznediately dramatic than was the case for the acute
childhood diseases, we already have reason for opti-
mism in what has been happening very recently to
adult mortality trends.

  In 1970, the death rate for adults aged 25 to 64
was even higher  than  in 1960 - 657 per 100,000,  up
from 640.

  Since then, however,  there has been an annual
average decrease of 2.6 percent in the death rate

6-1


for adults.  By 1976, the rate had dropped to 555.
And data for 1977 show a further 2.7 percent
decrease to 540 (Figure 6-A).

  More than one-third of all deaths among the 100
million American adults have been due to cardiovas-
cular diseases, principally coronary artery (heart)
disease and stroke (Figure 6-C).  And it is deaths
from those causes which have been declining and
accounting for most of the drop in mortality rate.

  There is every reason to believe that the down-
ward trend not only can be maintained but acceler-
ated with increased efforts on behalf of such pre-
ventive measures as high blood pressure detection
and control,  reduction of smoking, prudent diet,
increased exercise and fitness, and better stress
management.

  A reduction in cancer deaths should also be
achievable--to a worthwhile,   even  if necessarily
more limited, extent in the near future.

  One reason for slower progress against cancer is
that by the time malignancy becomes apparent, many
years have gone into its development.  In a sense,
any  currently  appearing   cancer   reflects  past
history--perhaps, for example, 35 years of smoking
in a 55-year-old patient with lung cancer.   There-
fore, it will take years for modifications of cancer
risk factors to be expressed in marked reductions in
cancer mortality.

  A second reason  is that declining rates for
certain   cancers  will   be more  than  offset by
increases in  occupational   and  smoking-related
malignancies  because of already-established adverse
effects.  The net result will be a small, gradual
rise for the next few years  in the age-adjusted
death rate for cancer.

  Prevention efforts--to reduce exposure to can-
cer-inducing agents and to foster more early detec-
tion and prompt treatment--need to be instituted now
to reverse the trend.

6-2


              FIGURE 6-A
DEATH RATES FOR AGES 25-94 YEARS: UNITED STATES,
       SELECTED YEARS 19ML1977

90
60

70

60


50


40



30

3                      1

1900    1910     1920     1930     1940     1950    1960     1970     1980

6-3


        FIGURE 6-B
DEATH RATES FOR AGES 25-94 YEARS:
  SELECTED COUNTRIES, 1975

-

I

Umted
states

Sweden

England
and
W&S

Japan       Chile

NOTE  me moi: recent year Of ddfd lo, Chile 1s 1971

Sources~ United States, National Center for Health Statistics, Divismn of Vita Statistics;
     other countries, United Nations.

6-4


              FIGURE 6-C
MAJOR CAUSES OF DEATH FOR AGES 26-64 YEARS:
        UNITED STATES, 1976

Heart
disease

Cancer     Stroke

Cirrhosis
of hver

All other
accldentr

Motor
veh&
accidents

Hornlade

0 Whne
m All other

Source: Based on data from the National Center for Health StatlstIcs. Dwsion of Vital Statistics.

6-5


Subgoal:  Reducing Heart Attacks and Strokes

  In 1977, heart disease was responsible for over

700,000 deaths--the leading cause of death for men
after age 40.  And although women, up to menopause,
have about one-third the heart disease rate of men,
their heart attack incidence thereafter increases,
begins to approach the male rate by age 70, and
virtually equals it by age 85.

   Heart disease not  only produces fatal heart
attacks;  it is also the greatest cause of permanent
disability claims  among  workers  under 65, and
responsible for more  days of hospitalization than
any other single disorder.  And it is the principal
cause of  limited activity for some 2.5 million
Americans under age 65.

  Stroke,  in 1977,  led to nearly 183,000 deaths,
almost 10 percent of the total mortality for the
year.   Although  some 250,000 Americans survive
strokes each year, many remain disabled by paraly-
sis,  speech difficulties, and memory loss.  Nearly
10 percent of nursing home admissions in people
under 65 are because of strokes.

  Although most stroke deaths (about 85 percent)
occur in people over 65, early deaths are not uncom-
mon,  particularly among blacks who, between ages
25 and 64, have a stroke death rate almost 2.5 times
that of whites.

   But we are  now beginning  to see a welcome
decline in death rates for both heart disease and
strokes.

  For heart disease, the death rate, which had
been increasing rapidly after 1940 began to level
off in the early 1960s and, between 1968 and 1977,
fell by 22 percent.  For stroke, the death rate, de-
clining gradually over the last two decades, dipped
more sharply, falling off 32 percent, between 1968
and 1977.

6-6


  Behind both diseases lies the process of athe-
roclerosis in which critical arteries become nar-
rowed by fatty deposits.  Beginning silently, even
as early as the first decade of life, atheroscle-
rosis  gradually thickens  the walls of affected
arteries with "plaques"'  which usually consist of a
core of cholesterol and fats.  The wall thickening
progressively narrows artery diameter, reducing the
amount of oxygen-carrying blood reaching the heart,
brain or other parts of the body.

  Manifestations do not usually appear until the
disease process is well advanced and blood flow
considerably reduced.  Chest pain (angina pectoris)
may appear when excitement,  physical effort, or
exposure to cold increases the heart's requirements
for oxygen beyond the level that can be supplied by
the impaired blood flow.  Angina may be a forerunner
of eventual heart attack--but heart attacks, fre-
quently fatal, can occur suddenly, without warning,
when an already narrowed coronary artery serving the
heart is further blocked, completely shutting off
flow to an area of the heart muscle.

  A stroke occurs when the blood and oxygen supply
to the brain is severely reduced. The mechanism can
be similar to that of a heart attack--further block-
ing of an artery supplying brain tissue, usually an
artery already compromised by atherosclerosis.  Most
strokes are of this type.  A stroke may also occur
when an artery ruptures in the brain and the hemor-
rhaging destroys brain tissue.

Risk Factors for Heart Disease and Stroke

  The importance of risk factors is not in ques-
tion.  Each individually is clearly linked to in-
creased likelihood of heart disease or stroke--and
in combination they multiply the likelihood.   What
only remains  uncertain is the precise extent to
which risk can be decreased by modifying the risk
factors.

Smoking. syo;; the late 194Os, research ,",I;
consistently      that cigarette  smokers

6-7


nearly twice the heart disease death rate of non-
smokers.    The   difference is   much  greater in
individuals under 65.

  Substances in cigarette smoke which may be
hazardous to the heart include nicotine and carbon
monoxide.

  Risk is proportional  to the amount of smoke
inhaled   and   the   number of  cigarettes   smoked.
Smokers of more than one pack a day are three times
more likely to experience a heart attack than
non-smokers (Figure 6-D).  Pipe and cigar smokers
have only slightly higher rates of coronary heart
disease than non-smokers.

  Hypertension..  High blood pressure contributes
to heart disease by putting an added burden on the
heart which must pump against the increased pressure
in the arteries and it also seems to be a factor in
the thickening of artery walls.  Hypertension in-
creases risk of stroke by promoting the atheroscle-
rotic process in arteries supplying the brain--and
by contributing to the rupture of relatively fragile
brain vessels.

  A blood pressure measurement consistently over
140 systolic (the pressure when the heart contracts)
and 90 diastolic (the pressure when the heart re-
laxes between beats) is usually considered abnormal.
And people with pressures exceeding 160/95 are con-
sidered to have hypertension which would benefit
from treatment.   About 35 million Americans have
pressures above 160/95.

  A study in Framingham, Massachusetts, has shown
that men aged 45 to 64 who have pressures of above
160/95 have two to three times the coronary heart
disease rate of those with pressures under 140/90.
Among people with systolic pressures above 160,
strokes are three times as frequent as among those
with systolic pressures under 140.

  The high incidence of stroke deaths at younger
ages among blacks is probably due in large measure

6-8


           FIGURE 60
           FIGURE 60
AGE-ADJUSTED RATES OF FIRST HEART AITACK
AGE-ADJUSTED RATES OF FIRST HEART AITACK
  BY SMOKING STATUS FOR WHITE MALES
  BY SMOKING STATUS FOR WHITE MALES
   AGES 30-59 YEARS: UNITED STATES
   AGES 30-59 YEARS: UNITED STATES

200







150

6-9


to the increased prevalence and severity of hyper-
tension which occurs in black Americans for reasons
not yet clear.

  Cholesterol.  Premature heart disease is unequi-
vocally associated with elevated blood cholesterol
levels.  Stroke risk, too,  is increased by elevated
serum cholesterol,  although the association is not
as strong as for heart disease.

  For American men, the average cholesterol level
is about 220 mg/dl (milligrams of cholesterol in a
deciliter of blood).   Heart attacks are five times
as frequent in men--and women--aged 35 to 44 who
have cholesterol levels above 265 as among those
with levels below 220.  In general,  the lower one's
blood cholesterol the less the likelihood of heart
disease;  the higher the cholesterol  level, the
greater the risk.

  It is cholesterol deposited from the blood which
goes into atherosclerotic plaques. And cholesterol-
carrier substances  in the blood,  called lipopro-
teins, have recently been found to play an important
role in  atherosclerotic disease.  One type--low-
density lipoproteins (LDL)--appears to accelerate
cholesterol deposition in artery walls.   However,
another  type--high-density  lipoproteins  (HAL)--
appears not to hasten the process, and may even be
protective.

  Current research suggests that measuring HDL and
LDL levels may be a more accurate means of predict-
ing risk for atherosclerosis and heart attack than
measuring serum cholesterol  alone.   Factors like
exercise and perhaps even simple dietary modifica-
tions may increase the ratio of HDL to LDL and
thereby possibly protect against heart disease.

  Direct evidence from animal studies supports the
linkage of atherosclerosis with high levels of fats
(particularly saturated) and cholesterol in the diet.

  Diabetes.  Diabetes is a fourth important risk
factor for cardiovascular disease.   Diabetics have

6-10


more severe atherosclerosis,  twice as many heart
attacks,  and about twice as many strokes as non-
diabetics of the same age. For diabetic women, the
risk of  atherosclerotic disease is five times
greater than for other women.

  Diabetics are also more likely to be hyperten-
sive and overweight.  Control of blood pressure and
elimination of smoking are especially important for
them since these risk factors still further heighten
their premature death rate.

  Other  risk factors.   Although they may be
somewhat less important in their effects than the
four major risk factors just  noted,  other risk
factors   for   coronary   heart   disease   include
overweight,   physical   inactivity,   personality
patterns which are related to stress,  genetic
predisposition, and oral contraceptive use.

  Even a moderate excess of weight may be asso-
ciated with increased levels of very low-density
lipoproteins  in the blood and with high blood
pressure and high blood sugar.   Still undetermined
is   whether  physical   inactivity--which  may be
associated with excess weight and elevated blood
cholesterol,  sugar,  and blood pressure levels--
independently increases the risk of premature heart
attack or stroke.

  All people face ordinary stresses of life and
work.   Some,  however,  invoke additional, extraor-
dinary  stresses.   Typically, they are extremely
ambitious,  competitive,  and  impatient,  and some
studies indicate that they are at higher risk of
coronary heart disease.

  In some families, early heart attacks--before
age 50--affect several closely related members,
leading to the belief that a genetic predisposition
to heart disease may exist.  Hypertension, diabetes,
and serum cholesterol abnormalities are,  in some
cases,  known to be hereditary, but other genetic
factors adding to heart disease risk have yet to be
identified.  Children of parents who have had heart

6-11


attacks before age 50 can be tested for relatively
rare hereditary fat metabolism disorders.  For most
people,  however  any contribution  to risk made by
genetic  conditions is  exacerbated by cigarette
smoking,  poor dietary habits, and other behavior
that members of a family often share in common.

  Some drugs may increase risk.   A substantial
increase  has been noted in women who use oral
contraceptives or estrogen replacements, and who may
have other risk associations.  For example, women
aged 40 to 44 who both use oral contraceptives and
smoke have about 10 times the risk of death from
heart attack as women who do neither.

Subgoal:  Reducing Death from Cancer

  Cancer, the disease most feared by Americans and

developed by one in four, claimed nearly 390,000
lives in 1977, making  it the second most common
cause of death.  More than a third of deaths occur
in the middle years  (ages 35 to 64) of life.
Although far more frequent among adults, cancer also
occurs in children.

  The most comnon fatal cancers are leukemia,
kidney and nervous system malignancies in children;
lung,  intestine and breast cancer in adults; and
cancer of the intestine, lung, prostate and uterus
in older Americans.   Almost half of all cancer
fatalities  in the United States are from three
varieties:  lung, large intestine, and breast.

  All cancers are similar in apparently occurring
when body cells begin to multiply without the usual
internal restraints.  The malignant cells push the
normal out of the way, spread out, and even migrate
to distant parts of the body.

  The process can be relatively quick, as in some
forms of leukemia.  But for the most common types,
including breast cancer, it is believed that 10, 15,
even 25 years may pass before all of the steps in
the biological chain of events leading to cancer are
completed.  Once they are,  varying lengths of time

6-12


may elapse before enough cancerous cells accumulate
to be recognized.

  Cancer is not a single disease but rather a
group of diseases occurring worldwide in man and all
other marrrnalian species.  Each type has its own rate
of occurrence and often tends to affect certain pop-
ulation groups sharing particular characteristics.

  Sex, race,  and other hereditary factors as well
as geographic, age,  and occupational differences--
when added to differences in habits and exposure to
certain substances--provide clues to the origin, and
prevention,  of many human cancers.  Many types of
malignancies are not necessarily fatal.  Some grow
very slowly and rarely spread; others can be halted
by prompt medical intervention.

  Although much remains to be learned about cancer
development,  extensive research has established that
in some cases something identifiable is responsible
for changing the behavior of cells and stimulating
their uncontrolled growth. A single cancer-inducing
(carcinogenic) agent such as radiation may trigger
this response.  While in rare instances cancer may
follow a single large exposure, usually it is due to
repeated low-dose exposures.

  Most carcinogens seem to have their major effect
in specific parts of the body, often related to
their mode of entry and their sites of activation,
destruction and exit from the body.  But cancer in
any one site may result from combined effects of
several agents or several events.  And variations in
the body's internal chemical environment or genetic
predisposition also play a role in determining the
response to potentially cancer-provoking stimuli.

  While the number of cancer victims has increased
dramatically in the past 40 years, much of the
increase is due to population growth.  When changes
in the size and age composition of the American
population are  taken into consideration, overall
cancer death rates have increased only slightly for
men since 1937 and have actually decreased slightly
for women.

6-13


  Also changed over the past several decades have
been the patterns of cancer types and incidences for
men and women (Figures 6-E and 6-F) and for whites
and other races.  Men have more cancer of the lung,
intestines, bladder and stomach than women and have
higher overall cancer  death rate--l63 per 100,000
versus 137 per 100,000 for women.  Whites intend to
have higher  rates than others of cancer of the
breast, intestines,  and bladder, but lower rates of
cancer of the prostate, cervix, and stomach.

  Cancer differences can be noted from one country
to another.  Compared to Japan, the United States
has more cancer of the breast but less cancer of the
stomach.  Such variations in cancer types and death
rates may be due to differences in hereditary,
environmental and behavioral factors and/or use of
early detection measures.  The tendency of people
who migrate to assume the cancer patterns of their
new home provides some clues to cancer causes.

Risk Factors for Cancers

  Among influences which have been identified as
potential  contributors to cancer development are
cigarette smoking,  alcohol,  certain dietary pat-
terns,  radiation,  sunlight,  occupational  hazards,
water and air pollutants, and heridity and predis-
posing medical conditions.

  Smoking.  Cigarette smoking is responsible for
more cancer and more cancer deaths than any other
known agent.  Not only do smokers have about 10
times the frequency of lung cancer; they also have
three to five times as much cancer of the oral
cavity, more than three times as much cancer of the
larynx,  and more than twice as much urinary bladder
cancer as non-smokers.

  Cigar  and pipe smokers have lower malignancy
rates than cigarette smokers except for cancers of
mouth and lip for which their risk is approximately
the same.  The fewer cigarettes smoked, the less the
risk.  The risk also may be lower for smokers of
filtered or low tar and nicotine cigarettes but

6-14


FIGURE 6E

AGE-ADJUSTED CANCER INCIDENCE RATES BY SITE
FDR MALES: UNITED STATES, SELECTED YEARS, 1947-1979

100
80

60

40




20




70 :
1945

I        I        I        I

FIGURE 6F

AGE-ADJUSTED CANCER INCIDENCE RATES BY StTE
FOR FEMALES: UNITED STATES, SELECTED YEARS, 1947-1976

1KI
80                                .*#a,
   k"l'llll~`~l~lllllllll#lllll~,~l,,l,~,,,,,,,,,,,,~,,,,,,,,,,~,~~l~`~    -8reast
60

NOTE  All rates 1`1 age-ad,"rtea to tne 1960 United staler pOp"latlOn

Source:  Data for 1947.1948 are from the Second National Cancer Survey; for 1969.1971 from the
  Third NatIonal Cancer Survev; and for 1973-1976, from the Surveillance, Epidem'iologv, and
    End Results ISEER) Program, National Cancer Institute.

6-15


evidence is limited and risk is still much higher
than for non-smokers.

  Smoking also can multiply--in some cases many-
fold--the risks associated with other carcinogenic
agents.  Heavy alcohol use,  associated with esopha-
geal cancer,  has a greatly intensified effect when
combined with cigarette smoking. People exposed to
carcinogens on the job may have much greater risk if
they also smoke.  The combination, for example, of
occupational  exposure to asbestos and cigarettes
increases lung cancer risk 90 times.

  Alcohol.  Higher rates of cancer of the larynx,
oral cavity,  and liver as well as of the esophagus
occur among people consuming large amounts of alco-
hol.  Whether the nutritional deficiencies sometimes
associated with heavy drinking increase suscepti-
bility to the effects of alcohol, tobacco, and other
carcinogens,  or whether alcohol itself causes the
damage is yet unknown.  Contaminants that accumulate
during manufacture of most alcoholic beverages may
be the harmful agents, rather than alcohol itself.

  Diet.  A role in cancer development has been
prop= for components of diet--and for some
methods of food preparation such as pickling and
charcoal broiling.

  Some of the information about dietary causes is
based on animal studies and may have limited rele-
vance to man.  Other information comes from compar-
isons of human cancer rates in different countries
and among migrants from one country to another.

  The typical American diet includes foods con-
taining many substances added to enhance taste,
improve  color,  and retard spoilage--as  well as
residues  of food packaging materials, materials
added to animal feed, and other chemicals.

  Some of these additives may actually help pre-
vent cancers--notably antioxidants and those that
prevent growth of molds which can produce car-
cinogens such as aflatoxin--but others may have

6-16


carcinogenic potential.   Studies thus far have not
been conclusive.   But,  because  the number  and
amounts of additives were much less 30 to 40 years
ago,  and because malignancy can take that long to
develop,  careful scrutiny of the health effects of
substances added to food is important.

  Variation in rates of cancers (which differ
greatly from  country to country) may relate to
differences in diet.

  For example, people in Japan eat much less beef
and total fat and more salt and pickled foods than
Americans; they have much lower rates of breast and
colon/rectum cancers, but higher rates of stomach
cancer.   These  differences   cannot  be entirely
genetic.

  Among Japanese immigrating to the United States,
rates for breast and colorectal cancers tend to in-
crease while those for stomach cancer decline as
eating habits become more like those here.   Such
trends are also found among imnigrants from other
countries.   But the precise relationship between
dietary differences and various cancers is still not
known.

  Radiation.  A connection between exposure to
radiation and cancer has been recognized ever since
malignancies appeared in scientists and technicians
who received large doses in their work with radium
and early x-ray devices.

  More recently,  increased risk of cancer has been
associated with radiation used for some diagnostic
and therapeutic purposes.  Because no radiation dose
may be so small as to be risk-free and exposures are
cumulative, some health professionals, while valuing
x-ray procedures,  have been working to reduce pa-
tient exposures.   Much more can be done in this
regard.

  Other sources of low-level radiation to which
the American population is exposed include those
related to natural background radiation,  nuclear
weapons fallout, and nuclear energy.

6-17


  Sunlight.  Sunlight can cause skin cancer--and
does among some people receiving large exposure,
particularly outdoor workers.  Americans living in
the South and Southwest have much higher skin cancer
rates than those in northern states.  People with
darker complexions are at lower risk.   Protective
clothing  and sun  lotions containing PABA (para-
aminobenzoic acid) or other compounds that screen
out harmful rays can help to prevent skin cancer,
and premature aging of the skin.

  Occupational exposure.  Each year in the United
States about 1,000 new chemicals are produced in
commercial quantities.   American workers are thus
exposed to an ever-increasing number of materials
that may have cancer-causing potential.

  More than 200 years ago, an association between
occupation and a specific cancer was recognized in
the higher incidence of cancer of the scrotum among
chimney sweeps.  Since then,  many substances have
been found to produce cancer among workers in a wide
variety of industries.

  Occupational exposures can cause cancers which
are rare in the general population--and, in the case
of some exposures,  can increase the incidence of a
number of cornnon types.

  Working with asbestos without appropriate pro-
tection, for example,  increases the incidence of the
rare malignancy, mesothelioma, as well as of lung
cancer.   And,  plastics workers exposed to vinyl
chloride are at 200 times greater risk for liver
cancer, four times greater risk for brain cancer,
and two times greater risk for lung cancer than the
general population.

  Occupational exposures  also may interact with
other environmental hazards for a great multiplica-
tion of risk as in the case of cigarette-smoking
asbestos workers.

  Nor are hazards from industrial substances con-
fined by workplace boundaries. Toxic materials may

6-18


pollute air outside as well as inside a plant, en-
dangering nearby residents.  For example, angiosar-
coma, a rare liver cancer linked to vinyl chloride
exposure,  has been diagnosed among people living
near vinyl chloride polymerization and fabrication
plants.

  Moreover,  contaminants  carried home on work
shoes and clothes can threaten families.  Documented
cases of mesothelioma have been found among people
whose  only known exposure  to asbestos has been
through living in a home with an asbestos worker.

  Water pollution.  Potentially carcinogenic in-
dustrial and agricultural wastes--including chlor-
dane,  aldrin,  dieldrin,  and benzene--are found in
some rivers and lakes from which drinking water is
taken.  Although their concentrations in drinking
water usually have been much lower than those known
to pose substantial risk, such substances can accu-
mulate in water supplies and may become concentrated
in fish or shellfish.  Their increasing amounts--and
varieties--make updating  and enforcement of water
quality standards essential.

  Air pollution.  Air quality varies greatly from
place to place within the United States. Air pollu-
tion comes primarily from automobile exhausts, the
burning of fuels,  and industrial activities.  Pollu-
tants such as asbestos, beryllium, benzene, and
other synthetic organic chemicals are potential car-
cinogens,  and several studies suggest that higher
levels of air pollution may be associated with in-
creased lung cancer rates.  The extent of increase
has not yet been quantified but close monitoring of
air quality is clearly indicated.

  Heredity.  Some cancers tend to run in families.
Sisters daughters of women with breast cancer,
for example, are at higher risk for the disease.

  But families often share environmental condi-
tions  and behavioral  characteristics,  making it
difficult to determine how much of family clustering
of cancer is really the result of heredity.

6-19


  The significance of a family history varies from
one type of cancer to another.  Overall, only one or
two percent of cancers are attributable primarily to
heredity;  in some rarer types, the percentage may be
higher.

  People with certain genetically-related condi-
tions have a higher cancer incidence and are prone
to develop malignancy earlier.  One example is the
predisposition of those with multiple intestinal
polyps to cancer of the colon.

Cancers at Specific Sites

  A great number of cancers and cancer deaths can
be prevented through two strategies:  limiting ex-
posure to cancer-causing substances, and early de-
tection and treatment before a cancer has spread.

  Lung and urinary bladder cancers are amenable to
the first strategy.  More than 80 percent of all
lung cancer  and up to 50 percent of all bladder
cancer could be prevented if people stopped smoking.
Skin cancer also  is largely preventable through
avoidance of excessive sun exposure.  Modifications
in  occupational   exposure  and diet may  help to
prevent other types of cancer.

  Once cancer develops,  many deaths can be pre-
vented by early detection and treatment.  For this,
screening procedures must identify accurately people
with cancer still in early enough stages to allow
effective treatment.  Available screening measures,
more widely applied, could probably prevent a third
or more of the deaths due to breast cancer in women
over 50, most deaths from cervical cancer, and many
of those due to prostate and rectal cancer.

  Lung.   Lung  cancer,  the most comnon lethal
malignancy in the United States, accounted for four
percent of total deaths and 25 percent of all cancer
deaths in 1977.  Approximately 80 percent of the
72,000 men and 23,000 women dying from lung cancer
did so as a result of cigarette smoking.  Early
identification techniques--such as chest x-rays and

6-20


sputum examination--generally do not discover lung
cancer before it has spread.   The elimination of
cigarette  smoking  and occupational  exposures to
carcinogenic substances is the best approach.

  Breast.  Affecting  nearly one in 13,  breast
cancer the most comTlon malignancy for American
women.  Although more frequent in older women, it
does not spare the young and, 28 percent of the
time, affects women under 50. Definitive prevention
by any simple means is not available--but risk of
death from breast cancer can be reduced substan-
tially by early diagnosis.

  Several  screening procedures are available--
self-examination  (most important), examination by
a physician,   and  mammography  (a type of  x-ray
screening).

  Most breast cancers are first found by women
themselves rather than by physicians during routine
examinations.   Women should examine their breasts
once a month.  Particular care should be taken by
those with family histories of breast cancer.   For
women still menstruating, the best time is just
after the period.  Menopausal  and postmenopausal
women should choose a specific day of the month for
breast self-examination so they are less likely to
forget to do so.  Although a lump, abnormal dis-
charge, or size irregularity is usually a symptom of
benign  rather than malignant  breast disease, a
physician's  examination is essential when any of
these conditions is noted.

  Periodic examination by a physician, in combina-
tion with mammography,  increases the number of
cancers identified early, before their spread.

  Mammography may identify cancerous cell deposits
too small to be detected even by careful physical
examination.  Among women over 50, it can contribute
to reducing breast cancer death rates.

  Mammography does use x-rays which, particularly
in higher doses, may cause cancer, and frequent use

6-21


of the procedure  carries  a risk which must be
weighed against potential benefits.  Each mammogram
may raise risk by a very small fraction.   It has
been estimated that if, for example, a woman has
five mammograms, her chance of ever developing
breast cancer would increase from 7.0 percent (no
mammograms) to 7.35 percent.

  Colon and rectum.   Cancers of the colon and
rectum, which make up 15 percent of all cancers and
are the second most common cause of death from
malignancy,  affect 100,000 Americans and lead to
50,000 deaths  annually.   They are  particularly
comTlon between ages 50 and 70.  Early indications
may include rectal bleeding and bowel habit changes.

  Premature death from colorectal cancers can
often be prevented by periodic medical examinations,
including use of instrument examination (sigmoidos-
copy or colonoscopy) when indicated, to detect early
disease amenable to treatment. People with family
histories of colorectal cancer have special need for
periodic examinations.

  People whose diet is relatively lacking in
fiber may have a higher incidence of colorectal
cancer.  The evidence that high fiber diets will
reduce the incidence is scanty at present, but such
diets are prudent and are likely to reduce the
chance of diverticulitis and hemorrhoidal disease.

  Prostate.   Prostate cancer incidence has been
increasing over the past 40 years, especially for
black men.  Four-fifths of cases occur after age
65.  Not enough is known about causes to permit a
strategy of prevention.

  The best available alternative is early detec-
tion   and  surgery.   Considering  improvements in
treatment over the last 15 years, the outlook is far
better when prostate cancer is still localized at
the time of diagnosis.  Rectal examination by a phy-
sician is the most reliable method of early detec-
tion and should be part of every physical exam for
men after 40.

6-22


  Cervix.   Invasive cancer of the cervix affects
20,000 American women and causes over 7,500 deaths
annually.   Rates of   incidence   and   death   have
declined substantially since the early 1950s.

  Risk of cervical cancer seems to increase with a
multiplicity of sex partners,  early and frequent
sexual activity, and multiple childbirth.

  Although the reduction in incidence and death
rates began before such early detection measures as
the Pap (Papanicolaou) smear were widely used, these
measures are probably responsible for at least part
of the continuing decline.

  The Pap smear-- for  analysis of cells from the
cervix--has greater potential for reducing cancer
deaths than any other screening method now avail-
able.  Smears--which can detect cells with cancerous
potential before they become invasive--should be
taken at periodic intervals:  for three consecutive
years beginning at age 20, or at the beginning of
sexual activity;  then every three years until age
35, every five years to age 60, then again there-
after every three years.  The screening frequency
should be increased for women using oral contracep-
tives or estrogen therapy, and in those found to
have pelvic abnormalities.

  Urinary bladder.   Bladder cancer, relatively
comnon in men, led to an estimated 6,900 deaths in
1977.  About 40 percent of cases occur before age 65
and the malignancy is most common in heavy smokers
and individuals exposed to cancer-causing occupa-
tional chemicals.

  Blood in the urine is the most common early
sign--but it may also signify other conditions', some
of which are not serious.

  The key to prevention lies in reducing cigarette
smoking and exposure to carcinogens in the work-
place.  Many deaths may be prevented through early
detection and treatment.

6-23


**********

  The pattern of cancer incidence has varied
widely--over  time,    across   national   boundaries,
within subgroups in the population.

  Only a small fraction of these differences can
be explained by heredity.  Environmental factors and
factors in individual behavior appear to be the
prime causes of most forms of cancer.

  Therefore,  many--perhaps   even  most--premature
deaths due to cancer should be preventable.

Other Important Problems

  Most notable among other problems posing threats
to the health of adults are accidents (which have
been considered in earlier chapters, and will be
again in  Chapter 9), alcohol abuse and mental
illness.  The latter two,  as well as periodontal
disease, deserve special comment here.

Alcohol Abuse

  It is difficult to overemphasize the profound
and pervasive influence of alcohol abuse as a cause
of death for Americans.

There are an estimated 10 million problem
drinkers in the country.

  In 1977, more than 30,000 Americans died from
cirrhosis of the liver--and 95 percent of the deaths
were alcohol-related.

  Alcohol is a contributor to several of the lead-
ing causes of death from age 15 to age 70, with
direct responsibility for certain cancers of the
liver.

  It is a risk factor in various other cancers--
and, rarely, in diabetes.

6-24


  It is an indirect cause in almost 150,000 deaths
annually from accidents, homicides, and suicides.

  Alcohol abuse also is a contributor to family
disruption,   child   and   spouse  abuse,   unwanted
pregnancy, rape, assault, other forms ofa;;olence,
job  instability,  economic  insecurity,      St111
other problems.

Drinking during pregnancy can cause abnormali-
ties in the fetus, leading to mental retardation and
other defects.  And special problems are presented
by the combined use of alcohol and sedatives.

  Chapter 10 will look in detail at the demography
of alcohol abuse in the United States and strategies
for its control.

Mental Health

  Mental illness is a substantial contributor to
disability and suffering for American adults.

  The President's Commission on Mental Health has
reported that three percent of the population--
nearly seven million people--sought treatment in
1975 by specialists in mental health and one to two
million were hospitalized for mental problems in
that year.

  In 1974, five percent of persons reporting limi-
tations on daily activities indicated mental and
nervous conditions to be the cause.  Surveys note a
large proportion of patients in the general medical
care  system have some emotional or psychiatric
problem.

  The Comnission's report also indicates that, at
any given time, up to 25 percent of the population
is estimated to be suffering from mild to moderate
depression, anxiety, or other emotional disorder.

  Depression and manic depressive disorders are
among the most severe types of mental  illness in
terms of prevalence, economic cost, and mortality.

6-25


Of the 29,000 suicides recorded in the United States
each year, more than 80 percent are believed to be
precipitated by depressive illness.  Severe depres-
sion or manic excitability handicaps an estimated
two to four of every 100 adults at any given time.

  Consistent  relationships   have   been   observed
between mental disorders and factors such as sex,
social class, and place of residence.

  Women have highest  rates of manic-depressive
psychosis while men have relatively high rates of
personality disorders.  The incidence of psychiatric
disorders is highest among people with lowest levels
of income,  education,  and occupation.  People in
cities have higher rates of anxiety, mild depres-
sion,  phobias,  self-doubt and other symptoms of
personality disorders, with only manic depressive
psychosis apparently higher in rural areas.

  There is persuasive evidence that appropriate
treatment  at the onset of acute psychosis can
markedly influence its outcome.

Periodontal Disease

  Disturbingly comnon among adults--and costly and
difficult to  treat--periodontal   disease   affects
tissues supporting the teeth.

  It is most often caused by bacterial deposits
(plaque) on the teeth--and, in its most frequent
form, gingivitis, produ-es inflammation of the gums,
with redness, swelling, and easy bleeding tendencies.

  Gingivitis often progresses to a more severe and

destructive form of periodontal disease--periodon-
titis.  At this point, bone and ligaments supporting
the teeth are gradually destroyed and the teeth
loosen or "drift."

  In its most advanced form, the disease causes
loss of teeth--and is, in fact, the prime reason for
tooth loss after age 35.  A recent survey found that
more than 30 percent of Americans between ages 55

6-26


and 64, and 45 percent of those 65 to 74, have lost
all of their natural teeth.

  Careful and thorough daily brushing and flossing
to remove bacterial plaque is effective in prevent-
ing and retarding progression of periodontal di-
sease.  Regular professional examination and treat-
ment to remove hard deposits that form on teeth,
correct predisposing factors,  and repair existing
damage are also  essential for control of this
disease.

**********

  Many  adult health problems  today--it bears
reemphasizing--can frequently be controlled by the
individual.  And the measures required are often not
particularly dramatic.

  An individual's risk of disease can be substan-
tially reduced (or increased) by a few simple per-
sonal decisions with respect to smoking, alcohol
use,  diet,  exercise,  seat belt use, and periodic
screening for major  diseases such as high blood
pressure and cancer.

  The potential exists to promote substantial
changes in the profile of disease and disability
among American adults.   But collective resources
will have to be mobilized to assist individuals
seeking to enhance their prospects for better
health, as well as to protect them from threats not
within their control.

  It is encouraging that many voluntary organiza-
tions, large businesses, and community agencies have
undertaken programs to help people adapt lifestyles
for a healthier life.  With a broad-based effort to
provide this kind of support, we can anticipate im-
pressive gains in the health of adults.

6-27


   CHAPTER 7
HEALTHY OLDER ADULTS

Goal:  To improve the health and quality
    of life for older adults and, by
   1990, to reduce the average an-
   nual number of days of restricted
    activity due to acute and chronic
     conditions  by 20 percent, to
    fewer than 30 days per year for
   people aged 65 and older.

  If longer life has been one of society's most
conspicuous  accomplishments,  there is  compelling
need now for another:  a better, healthier life for
older people.

  More Americans today live to older age than ever
before.  Whereas .in 1900 there were only three
million Americans aged 65 and over, making up four
percent of the population, now there are 24 million,
composing 11 percent.  By the year 2030, people 65
and over will number 50 million and comprise 17
percent of our population.

  The death rate for older Americans compares well
with that for older citizens of other countries,
although we  still rank behind countries such as
Japan and Iceland (Figure 7-B).  For all Americans
over 65 the death rate is down from about 8,300 per
100,000 in 1900 to about 5,400 in 1977 (Figure 7-A).
And for those 65 to 74, it has been amost halved--
from 5,600 per 100,000 in 1900 to 3,100 in 1977.

But we have cause for concern.

  The reasons for considering age 75 as marking
the start of old age are mostly social, rather than
biological.  Aging is a subtle, gradual, lifetime

7-l


IO

6

FIGURE 7-A

DEATH RATES FOR AGES 65 YEARS AND OVER:
UNITED STATES, SELECTED YEARS 1900-1977

1900    1910     1920    1930     1940     1950     1960     1970     198(

7-2


           FIGURE 7-B
DEATH RATES FOR AGE 96 YEARS AND OVER:
    SELECTED COUNTRIES, 1975

70

60

50


40


30



20


10


0

I

United
states

England
and
WAS

Japan       Chile

Sources: United States, National Center for Health Statmics, Dwirton of Vml Statistics:
     other countries. United Nations.

7-3


             FIGURE 7-C
MAJOR CAUSES OF DEATH FOR AGES 66 YEARS AND
      OVER: UNITED STATES, 1976

3,000









2,000









l.ooO









  0

Whate

All other

Cancer     Stroke

Arterio
sclerosis

Diabetes
mellitus

Source Based on data from the National Center for Health Statistics. Division of Vital Statistox

7-4


process  and there are startling contrasts in how
individuals   age.    Even   within an  individual,
different body systems age at different rates.

  In short, age 65 does not mark the start of any
inevitable uniform decline in physical and psycho-
logical functioning.

  Nevertheless,  the proportion of people with
health problems increases with age and, as a group,
the elderly are more likely than younger persons to
suffer from multiple, chronic, and often disabling
conditions.

  Eighty percent of our older people have one or
more chronic conditions and their medical treatment
accounts for about 30 percent of the Nation's health
care expenditures.

  The long-term goal of a health promotion and
disease prevention strategy for our older people
must not only be to achieve further increases in
longevity, but also to allow each individual to seek
an  independent  and rewarding  life in old age,
unlimited by many health problems that are within
his or her capacity to control.

  "Quality of life"  is a phrase sometimes used to
describe the latter goal.   It is not something
readily measured-- but  activity limitations due to
illness or injury clearly compromise the quality of
an older person's life.

  Over the last decade,  the proportion of people
over 65 who have had to place limits on themselves,
primarily because of chronic conditions, has fluc-
tuated between an estimated 42 and 47 percent--only
slightly less than half the 24 million elderly.

  And the average number of days of limitation has
changed little in recent years, ranging from 31 to
38 days per person per year.

7-5


  But a large portion of chronic activity limita-
tion  stems from respiratory conditions such as
chronic bronchitis and emphysema, and reductions in
cigarette smoking among  adults should lower the
incidence of these conditions by 1990.

  Moreover,  a relatively small reduction in the
incidence of strokes or a significant increase in
persons protected from influenza and its compli-
cations could produce a  noticeable reduction in
activity limitation.

  There is much that can and should be done to
help make older Americans healthier and better able
to function independently.

Subgoal:  Increasing the Number of Older Adults Who
Can Function Independently

  As do younger people, older Americans hope for a
state of well-being  which would allow them to
perform  at their highest functional capacity on
physical, psychological, and social levels.

  Their  greatest fear is  of being helpless,
useless, sick, or unable to care for themselves.

  Despite a cornnon misconception, most elderly
Americans can and do remain in their own homes. In
1975, 77 percent had their own households--51 per-
cent living with a spouse, 26 percent living alone--
and 18 percent lived with someone other than a
spouse.  Only five percent lived in institutions.

  Although the majority of the elderly are vigor-

ous and completely independent, there are 45 percent
with certain activity limitations--some associated
with mental disabilities, but most due to physical
handicaps caused by heart conditions, arthritis and
rheumatism, hearing loss, and visual impairments.

  Up to 20 percent of older people--from one-third
to one-half of those with any activity limitations--
are handicapped in ability to move about freely,

7-6


compared with two or three percent of the 17 to 64
year old population.

  Yet it must be reemphasized that only five
percent reside in institutions--and many of these
are temporary residents who   are  recovering from
illness and will return to the community.

  With adequate social and health services, a
greater proportion of the elderly could maintain a
relatively independent lifestyle and vastly improve
the quality of their lives.

Disease-Related Factors of Dependency

  Severe physical  and mental decline in older
people is not inevitable. While some changes with
age are normal, many others can be avoided.

  Although about half of the Nation's nearly one
million elderly living in long-term care institu-
tions are there because they were diagnosed as
senile, that diagnosis is not always justified.

  A mistaken diagnosis may be made because physi-
cians and families may attribute mental decline and
behavioral changes associated with physical condi-
tions to senility,  and fail to initiate appropriate
and timely treatment.

  Among the many causes of apparent senility which
can be treated to reverse the condition are drug
interactions,   depression,   metabolic   disorders
(thyroid, kidney, liver,  and pituitary malfunction,
as well as hypercalcemia and Gushing's Syndrome),
chronic  subdural hematoma, certain tumors, alcohol
toxicities,   chemical   intoxications  (arsenic   and
mercury), nutritional deficiencies, sensory depriva-
tion due to social isolation or failing sight or
hearing,  chronic infections,  hypoxia or hypercapnia
associated with chronic lung disease, and anemia.

  So numerous are the reversible causes of mental
impairment that comprehensive diagnostic evaluation
is  often indicated.  Moreover, there is growing

7-7


consensus among authorities that even with irrever-
sible organic brain syndrome measures are available
to lessen patient discomfort, to slow or arrest
deterioration,  and to help the patient make use of
residual strengths.

  Emphasis needs to be given, too, to the poten-
tially adverse effects of the many and varied drugs
prescribed for the elderly.  Surveys indicate that
older people often have more medications prescribed
for them than really needed--a danger which is
frequently overlooked.

  Evidence is accumulating to show that in older
people the body's handling of drugs is quite dif-
ferent compared with the younger adults on whom drug
clinical trials are usually performed.  Moreover,
the elderly,  often suffering from multiple chronic
diseases, follow complicated drug regimens that can
lead to unanticipated drug interactions.

  The mental confusion,  and other untoward effects
on physical health caused by drugs and drug inter-
actions,  can be minimized if older people have
access  to a continuing,  well-informed source of
medical care,  with proper attention given to only
needed and suitable drugs and to patient education
about drugs and drug effects.

  At some point, too, elderly people are likely to
need health or social system support because of
social isolation,  a dramatic change in their lives
such as  retirement,  loss of a spouse, reduced
income, or disease or injury.

  Among the most frequent chronic conditions and
impairments for older people in the community are:
arthritis,  which affects 44 percent of those over
65; reduced vision, 22 percent; hearing impairments,
29 percent; heart conditions, 20 percent; and hyper-
tension,  35 percent.  The elderly also, regardless
of whether they are chronically limited in activity
or mobility,  are subject to an average of 5.5 weeks
of short-term restricted activity a year.  One third
of this results from acute illnesses or injuries.

7-a


Some acute episodes, such as burns, falls, or
influenza and pneumonia, may be preventable.

  Although most of the elderly are able to assess
their own health status quite reliably, they may not
always seek needed attention promptly.  The problem
may be due in part to unavailability of needed
services,  especially in rural consnunities.   But it
may also be related to fatalism, fear of confine-
ment, poor transportation, or economic factors.

  Communities would do well to develop outreach
programs to find the sick and disabled in this
population and help them quickly--when help can be
most effective as well as most economical.

  The potential of such programs has been demon-
strated in a four-year study in Texas:  the average
number of short stay hospital days for mental ill-
ness patients 65 and over was reduced from 111 to 53
in a county that had a vigorous outreach and refer-
ral program;  a similar county without such a program
retained an average of 114 hospital days for similar
patients.

  Programs of geriatric screening can have great
value in finding still-minor disabilities which, if
left undiagnosed and untreated, can lead to severe
handicap.   Such conditions which are very much
amenable to early detection and treatment include
glaucoma,  hypertension,    some  types of  anemia,
depression,  hearing  disorders,   diabetes,    some
cancers,  and over-medication.

  The objective  of an early detection  program
should be to preserve physical and mental health and
enable older people to remain in their homes for as
long as they wish and are able to do so.   The
screening should consist of systematic examination
covering total physical, mental and social health.

  Health surveillance and health maintenance for
the elderly are most effective when a comprehensive,
integrated system of geriatric services is provided
at a single location.

7-9


  One reason is that many of the conditions common
among the aged are  linked with other conditions.
Diabetes,  for example, may  be associated with
peripheral blood vessel disease which requires good
foot care.  But visual impairment, common in elderly
diabetics,  makes such care difficult and limited
mobility due to arthritis may compound the problem.

  Special diets may be necessary for people with
diabetes, heart disease, or hypertension.  Diets of
elderly people are more likely to be deficient--in
calcium,  iron and fiber, for example--than those of
the rest of the population. Taste and smell altera-
tions in older people may diminish enjoyment of
food,  creating difficulties in satisfying nutri-
tional needs.  And absence of teeth, problems with
dentures,  and gum disease can make the situation
worse.

  Many elderly people, therefore, need a range of
services--dietary guidance,  we  care,  foot care,
dental care, and social assistance, as well as
routine medical care.  And these are best provided
at one center.

Social and Psychological Factors of Dependency

  Abrupt  changes in  social  dynamics--and the
elderly often face them--can create severe emotional
stress and lead to serious physical illness, even
premature death.

  Older people are especially likely to experience
drastic changes in family circumstances as spouses
die and children move to other cities.

  The stress of loss and grief is compounded by
the absence of support which a family can provide.
Stress is exacerbated still more when death of a
spouse   forces   the   survivor to  change  living
arrangements and move to unfamiliar surroundings.

  The elderly, too, must adjust to the change in
status which comes with retirement--including the
associated financial constraints many experience.

7-10


  Although the number  of older people living in
poverty has dropped by 60 percent since 1959, due in
large measure to Social Security benefits, still 14
percent of older Americans have incomes below the
poverty level --a proportion higher than for the
population as a whole (less than 12 percent).

  Moreover,  elderly blacks are affected to much
greater extent; 36 percent have below-poverty income
levels.   And women are  constrained--with median
incomes  only  about  half those of men  ($3,100
annually versus $5,500 for men in 1977).

  Fear of the cost of severe illness may cause
older people to  conserve their limited financial
resources.  They select cheaper foods and housing,
and make more limited use of preventive health
services.   Too often,  the fear--let alone the
reality--of   financial   straits  prevents  elderly
people from leading the full and active lives of
which they are capable.

  Depression,  a significant problem, may reflect
loss of purpose in life.   It is also related to
presence of physical disease, loss of friends and
relatives,   other   social  difficulties,   economic
problems,  and sometimes side effects of drugs often
used by  the  elderly   for   such   conditions as
Parkinson's disease and hypertension.

  Depression   can  be mentally and emotionally
devastating,  responsible for suicide or for seeming
senility which may lead to needless institutional-
ization.  It can exacerbate existing physical symp-
toms and may provoke new physical symptoms.

  Many kinds of care and services are needed to
deal with the complex, interrelated social, mental,
and physical aspects of aging.

  Limited dependency need not lead inexorably to
total dependency.  All who are functionally depend-
ent,  whether for a physical or mental condition,
must be allowed--and encouraged--to do as much as
possible for themselves,  otherwise their abilities
may deteriorate rapidly.

7-11


  Absence of opportunity to choose among care and
service  options--as  well as  to participate in
everyday tasks and decisions--is likely to produce
apathy and accelerate dependency.  The opportunity
for choice not only promotes health; it also helps
preserve individual dignity and sense of worth.

  We know now what programs and services can help
prevent deterioration,  avoid needless institutional-
ization, and maintain functional independence.

  They include programs for:  safe and affordable
housing; nutritious food availability through "meals
on wheels"  and group meal services; communication
and transportation  services,  including teleptiones
and escorts;  recreation and education programs to
promote  enjoyment,  challenge   and  stimulation;
community centers  to offer social opportunities;
in-home services such as homemaker, visiting nurse,
and home health care;  ready access (including by
telephone) to advice from a health professional;
provision of eyeglasses,  hearing aids,  talking
books,  and large print publications; legal aid and
counseling  services;   volunteer   and  employment
opportunities to provide a continuing sense of
purpose in life; and, not least of all, exercise.

   Exercise  and fitness for older people need
emphasis.  Aging is not-- or should not--be a process
of mere passivity.  Nor should the obsolescent image
of inevitable incapacitation be allowed to continue.
Movement  is part  of functional living--and the
quality of intellectual and physical performance is
enhanced by remaining or becoming physically fit in
old age.

  Evidence for  the viability of activity in
enhancing function  in old age is being developed
through long-range  studies such as those of the
Gerontology Center of the University of Southern
California.  These studies indicate that people in
their sixties and seventies and even beyond can
retain, with carefully planned exercise, much of the
vigor of their forties.

7-12


  Older people can be more functionally independ-
ent.

Subgoal:  Reducing Premature Death from Influenza
and Pneumonia

  In 1977 influenza and pneumonia together consti-
tuted the fourth leading cause of death among older
people.

  It may be true that for some of the elderly who
are in late stages of physical and mental deteriora-
tion,  death from these acute infections may not be
untimely.  Pneumonia has been called the "old man's
friend"  for the painless  ending of life it may
provide.

  But many deaths occur in older people otherwise
healthy and with much yet to live for. They can be
prevented.

  The greatest risk from the yearly influenza out-
breaks occurs among the chronically ill and elderly.

  A person over 75 is more than 10 times as likely
to die of influenza as someone aged 55 to 64. Many
of the chronically ill  also  are older persons.
Chronic  conditions  which  increase  risk  include:
heart, lung,  and kidney disease; diabetes and other
metabolic disorders which increase susceptibility to
infections;  severe anemia;  and diseases,  including
some  malignancies,  which  compromise  the body's
defensive immune system.

  For all high-risk individuals, annual vaccina-
tion against  influenza is recommended--and those
over age 65 should therefore seek the advice of
public health authorities and personal physicians.

  For pneumococcal pneumonia, we now have a signi-
ficant development.  This lung infection has been
responsible for 54,000 deaths a year.   Even with
antibiotic treatment,  it has been a serious threat
to older people.  The death rate has been 2.5 times
higher for those aged 65 to 74, and 10 times higher

7-13


for those 75 to 84, than for the population as a
whole.

  A newly-developed pneumococcal vaccine promises
to be an effective preventive measure--particularly
for special populations of the elderly, such as
those in nursing homes  and  institutions  where,
because of close contact, disease spread is more
rapid.

  And prevention of both influenza and pneumococ-
cal pneumonia can be vital for people with chronic
lung diseases.  Bronchitis, emphysema, and asthma
are  prevalent   among   the  elderly  and  together
constitute the eighth leading cause of death after
age 65.  The elderly with such conditions cannot
tolerate well the added burden of acute respiratory
infections.

Other Important Problems

  Of American babies born today, three-fourths can
expect to reach age 65;  almost half will reach 75;
and one-fourth will reach age 85.

  Although many people are living longer, there
appears to be a biological limit to the lifespan and
it seems unlikely that,  at least for the near fu-
ture,  any spectacular further gains in life expec-
tancy can be anticipated.

  While long life is  desired by people in all
cultures,  quality of life may be even more impor-
tant.    And   Americans    now   are  witnessing   the
emergence of a new concept of aging.

  It calls for the highest possible level of
health throughout the later years--and, finally,
dignified circumstances at the end of life.

  It considers that a healthy society will view
old age-- and the inevitable death at its end--not as
unnatural, but an integral part of the life span.

  And it calls for society to learn how to help
those for whom medical care can offer no more, so

7-14


that death becomes possible without pain, discom-
fort, humiliation or financial worries.

  A very real concern of the elderly is a prospect
of being exposed to sophisticated technology that
prolongs life beyond the time when it is meaningful
and enjoyable.  Nor can they view a busy, impersonal
hospital as a comfortable setting for an individual
who is dying.  They have an  additional anxiety:
that the high costs of extended hospital stay place
a heavy financial burden on surviving spouse or
other family members.

  Fears and anxieties about conditions surrounding
death can be reduced.

  When it becomes apparent that death is at hand,
the health care system should be willing to accept
the obligation to allow it to happen with as little
pain and suffering as possible.  The patient should
be allowed to be in peaceful surroundings, prefer-
ably at home.  Last year,  most older Americans died
away from home.  When death is near, the greatest
comfort lies in being in a home setting amidst the
comfort and support that family members can provide.

**********

  Many health problems of the elder ly reflect past
environments  and lifestyles.   The  occurrence of
heart disease, stroke, cancer, and  other chronic
afflictions may be rooted in earlier 1 ife.

  When these conditions no longer can be avoided
through preventive measures, early diagnosis and
treatment  very  often  can postpone death, avoid
serious complications, and minimize pain, disability
and emotional anguish.

  Some health problems may, be as much the result
of basic human biology as of environment and life-
style.   Arthritis, diabetes, and some types of
cancer,  for example, may arise from changes in
structure and function of aging cells.  Even though
knowledge is  not now available to prevent these
diseases, their course can be influenced.

7-15


  There remain, too,  many preventable conditions
to which older people are vulnerable--including
those such as influenza and pneumococcal pneumonia
for which immunizations are available, and those
caused or intensified by poor nutrition, lack of
exercise, and other lifestyle deficiencies.

  Thus, many measures can be applied to increase
independence,  self-sufficiency and quality of life
for the elderly.

7-16


SECTION III - ACTIONS FOR HEALTH


FIFTEEN
PRIORITY ACTIVITIES

  Attaining the national goals described in Sec-
tion II will depend on the development of effective
strategies, many of which are applicable to several
life stages.

  This section  is concerned with 15 important
activities--grouped into three categories:

0   key preventive services which can be de-
  livered to individuals by health providers
  (Chapter 8);

a   measures which can be used by governmental
  and other agencies, as well as by industry,
  to protect people from harm (Chapter 9); and

e   activities which individuals and communi-
  ties can use to promote healthy lifestyles
  (Chapter 10).

  All are based on recommendations from a number
of working groups recently sponsored by the Public
Health Service and reflect the setting of priorities
from a national perspective.  It must be recognized
that in some conrnunities these priorities may need
to be modified to local health conditions.

  But developing measurable objectives within each
of these areas,  to be achieved within a reasonable
amount of time, ought to do much to provide a better
focus--and workable structure for both national and
local efforts to promote health and prevent disease.

III-1


     CHAPTER 8
PREVENTIVE HEALTH SERVICES

  People are accustomed to seeking medical care
only when they feel ill and ordinarily perceive no
need for preventive health services when they feel
well.

  But we have evidence now that certain key
services can do much to preserve health--and that
people can be attracted to using them, with striking
benefits, when they are offered.

  Not by any means has every service delivered in
the past in the name of prevention been efficient.
Routine annual checkups, although traditional, have
not been as effective in reducing health problems as
the tailoring of pertinent screening, detection,
diagnostic and treatment services to specific risks
for individuals at specific ages.

  Major progress has been made, however, toward
defining what preventive health services should be
delivered to the well population, designed for the
specific needs of different age and risk groups.
Proposed by various expert review panels, they have
been   modified as   new  procedures   have   become
available and others found to be less effective.

  While the proposals differ in some respects,
they are  notable for their similarities.   What
amounts almost to a national consensus on a core of
essential preventive services has been developing.
One list representative of the current view has been
prepared for the Institute of Medicine of the
National Academy of Sciences and is summarized in
the Background Papers to this Report.

  The five priority preventive services discussed
in this  chapter --family planning, pregnancy and
infant care,  immunizations,  sexually transmissible

8-l


diseases services, and high blood pressure control--
are typical of the range of activities, the settings
for delivery,  and the blend of public and private,
individual and organized efforts necessary for a
well-rounded prevention strategy.

  Other preventive services may also be important
and some are discussed in Section II--e.g. testing
for serum cholesterol levels or screening for cancer
in appropriate risk groups.

   The five  included here are priority services
with potential  for substantially reducing death,
disease and disability from problems affecting large
numbers of people at earlier ages.

Family Planning

  All pregnancies  should be wanted.  Any child
whose birth is planned is far more likely to get off
to a healthy start in  life and to receive the
continuing parental  love and support needed for
healthy development.

  Yet, of the more than four million pregnancies a
year in this country, one million are terminated by
legal abortion.  And of the slightly more than three
million births, an  estimated one-third are un-
planned.   It appears, then,  that half of all
pregnancies are mistimed and many are unwanted.

  A large increase  in demand for abortions has
come from women aged 15 to 19.

  From 1973 to 1977, reported legal abortions in
the United States increased by an annual average of
about 15 percent.   In 1977,  over 1,079,OOO were
reported-- and over 332,000 of these were for women
under 20.  Although they represent 21 percent of all
women of  childbearing  age,  15 to 19-year-olds
accounted for about one-third of all abortions and
only 17 percent of live births.

  But unwanted pregnancies are not limited to
unwed teenagers.  Each year,  an estimated 300,000

8-2


married women have babies they say they do not
want.  In 1977, there were 190 legal abortions for
every 1,000 live births among women who already had
given birth to one child.   The abortion rate for
women with two children was 297--and for women with
three children it was 358--for every 1,000 live
births.

  Unplanned births affect not only the health of
children but also the social well-being of mothers.
Early  child-bearing  interferes  with  educational
attainment--and,  because education is related to
occupation  and  income,  can permanently influence
social and economic status.

  The association of unwanted births with lower
socioeconomic conditions and poverty also persists.
And, clearly, having more children than desired can
have adverse health and social effects on families.

Contraceptive Efficacy and Safety

  Unplanned   and  unwanted  pregnancies   can be
prevented   with  relatively   safe   and   effective
contraceptives.

  Among the most widely used and efficient are
male and female sterilization, oral contraceptives
("the pill"), and  intrauterine devices (IUDs).
Vaginal diaphragms, condoms, and spermicides (foam
and jelly) are somewhat less effective but still
acceptable and satisfactory.

  The efficacy of contraceptives is determined by
pregnancy rates  among sexually active women cor-
rectly using a method.  (Many methods require active
effort by a woman or her partner and low efficacy
can be due to failure to use a method consistently
and well rather than to limitations inherent in the
method.)

  The established efficacy rates are:  virtually
100 percent for sterilization; 98 to 99 percent for
oral contraceptives;  96 to 98 percent for IUDs; 85
to 90 percent for diaphragm with contraceptive cream

8-3


or jelly; 90 percent for condoms; 85 percent for
spermicides.  Periodic abstinence (rhythm method) is
less reliable--about 80 percent dependable when used
scientifically and conscientiously.

  Actually, most people do not consistently use a
contraceptive method correctly, and efficacies may
be considerably lower than those indicated above.
Often,  incorrect use results from inadequate or
inappropriate  instructions given by professional
providers.

  Although not all long-term effects may be known
for oral contraceptives, the relative safety of the
various contraceptive methods is well established
except for certain high-risk groups.

  Among women under 30,  the risk of death asso-
ciated with the major birth control methods is eight
to 12 times lower than the risk of dying as a result
of a pregnancy-related circumstance.  After 30, risk
rises for women who use oral contraceptives and also
smoke but remains low for nonsmokers.

  In both cases, however, risk is less than that
for women who use no  method of contraception.
Adverse reactions can occur in some cases with use
of a particular method; when they do, a different
method often is more appropriate.

The Non-Users

  Although more women than ever before are users
of contraceptives, including more than 80 percent of
married women aged 15 to 44, 25 percent of sexually
active unmarried women aged 15 to 19 never use
contraceptives and about 45 percent use them only
occasionally.

  Reasons given  by teenage women for not using
contraceptives are that they can predict the time of
month when they are fertile, that they have a low
risk of pregnancy,  and that contraceptive services
are not available.

8-4


  Yet, in fact the services are widely available.
Virtually all primary care physicians provide con-
traceptives or family planning counseling.   There
are also an estimated 6,000 family planning clinics
in the country,  a six-fold increase in the last 10
years.

  What is apparently lacking is an effective out-
reach and information program to enhance practical
accessibility and timely use of the services.

  Where they are carefully designed and compre-
hensive,  community-based programs serving pregnant
teenagers have succeeded in reducing one of the
problems of greatest concern--the rate of repeat
pregnancies among adolescents.   In Delaware and
Baltimore,  for example,  programs  which provide
education,  medical and social services, and infant
day care have been reporting one-year repeat preg-
nancy rates less than half the national 25 percent
average for adolescents.  Such programs need more
study but early results are encouraging.

  Primary prevention  efforts must also be more
effective.

  Making family planning information available at
the earliest possible age is one need.   Peers now
are the most common source of information.  Unfor-
tunately this information may often be of question-
able completeness and accuracy.  In theory, parents
are the most important potential resource for better
information,  and efforts should be made to improve
both their knowledge and their ability to communi-
cate the knowledge to their children.

  Sex education courses should teach males as well
as females the importance of assuming responsibility
for practicing birth control.

  However,  only eight States and the District of
Columbia now mandate some form of sex education as
part of health education curricula, and only 39
percent  of the Nation's  school  districts offer
information on human reproduction and sexuality.

8-5


  A major focus of primary prevention efforts must
be on providing contraceptive information and ser-
vices to all sexually active teenagers in a manner
that is accessible, convenient, inexpensive and,
perhaps most importantly, is effective in comnuni-
eating with them.

  Finally, family planning involves more than the
question of "when" to have a child; for some people,
the question is "whether." There are couples at
high risk of conceiving a child with an inherited
disorder.  They may wish to consider that risk in
deciding whether or not to have children.  Alterna-
tives available to such couples include adoption,
artificial insemination,  or conception and use of
fetal diagnostic measures.

  In some cases--such as sickle cell  anemia,
Tay-Sachs disease,  and hemophilia--the  important
genetic  characteristics  can be detected before
pregnancy through analysis of blood samples (carrier
detection).   Other  genetic  disorders,   described
below,  can be detected during the prenatal period
through  amniocentesis   and  analysis of  amniotic
fluid, but detection of an abnormality may require a
decision on an abortion.

  There should be greater effort by physicians,
clinics,  other health providers--and by schools--to
make the availability of these tests and alterna-
tives more widely known.

Pregnancy and Infant Care

  The chance that an infant will be of low birth
weight  and at  increased  risk of  developmental
problems,  and perhaps death,  is heightened by lack
of early, regular, quality prenatal care, as noted
in Chapter 3.

  Although between 1969 and 1977 the proportion of
women receiving prenatal care during the first three
months of pregnancy increased from 68 to 74 percent,
too many still do not receive care until the last
three months--and the greatest risk is for the one
to two percent who receive none at all.

8-6


  From 1950 to 1977, infant mortality dropped from
30 to 14 deaths per 1,000 live births. While some
of the improvement was due to greater availability
of regionalized intensive care units for newborns,
better prenatal services have clearly played an
important role.

  Maternity and Infant Care (MIC) Projects--part
of a  national effort to provide  assistance to
vulnerable   populations--have   consistently   been
associated  with  declines in  low birth weight
incidence and infant mortality.

  In Birmingham, Alabama, for example, after the
MIC project began in 1967, prenatal clinics avail-
able for low income pregnant women increased and the
proportion of women receiving prenatal care during
the first trimester rose from 24 percent in 1968 to
39 percent in 1978.  Although direct cause and
effect relationship  cannot be determined,  infant
mortality in this area dropped from 25 deaths per
1,000 live births in 1965 to about 14 in 1977--and
infant deaths during the first month of life went
from 19 to 10 per 1,000 live births, a 47 percent
decrease.

  In Denver, Colorado, infant mortality was 28 per
1,000 live births when the MIC project began in
1965; by 1972,  it was down to 17 and the incidence
of low birth weight also had declined.

Prenatal Care

  What are the important services needed during
pregnancy?

  They include thorough assessment of any special
risks because of family history or past personal
medical problems;  physical  examination and basic
laboratory tests; amniocentesis where indicated; and
counseling on  nutrition,  smoking,   alcohol   use,
exercise, sexual activity, and family planning
(Figure 8-A).

  Through  a prospective mother's carefully re-
corded medical experience and family history, it is

8-7


    Figure 8-A
Preventive Services for
The Pregnant Woman and Fetus

           INITIAL      SUBSEQUENT
SERVICES        VISIT-       vIsIlS*

HlSTORv

PHYSICAL
EXAtllnlATION

LABORATORY
EXAMINATIONS

CoUHSE:IYG
WITH REFERRALS
A; NECESSARY
AND DESIRED

General Medical

Family and Genetic

Previous Pwgndncies

current Pregnancy

General

Blood Pressure

Height and Weight

Fetal Development

VORL

Papanlcola" Smear

HemaglobinlHematocrit

Urinalysis for Sugar
and Protein

Rh Determlnatlon

Bloodgroup Oetermlnation
Rubella RAI Titre

A~"~OC~~t~5,*
(for women OYer 35)'

.

.

.

.           .

.

.           .

.           .

          .

.

Y"tr~t~a" Of Infant,
lncludlng Breastfeeding o

????????? ?????*?        ?

??? ??? ?o????o? ???o?? ?????
durlrg Pregnancy        .

Sexual lntercwrse
dbrlng Pregnancy        .

Signs of Abnormal Pregnancy a

.

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.

.

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possible to identify factors which may put mother
and fetus at special risk for avoidable problems.

  About 80 percent of women at high risk of having
a low birth weight infant can be identified in the
first prenatal visit,  and action can be taken to
reduce the risk.  Without such care, as noted in
Chapter 3,  an expectant mother is three times as
likely to have a low birth weight child.

  Through family history, risk can be identified
for several inherited diseases, including Down syn-
drome,  Tay-Sachs disease,  and metabolic disorders,
all discussed in Chapter 3.

  Women with histories of such problems as re-
peated miscarriages, bleeding, and premature mem-
brane rupture are at increased risk for not having a
live and healthy baby--but measures can be taken
during pregnancy to reduce the risk.

  Also needing more intensive obstetrical care are
women who have congenital reproductive tract malfor-
mations or medical problems such as diabetes, hypo-
or hyperthyroidism, heart disease or kidney disease.

  Laboratory tests are important because they can
confirm problems suggested by an expectant mother's
family or individual history.

  Women who tend to be more susceptible to toxemia
of pregnancy are  those with high blood pressure,
diabetes or kidney disease.

  Toxemia, which, when present, usually occurs
during the second half of pregnancy, is character-
ized by rapid weight gain, swelling of legs and
eyelids,  headaches,  elevated blood pressure,  and
loss of protein in the urine.  If it persists, it
can threaten the pregnant woman's  life through
complications  such as convulsions and stroke--and
lead to fetal death.


  When detected,  toxemia can be controlled by
rest,  sedatives,  antihypertensive and anticonvulsant
drugs,  and correction of chemical imbalances. In
most cases,  it subsides after pregnancy but in some
it has residual effects.

  For women 35 and over, those with a history of
multiple miscarriages, and others with certain gene-
tic indications,  amniocentesis should be offered.
In this fetal diagnostic procedure, which is used at
about the 16th week of pregnancy, a needle is in-
serted through the wall of the woman's abdomen into
the womb to withdraw a sample of amniotic fluid con-
taining cells shed by the developing fetus.  Cells
and fluid can be analyzed for chromosomal and bio-
chemical defects.

  Currently,  about 100 conditions can be reliably
detected by amniocentesis, including Down syndrome
and neural tube defects.  Neural tube defects also
can be detected during pregnancy by a blood test
and, in   some  cases,  by ultrasound examination.
Women with family histories of such genetic pro-
blems,  or of multiple birth defects or inherited
metabolic disorders, are at higher risk of having a
fetus with a defect detectable through amniocentesis.

  Also very important in prenatal  care is  the
counseling of expectant mothers on potential pro-
blems for the fetus that may be caused by smoking,
alcohol use, and poor nutrition, including referral,
when necessary, to suitable social support services.

  It would be difficult to overemphasize the need
for seeing to it that nutritional requirements are
met during pregnancy.  There are increased require-
ments--especially   for  calories,   iron,  calcium,
phosphorus  and protein-- and  all the more so for
pregnant teenagers whose requirements may be further
increased by habitual poor dietary habits coupled
with the accelerated needs associated with adoles-
cent growth.

  Maternal nutritional deficits have been shown to
materially increase chances for low birth weight or
stillbirth.

8-10


  As early as 30 years ago, diet corrections--even
in the last weeks of pregnancy--for women who had
experienced famine conditions in the first trimester
were found to help offset the potential effect of
severe caloric deficiencies on the birth weight of
their babies.

  Although famine conditions do not exist in the
United States,  nutritional and socioeconomic status
are linked, and many pregnant women, even some with
incomes above poverty level, are not receiving ade-
quate diets for normal fetal development. Providing
an important adjunct to good health care are pro-
grams   such  as the Department  of Agriculture's
Special Supplemental Food Program for Women, Infants
and Children (WIC) which gives dietary supplements
and nutrition education at no cost for certain preg-
nant women, infants,  and children up to five years
of age.

  Even before they become pregnant, women need to
know about factors that may affect the health of
their future babies.  While providing information
about risks of using cigarettes, alcohol and drugs,
is an important part of prenatal care, many women
are pregnant several  weeks before knowing they
are--and it is at the very early stages that the
fetus is most vulnerable.

  Early on, too,  the fetus can be affected by
toxic chemicals and infectious agents.  Moreover,
exposure to ionizing radiation above a certain level
in the first week or two of pregnancy increases risk
of spontaneous  abortion --and subsequent exposure,
especially during weeks two through six, increases
risk of malformations and some childhood cancers,
including leukemia.

  Here,  again, we  need intensified educational
efforts by schools, health providers, and the media.

The Birth Process

  Although most women experience uncomplicated
childbirth,  about 20 percent  have some problem

8-11


during  labor,  according to  the 1972 National
Natality Survey.

  There may, for example, be hemorrhaging, sudden
worsening of toxemia, or impairment of oxygen supply
to the fetus because of its position in the uterus.

  Because these problems require prompt interven-
tion,  preventive care during pregnancy should also
focus on the birth process itself and include edu-
cation  about childbirth and preparation  of both
parents, with underscoring of the importance of se-
lecting a place for delivery in or near facilities
that can be used to respond to emergency situations.

  Recent technological  advances promise improved
capability for responding to birth process problems.
Electronic fetal monitoring, for example, has im-
proved ability to detect fetal distress and there-
fore to save the lives of many high risk infants.
While the technique, if not used properly, may lead
to needless surgical deliveries as well as maternal
infections,  it can offer significant benefits when
appropriately used to monitor high risk pregnancies.

Postnatal Care

  Once a baby is born,  prospects for good health
can be enhanced by a number of preventive services
(Figure 8-B).

  A simple blood test can be used to screen new-
borns  for PKU (phenylketonuria)   and  congenital
hypothyroidism.  With dietary manipulation for an
infant with PKU, and thyroid hormone medication for
one  with hypothyroidism, mental  retardation  and
other problems that otherwise would develop can be
avoided.

  Routine neonatal care also includes intramus-
cular administration of vitamin K to prevent the
bleeding which occasionally occurs in newborns, and
instillation of silver nitrate solution in the eyes
to prevent eye infection which might occur if the
mother has active gonorrhea.

8-12


Figure 8-B

Preventive Services for the Normal Infant

             BIP,TH      SECOND      SUBSEQUENl
SERV!CES        VISIT      VISIT]       VIS:TS*

HISTORY AND
PHYSICAL
EXAMINATION

PROCEDURES

IFMIJNIZATIONS

Length and Weight         @         e          .

Head Circumference        .

Urine Stream            .

Check for Congenital
Abnormalities           6                    .

Developmental Assessment                        .


PKU Screening Test                  .

Thyroxln T4                      .

Vitamin K                       o

Silver Nitrate
Prophylaxis            .


Diptheria                                  .

Pertussis                                  .

Tetanus                                   .

Measles'
Mumps3
Rubella3

Poliomyelitis                               .

Infant Nutrition and Feeding
Practices (especially breast-
feeding)

Parenting

Infant Hygiene

Accidental Injury Prevention (including

PARENTAL COUN-    use of automobile restraints)

SELING, WITH    Family Planning and Referral
REFERRALS AS      for Services
NECESSARY AND
DESIRED       Child Care Arrangements

          Medical Care Arrangements

Parental Smoking, Use of
Alcohol and Drugs

Parental Nutrition, Physical
Activity and Exercise

In Response to Parental
Concerns

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.          @

.          .

.          I


e          .


.          .


.          .

'Second visit should occur within 10 days or before leaving the hospltal
,::a~: health visits the rest of first year or enough to provide immunira-
3Should be administered at 18 months of age

a- 13


  Prevention of Rh (rhesus) sensitization is a
major advance.  The sensitization can occur when a
mother has Rh negative blood and the fetus' type is
Rh positive.  It can be prevented by administering a
blood protein-- Rh  immune globulin--to the mother
after the birth of an Rh positive baby or after an
abortion or miscarriage.  If the immune globulin is
not administered, the mother may develop antibodies
to the baby's red blood cells and the antibodies,
during a subsequent pregnancy with an Rh positive
fetus,  may destroy the  infant's red blood cells,
producing   anemia,   brain   damage,   spontaneous
abortion, or death.

  Since introduction of Rh immune globulin in
1968, the estimated incidence of erythroblastosis
fetalis (the disease caused by Rh incompatability)
has dropped from about 4.1 cases per 1,000 births in
1970 to about 1.6 per 1,000 in 1977.

  Despite its relative lack of public attention,
the disease is still  a significant preventable
problem which affected 233 infants in 1976, 10 times
the number born with congenital rubella syndrome
that year.  Yet, appropriate postnatal intervention
could do away almost entirely with the disease.

ing Bl;;;stvf";ding.  Emotional and physical nurtur-
           to an infant's health and breast
feeding provides a way of enhancing both.

  Until this century, breast feeding was the prin-
cipal source of nutrition for infants during the
first six months of life, the period of most rapid
growth.   In the 1940s about two-thirds of infants
were being breast-fed but by the late 1960s and
early 197Os,  the proportion was down to about 15
percent.  Recently,  the trend has reversed; a 1976
survey found more than half of all mothers breast
feeding.

  Human breast milk provides nutritionally com-
plete,  convenient,  prewarmed food for infants.
Breast feeding also increases mother-infant contact,

8-14


confers some protection from infectious diseases by
transferring antibodies from mother to child, and
helps women who have gained excessive weight during
pregnancy to lose it.

  Moreover,  breast fed infants rarely are obese
and virtually never develop iron deficiency anemia,
the most common nutritional problem of American
infants.  If the nursing mother is healthy and well
fed, -fluoride and possibly vitamin D may be the only
supplements needed by the baby.   After about four
months, a source of iron may also have to be added
to the diet.

  Commercial  formulas   are   available  and  when
prepared according to directions provide adequate
nutrition but,  in contrast to breast feeding, they
are not regarded as the optimal food source.

  Solid foods.  Solid foods should be introduced
with care--generally not until the baby is at least
three months old.   No adverse effects occur when
solid food--and cow's milk--introduction is delayed
until much later in infancy.

  On the other hand,  when fed too early, solid
food may predispose an infant to food allergies,
overeating, and choking.

  In choosing  solid foods,  mothers should use
nutritional value rather than taste as the primary
guideline.  An infant does not need sweetened or
salted food and commercial baby foods should not be
supplemented with extra sugar or salt.

  New foods should be introduced one at a time,
with each continued for a week before another is
introduced.  This helps identify and avoid food
intolerances or allergies.  Commonly,  rice cereals
are used first, followed by fruits and vegetables,
and finally by meat.  To determine the proper diet
for an infant,  parents would do well to consult a
pediatrician,   dietitian, or    other    health
professional.

8-15


Immunizations

  Because of vaccines, diseases that once ranked
among the leading causes of death, particularly for
children,   now   are  regarded  with less concern.
Figure 8-C shows the change in incidence due to
immunization.

  But while substantially reduced as threats in
most cases--and eliminated in the case of smallpox--
these diseases still can be quite dangerous. Recent
epidemics of measles and pertussis, and occasional
outbreaks of diphtheria and polio, indicate that,
short of  complete  eradication,  reduction in a
disease's incidence is temporary and immunization
must be continually emphasized.

Childhood Immunization

  Each of the seven major childhood infectious
diseases which can be prevented by imnunization--
measles, mumps, rubella, polio, diphtheria, pertus-
sis,  and tetanus--can  cause permanent disability
and, in some cases, death.

  The provision of protection against these prob-
lems has become a national priority.  When polio
vaccination became possible in the 1950s the Federal
government moved to provide funds to State and local
health departments for large-scale immunization cam-
paigns.  Similar campaigns were begun when measles
and rubella vaccines were introduced.  The combined
Federal,  State and local efforts were notably
successful (Figure 8-C).

Yet vigilance in maintaining immunization levels
has waned and large numbers of children are not
adequately immunized.  In 1976, more than a third of
all children under age 15 were not properly pro-
tected--and the following year rubella cases in-
creased by 63 percent, measles cases by 39 percent,
and whooping cough cases by 115 percent.

  In response to the low immunization levels and
disease increases,  the President in 1977 began a

8-16


               FIGURE 8-C
REPORTED CASES OF MEASLES AND POLIOMYELITIS:
       UNITED STATES, 1991-1979

800.000 r

         MEASLES
4

300,000 -



200.000 -


100,cQo -

1950      1955      1960      1965      1970      1975      1960

   60.000                     POLIOMYELITIS


E   50,000
Lo               lnrroductlon of Polio Vaccine

1950      1955      1960      1965      1970      1975      1960

8-17


major   Childhood   Immunization   Initiative.   That
Initiative reflects recognition of the need for a
coordinated, broadly-based national effort to attain
and sustain adequate immunization protection.

  With the combination of safe, effective vac-
cines,  public and private programs, and a reliable
disease   surveillance   and   outbreak   containment
system,  infectious diseases can be controlled. In
fact,  complete  elimination of measles is  within
reach and has been set as a national goal.

  Although universal childhood immunization could
eliminate a vast amount of suffering and permanent
damage,  barriers exist.   Public interest must be
maintained and parents must ensure that children are
protected.  The effort must be broad, involving not
only public and private  health sectors but also
education,  social  services,  and other fields. A
recommended schedule is shown in Figure 8-D.

  To help parents, health departments and schools
should maintain outreach programs  and educational
efforts as well as programs making health services
available on a continuing basis.

  The poor are of particular concern since survey
data indicate they consistently have lower immuniza-
tion levels and higher disease incidence.  Medicaid
experience has shown that even where payment for
preventive services is provided, there is no assur-
ance that the services will be used.

  On the other hand, neighborhood health centers,
children and youth centers, and Health Maintenance
Organizations have demonstrated that where services
are provided in an organized setting, responsive to
the needs of the population served, and coupled with
outreach and follow-up efforts, preventive services
may be used appropriately by all income groups.

Other Vaccines

  Influenza virus  strains  change periodically,
necessitating  production   and  testing of    new

8-18


FIGURE 8-D

SCHEDULE FOR CHILDHOOD IMMUNIZATION

Diphtheria
Pertussis
Tetanus    Polio    Measles   Rubella  Mumps

Age'
2 months                0          a

4 months                0          0

6 months                D      o (optional)
15 months:                                  o         ?        ?

18 months                o          o
4-6 years               0          a
14-16years3              D

'Immunizations beginning in early infancy are the recommended practice.
They can be provided in later years, however, according to a schedule
recommended by a family physician.
2Measles, rubella, and mumps vaccines can be given in a combined
form, at about 15 months of age, with a single injection.
3Children should receive a sixth tetanus-diphtheria injection (booster)
at age 14-16 years, and every 10 years thereafter.

Source:  Parents' Guide to Childhood Ionization, USDHEW Center
     for Disease Control

8-19


vaccines,  often on short notice, yet vaccines for
many strains have been successfully developed. An
individual using the appropriate vaccine prior to
the influenza season is 70 to 90 percent less likely
to contract the disease.   Annual vaccination is
recommended for individuals determined to be at risk
because of being over  age 65 or with a chronic
disease, especially chronic obstructive lung disease.

  Vaccines against certain types of meningococcal
meningitis are licensed and usable in case of epide-
mics.  Research is under way to develop vaccines
against other causes of bacterial meningitis, hepa-
titis,  and several viral respiratory diseases of
infants and young children but it will be several
more years before these become generally available.

  A vaccine with potential for reducing pneumococ-
cal pneumonia by 60 to 65 percent is now available--
and important because some types of pneumococci are
becoming resistant to antibiotics.  Use at present
is limited to people facing greatest danger from
pneumonia:  many of the elderly, people with chronic
debilitating diseases  or sickle cell anemia,  and
those with inadequate spleen function.   It has not
been licensed for use in children under age two.
Because the risk of dying from pneumococcal disease,
acquired as a complication of influenza or other-
wise,  increases with age,  vaccination value also
increases with age.

Sexually Transmissible Diseases Services

  In 1977,  some 10 million cases of sexually
transmissible   diseases   occurred in   the  United
States, 86 percent of them in 15 to 29 year olds.
The diseases present significant health problems.

  No vaccine  is currently available to combat
these infections but intensive efforts are under way
to develop a vaccine against gonorrhea, the most
common of the more serious diseases.

  "Venereal disease" no longer is an adequate term
since it has been traditionally limited to syphilis,

8-20


gonorrhea, lymphogranuloma venereum, chancroid, and
granuloma inguinale. Now, however, with other dis-
eases known to be transmitted during sexual contact,
such as two types of hepatitis, a more appropriate
term is "sexually transmissible diseases."

  The most comnon of those identified to date
include:

0   trichomoniasis--3 million cases annually;


0   gonorrhea--2.5 million cases;


0   non-gonococcal  urethritis (NGU)--caused by
  organisms  such as  chlamydia  and  myco-
  plasma--2.5 million cases;

    0   genital herpes-- 300,000 cases; and


   0   syphilis--25,000 new cases a year.

  While most of the diseases may cause burning,
itching,  and discharge,  often they occur without
symptoms  and persons who have frequent sexual
contact with different partners should be examined
periodically.

  Several of the diseases can lead to serious
complications.

  In young women, for instance, pelvic inflam-
matory disease from extensive gonorrhea1 infection
or abscess in the Delvic cavity and reDroductive
organs is t he leading cause of infertility and
sterility.   Gonorrhea also is a cause of acute
arthritis in young adults.

  Genital  herpes--which is  manifested by very
painful lesi ons  similar to cold sores or fever
blisters--can cause severe neurological damage in an
infant infected while passing through the birth
canal.  Such infection occurs in about 50 percent of
infants delivered vaginally by infected mothers--and
active lesions in a pregnant woman are an indication
for a Cesarean section.

8-21


  Although unchecked syphilis can have serious
consequences,  the availability of penicillin and an
organized control effort have almost eliminated it
in the general population.  Certain groups, how-
ever-- including homosexuals, migrant workers, and
the poor--remain at high risk.   The life of an
infant with congenital syphilis is threatened when
appropriate treatment is not provided.

  For trichomoniasis,  long-term consequences   are
not yet known, but no severe complications have been
detected thus far.  The consequences of infection by
chlarnydia,  one agent of non-gonococcal urethritis,
have recently been discovered to be eye infection
and pneumonia in infants, and pelvic inflarrmatory
disease in women.

  Substantial   difficulties   hinder   control of
sexually transmissible diseases.  Feelings of guilt
or shame can make it difficult for some patients to
seek proper care.  Professional and paraprofessional
training related to the diseases has never been a
priority in  curriculum development.   Some health
professionals find it difficult to provide care in a
straightforward, nonjudgmental manner.  In addition,
these diseases may receive less attention because
they are most prevalent in groups without signifi-
cant political influence--the young minority groups,
inner city dwellers, and homosexuals.

Nevertheless, there have been successes.

  After World War II, again in the mid-1960s, and
once more in the mid-70s, renewed efforts success-
fully reduced the incidence of syphilis. Gonorrhea,
which had quadrupled in incidence between 1960 and
1975, began to plateau  in 1975 after a national
gonorrhea control program was initiated with Federal
funding in 1972.

  One striking example of progress is found in a
pilot program started in 1969 in Memphis, Tennessee,
to control gonorrhea and resulting pelvic inflam-
matory disease.  It focused on increasing public
awareness and education about gonorrhea, expanding

8-22


and extending the hours of clinic facilities, and
increasing  gonorrhea  screening,  casefinding  and
counseling.

  By 1976, results were apparent:  hospitalization
rates for pelvic inflammatory disease were down by
50 percent from 1971--with the reductions most
dramatic in hospitals serving predominantly young,
poor women,  the population  mainly served by the
national gonorrhea control program.

  As the Memphis program indicates, the essential
elements  for  controlling  sexually  transmissible
diseases include education of the public, particu-
larly adolescents,  to understand early signs of
disease and the kind of sexual behavior which in-
creases risk;  encouraging males with multiple part-
ners to use condoms;  screening high risk groups;
treatment with appropriate antibiotics of all found
infected;  and identification and treatment of sexual
contacts.

  There is clear evidence that most important in
attracting those who need the services are both the
quality of the services and the attitudes with which
they are delivered.

  While existing programs are interrupting the
transmission of syphilis and slowing the transmis-
sion of gonorrhea,  many vulnerable groups are not
yet being served.  To approach them effectively will
require not only the efforts of sexually transmis-
sible disease clinics and investigators  but also
those of family planning clinics, private physi-
cians, schools and employers.

High Blood Pressure Control

  Controlling   elevated   blood   pressure,   which
affects one in six Americans, is an essential if we
are to reduce the 500,000 strokes and 1,250,OOO
heart attacks which occur annually.

  Hypertension often begins early in life and
becomes progressively more severe with age.   It is

8-23


one of the most important risk factors for coronary
heart disease--and, for stroke, the most important.

  Blood pressure elevation is more frequent, up to
age 55,  in men than women, but the reverse is true
after 55.  Blacks are twice as likely as whites to
have it and it is more frequent in people with lower
incomes and lower education levels.

  In only about 10 percent of people with hyper-
tension is there a known cause such as kidney
disease or toxemia of pregnancy which sometimes may
be followed by permanent blood pressure elevation.
Excessive salt in the diet and stress are factors
not yet completely understood; they may contribute
to the development in some cases of what is called
"essential"  hypertension in the 90 percent of pa-
tients in whom the disease is present without any
known organic cause.  Recent evidence indicates that
the hypothalamic region of the brain plays a role in
the development of essential hypertension but more
research is needed to clarify the role.

  Although hypertension cannot be cured--except in
the relatively few  cases where a surgically or
otherwise curable cause may be involved--effective
treatments to control it are available.   In most
cases, medica*ion is needed for a lifetime.

  One problem is that because high blood pressure
does not usually produce symptoms, many people do
not take required medications, even when they are
supposedly under medical care, because of failure to
understand the significance of hypertension and its
control.  Some stop taking medication because they
experience adverse reactions, as can occur with many
medications.  Yet very often an adjustment of dosage
or use of an alternative drug more suitable for the
individual can minimize or eliminate undesirable
effects.

  It is unfortunately true, too, that some physi-
cians are not attentive enough to close control of
high blood pressure for their patients.

8-24


  Exactly how high an individual's pressure should
be before treatment begins is not yet settled.   But
it is clearly beneficial when diastolic pressure--
the second pressure reading, taken between beats of
the heart--exceeds 105.  Although research conti-
nues,  it is generally believed that there are also
benefits from treatment when diastolic pressure is
above 95--especially when other risk  factors for
cardiovascular disease,  such as a family history of
the disease, excessive smoking, and elevated choles-
terol levels are also present.

  The risk of long-term use of antihypertensive
medication in young people is unknown but thought to
be low and certainly less than the risk of untreated
hypertension.   In some elderly people with only
mildly elevated pressure,  possible side effects may
outweigh benefits of treatment.

  Measures other than drugs that may be useful in
preventing or treating hypertension are being inves-
tigated.  Weight loss and dietary salt restriction
lessen need for medication in some people and permit
use of smaller doses for others.   Exercise and
relaxation therapy (biofeedback) can be helpful in
some circumstances and are under study.

  Because hypertension is a "silent" disease, a
National High Blood Pressure Education Program was
initiated in 1972 by the Department  of Health,
Education and Welfare.  Targeted especially to high
risk groups,  it seeks to alert people to the high
frequency and significance of blood pressure eleva-
tion and the importance of periodic blood pressure
examinations.

  And since 1972,  as a result of education and
screening efforts by government, voluntary health
agencies,  comnunity leaders, medical societies, and
health care providers, the proportion of people with
hypertension who know they have it has increased
from 50 percent to more than 70 percent.

  Moreover,  between 1972 and 1974, nationwide
surveys indicate that the proportion of those with

8-25


hypertension   who   received   effective   treatment
doubled from 15 percent to 30 percent, and more
recent State and community studies indicate that the
trend is continuing.

  For example,  studies in New York (Westchester
County, 1975), Illinois (Chicago, 1977), and Mary-
land (1978) have found, respectively, 43 percent, 59
percent,  and 71 percent of the hypertensive popu-
lation under proper care.

  A longitudinal survey of a predominantly black
area in Baltimore found that hypertensive patients
whose pressure  was controlled increased from 17
percent to 60 percent between 1971 and 1978.

The effects?

  From 1972 to 1976, the age-adjusted death rate
for all cardiovascular diseases declined by about 15
percent and stroke mortality fell by 25 percent.
These improvements are almost surely due in part to
better high blood pressure control.

  A program in Milwaukee is one example of many
successful commmunity hypertension control efforts
which have produced these gains.  Initiated in 1974,
the Milwaukee effort involved many community re-
sources,  including the health department, a medical
school,  voluntary organizations, an insurance com-
pany, the local media, industrial firms, and others.
An important element in the program was development
of a well-designed p'tient  tracking system for
thorough follow-up after connnunity screening of
nearly 200,000 persons.

  And in Milwaukee,  heart attack deaths in 1977
were 17 percent less than the average annual rate
for 1971 to 1973.  Stroke deaths dropped 38 percent
in the four years of program operation.

  Use of the worksite for hypertension control
programs is especially rewarding.  The occupational
setting affords unique access to working people who
may be not only at higher risk for cardiovascular

8-26


disease but who are also less likely to follow
through with appropriate treatment for hypertension.

  As one example,  a collaborative union/employer
program providing hypertensive services at worksites
for store workers in New York City has been success-
ful in increasing, from 14 percent in 1973 to about
80 percent currently,  the proportion of hyperten-
sives  whose blood pressure is  under  effective
control.

  The strategy for hypertension control entails
using   resources  and services from a variety of
sectors.  And it also entails dealing with the kinds
of individual motivation,  lifestyle changes, and
long-term intervention which are needed to address
today's major health problems.  But the results can
be dramatic.

*********

  This chapter has urged greater use of family
planning services,  improved care for pregnant women
and newborn children,  immunization for vaccine-pre-
ventable diseases, control of sexually transmissible
diseases, and better high blood pressure control.

  Each of these measures can improve the quality
of life for many people and each is achievable with
our current state of knowledge.

8-27


  CHAPTER 9
HEALTH PROTECTION

  The American environment today contains health
hazards with the potential to kill, injure and
disable individuals and substantially affect the
health of entire communities.

  Some estimates hold that perhaps 20 percent of
all premature deaths-- and a vast amount of disease
and disability--could be eliminated by protecting
our people from environmental hazards.

  We have seen past improvements in protection--
through better sanitation, better housing, better
water-- contribute  greatly to the increased life
expectancy of the last 80 years.

  But, during this same period, rapid industrial
and technological development, social changes, and a
larger United States population, concentrated in-
creasingly in urban areas, have increased the com-
plexities of maintaining a healthy and safe physical
environment.

  Nevertheless, measures are available to com-
munities to provide better health protection.

  Many  communities  and States have begun to
develop health and safety standards to protect their
citizens.   And Federal laws and Executive Branch
initiatives during the past 15 years have created an
extensive Federal regulatory effort to help them.*

* Health protection responsibilities are presently
distributed among  several Federal regulatory and
research organizations:   the Environmental Protec-
tion Agency; the Department of Labor's Occupational

9-l


  This chapter  is concerned with five areas in
which National, State and local efforts can signifi-
cantly improve health and the quality of life for
this and future generations of Americans:   toxic
agent  control,  occupational  safety  and health,
accidental injury control, fluoridation of community
water supplies, and infectious agent control.

Toxic Agent Control

  Toxic factors  in today's environment present
formidable challenges.

  During  a lifetime,  people are exposed, often
unwittingly, to hazards from many sources.

Although how all of these hazards interact is
not known, for some it is known that their destruc-
tive potential can increase markedly when people are
exposed to more than one.

Exposure Sources

  Many of the agents posing new threats to
American health are chemicals developed for indus-
trial and agricultural purposes.

Safety and  Health Administration;   the  Nuclear
Regulatory Commission;  the Consumer Product Safety
Commission;   the  Department of  Transportation's
National Highway Traffic Safety Administration; the
Department of Treasury's Bureau of Alcohol, Tobacco
and Firearms; the Department of Agriculture's Food
Safety and Quality Service; and the Department of
Health,  Education  and Welfare's Food and Drug
Administration, Center for Disease Control, National
Institute  for Occupational  Safety  and  Health,
National Institute of Environmental Health Sciences,
and National Cancer Institute.

g-2


  The growth of synthetic chemicals in the last 25
years has been extraordinary:  more than four mil-
lion chemical compounds are now recognized; more
than 60,000 are commercially produced; about 1,000
new ones are introduced each year.

  Some make their way into water and food sup-
plies.  While there are now substantially fewer
dangers from contamination of drinking water by
bacteria, the dangers of contamination by oil, fuel
and organic chemicals are very real.

  With the growth in use of chemicals for industry
and farming,  the Nation's waterways have become
vulnerable dumping grounds for wastes from these
uses.   Food  supplies as  well    are  subject to
contamination or treatment with chemicals  in the
course of   growth,   fertilizing,   harvesting,
processing and storage.

  The dangers are demonstrated by recent incidents
involving Kepone,  polychlorinated biphenyls (PCBs),
and polybrominated biphenyls (PBBs).

  The insecticide Kepone, discharged from the
Virginia plant in which it was manufactured,
contaminated edible fish as it spread in unknown
quantities to the James River, Chesapeake Bay, and
the Atlantic Ocean.  It caused serious neurologic
and reproductive  effects in  workers  exposed to
it--and,  in experimental animals, has caused cancer
as well.  It is no longer manufactured.

  PCBs have been produced in huge quantities for
use as plasticizers and insulation for electrical
equipment.  Not until tens of millions of pounds
were produced and released into the environment was
there any realization of how toxic and persistent
these substances are.

  Despite limited restrictions imposed in the
early 1970s by industry to reduce production and
use,  high PCB levels continue to persist in the

9-3


Great Lakes and other major waters across the na-
tion.  In the past few years, PCBs have been found
in tissues of humans and in the milk of nursing
mothers.  When fed experimentally to nursing mon-
keys, PCBs have led to serious injury of offspring.

  Similarly, in 1973, the accidental mixing of the
fire retardant polybrominated biphenyl in cattle
feed resulted in contamination of food and livestock
throughout Michigan.  Growth deformities occurred in
many of the cattle; thousands had to be destroyed.
The health effects on the population which consumed
contaminated food are still under study, but large
numbers of people have been found to have elevated
levels of PBB in their bodies.

Air pollution is another major source of hazard.

  About 80 percent of Americans now live in urban
areas  where  toxic gases  or particulate matter
pollute the air.  Most of the pollution results from
combustion of fossil fuels by automobiles and in
industrial activities.

Four groups of air pollutants are of major
concern:  sulfur oxides,  including sulfur dioxide
(SO2) and sulfur-containing aerosols; carbon mon-
oxide;  photochemical oxidants, particularly ozone;
and nitrogen
aerosols.   oxides such as N02, NO and nitrite

  Increased air pollution has been associated with
debilitating respiratory diseases such as acute and
chronic bronchitis and pneumonia, and exacerbation
of symptoms in people who already have pulmonary
disease.  Of concern, too,  are poisoning from lead
emitted to the air and the possibility of cancer
from pollutants such as asbestos, beryllium, ben-
zene,  and other synthetic organic  chemicals with
carcinogenic potential.

Chemicals can be hazardous not only during their
manufacture,  formulation and use, but also during

9-4


transportation and disposal.  Community-wide expo-
sures have resulted from accidents during movement
of large  volumes  of chemicals   across  land and
waterways.

  And exposure problems  are exacerbated by many
community waste  disposal sites containing large
quantities of unkown chemical products.  Many of
these sites have been in use since the mid-1940s and
their deposits may include highly toxic materials
that   can   contaminate  surface or  ground water
supplies or the atmosphere itself.

  Leakage of chemicals from the Love Canal site in
upstate New York reveals the risks to public health
from chemical wastes disposed of before the initia-
tion of regulatory controls. As chemicals began to
leak out of the land-filled canal, concern arose
about exposure for residents of homes built on the
site.  More than 80 different compounds have been
identified, 11 of them known or suspected carcino-
gens.  There has been a significantly higher rate of
spontaneous abortions among exposed women.  An asso-
ciation   with  congenital   abnormalities is   also
suspected.

  Several   thousand  such disposal  sites  exist
throughout the country and close monitoring is
needed to safeguard against harmful exposures.

  Radiation is  another environmental source of
human illness.  About half of all ionizing radiation
to which the general population is exposed comes
from naturally occurring radioactive materials in
the water, soil and air.  Another 45 percent is from
medical and dental use of x-rays and from radioac-
tive materials used for diagnosis and treatment.
The remaining five percent comes from fallout,
industrial uses,  production of nuclear power, and
consumer products.

  Ionizing radiation from nuclear energy and me-
dical diagnosis and treatment can, if there is expo-
sure to large enough doses, cause cancer, genetic

9-5


defects,  and tissue injury.  The entire population
is also at potential risk as the cumulative dose of
exposure to low-level  ionizing  radiation grows.
Non-ionizing radiation,  such as from ultraviolet
rays and microwaves, carries lesser risk with single
exposure, but the possibility of harmful effects is
increased because total potential exposure is large.

Health Effects

  It takes at least 20 years to determine full
effects of many new compounds on human health--and
health problems  caused by some compounds in use
today may not be known until the Zlst century.

  But it is clear that toxic compounds can have
diverse, serious effects.   They are capable of
producing  reproductive  and developmental impair-
ments,  mutagenesis,   cancer,  chronic degenerative
diseases, neurologic and behavioral impairments, and
immunologic diseases.

  Evidence for  such capability comes from the
experience of occupational groups exposed to greater
chemical or physical hazards than those to which the
general population is exposed.  If high exposure
causes serious disease,  the same ill effects may
occur in people exposed to much lower doses over a
long period. For example, a single intense exposure
to nuclear radiation produced very high rates of
certain   cancers   and  other  illnesses  among the
populations of Hiroshima and Nagasaki, but radiation
in much smaller doses also causes cancer over time
in susceptible individuals.

  Because successful reproduction and development
are essential to healthy propagation of the species,
agents that affect reproductive capacity or fetal
development are of concern.  Recent data show, for
example,  that men exposed to toxic agricultural
chemicals such as Kepone and dibromochloropropane
are at greater risk for impotence and infertility.
In addition,  more than 20 agents are known to be
associated with human birth defects and many times
that number  cause birth defects in  laboratory
animals.

9-6


  Of possibly even greater concern is the poten-
tial occurrence of mutations from exposure to envi-
ronmental  agents.  A mutation--a change in the
genetic material  of a cell--can alter biologic
development.   If a mutation involves non-sex cells
or is  so drastic as to be lethal, effects are
confined to a single generation.   But if the
mutation  involves egg or  sperm cells of either
parents or fetus,  the effects can be passed along
indefinitely from generation to generation.

  Probably the most widely discussed effect of
hazardous substances is cancer.  Statements that up
to 90 percent of human cancers are due to environ-
mental factors have received much attention but
these estimates include as environmental sources
such factors as diet, alcohol, and cigarette smoking.

  Nevertheless, there are substantial threats from
chemicals   and   radiation.    The   National   Cancer
Institute currently lists at least 20 chemicals and
compounds for which there is epidemiological evi-
dence of human cancer causation.  Among them are
asbestos, benzene, vinyl chloride, and arsenic. In
addition,  over 2,300 specific chemicals are sus-
pected  carcinogens,  including   some  insecticides,
herbicides,  asphalt fumes, wood dust, and coal tar
volatiles.  They are believed to work through varied
mechanisms.

  Some produce mutations in the genetic material
of cells which then reproduce unchecked; others may
suppress the immune mechanism which usually destroys
tumor cells; and others may stimulate the prolifera-
tion of tumor cells themselves. More than one mech-
anism may work at one time; the effects of exposure
to single agents may be additive; and concurrent
exposure to multiple agents may be more hazardous
than the sum of the individual exposures.

  In addition to cancer,  environmental agents can
cause other degenerative diseases,  including arte-
riosclerosis,  heart disease, hypertension, emphy-
sema,  chronic bronchitis, kidney disease,  liver
disease, diabetes, anemia, neurologic and behavioral
disorders, and immunologic diseases.

9-7


  There is virtually no major chronic disease to
which  environmental  factors do not contribute,
directly or indirectly.  Some of the most striking
effects noted to date have been the neurologic and
behavioral problems of workers exposed to certain
pesticides, organic solvents, and inorganic metals.

Detection and Control

  Protection  against toxic environmental agents
depends upon reliable methods of identifying hazards
to health.  Clinical and epidemiologic research has
helped recognize harmful  substances by finding
unusually high rates of disease occurrence in
certain  population groups with unique exposure
histories.

  But disease generally occurs after a long latent
period during which large numbers of people may be
exposed to what will turn out to be the hazardous
agent.  Methods are needed to demonstrate biologic
changes with potential  for leading to disease--
before disease actually occurs.

  Animal studies provide one such method.   With
one or two possible exceptions, all agents known to
produce human cancer also produce cancer in experi-
mental animals.  There is a popular misconception
that under laboratory conditions any compound can
cause cancer in animals.  A study conducted for the
National Cancer Institute found, however, that fewer
than 10 percent of 120 comnon pesticides caused more
tumors than expected when fed continuously to mice
in high doses for 18 months, beginning in infancy.

  Actually,  animal studies have more often proved
prophetic than  not.   That estrogen  replacement
therapy for women would increase risk of uterine
and,  possibly,  breast cancer was predicted accur-
ately by studies on several species of animals in
the 1930s.  Studies on quail in 1964 showed that
Kepone could cause reproductive failure and nervous
system disease.  And studies on rats indicated that
vinyl chloride gas would prove to be carcinogenic in
the industrial setting.

9-8


  A principal drawback to current animal testing
procedures is the time and expense they require. A
complete animal test of any suspected substance can
take upwards of three years and cost several hundred
thousand dollars.  Several billion dollars would be
needed to fully test the backlog of organic chem-
icals now in the environment but still untested.

  Fortunately,  encouraging progress is being made
in developing rapid,   less  expensive tests for
carcinogenicity and mutagenicity.  Such approaches
are designed to observe  the short-term effects of
toxic agents at the cellular or biochemical level.

  They include tests for mutagenesis in mammalian
cells,  insects,  and microorganisms;  identification
of  any damage to or repair of DNA; malignant
transformation of cells in culture; and chemical
reactivity of   activated   substances.   The  rapid
procedures can be used to screen large numbers of
suspected toxic agents to determine which to subject
to more intensive animal studies.

  When it comes  to implementing measures to
improve the quality of the environment, the chal-
lenge falls to all sectors of our society--indi-
viduals,  health professionals,  private  industry,
community groups, and government.

  At the Federal level, several departments and
agencies,  noted earlier,  conduct programs to iden-
tify,  monitor,  evaluate,   and   control   harmful
environmental contaminants.

  Although these programs appear to have broad
public  support,  their economic and technological
impact can be substantial, and they are an in-
creasingly common  subject  of debate inside and
outside government.

  Nevertheless, it is  clear that the Federal
government must continue to bear major  responsi-
bility for setting and enforcing pollution standards
and for dealing  with health risks related to
environmental contamination.  A strong emphasis on

9-9


refinement of   tests   which   can  help  identify
potential new hazards is especially important.

  State and municipal  governments can reduce
environmental hazards by monitoring the safety of
air and drinking water; controlling use of ionizing
radiation;  providing  adequate   sewage  disposal;
requiring auto safety and emission inspections; and
regulating the use of pesticides and other agricul-
tural chemicals.

  At the   local  level,  individuals,  comunity
grows,  and government agencies,  including public
health departments   and  health planning  bodies
(health systems agencies), can identify health
hazards unique to a particular community.  Easily
observable effects on  chronic diseases may on
occasion  be detected by community surveillance.
Local  education programs  can help inform people
about the hazards of toxic agents in the environment
and how to protect themselves against them.

Although some significant environmental reforms
have been achieved in recent years and the Nation's
air and water are cleaner, environmental programs
are frequently challenged and need stronger support.

  Part of the problem in controlling environmental
hazards is that they are produced as individuals or
industries pursue diverse activities which have
become parts of our daily lives.  The automobile,
electric power generation, plastics manufacture, and
construction   are  all  integral parts  of present
lifestyles and the economy--and all pose health and
safety hazards.

  The challenge is to reduce the hazards without
undue sacrifice.  But some changes in lifestyle may
be necessary.  Reduced use of automobiles is one.
Eliminating waste in the use of energy is another.
Reducing consumer demand is a third, and recycling
is a fourth.

Because of the strength of competing interests,
health does not always emerge as the top priority.

9-10


But achievements of the past few years indicate
that,   notwithstanding   obstacles,   environmental
changes can produce substantial health benefits.

Occupational Safety and Health

  There   are   more   than  97 milli,on   American
workers--many of  them exposed  to some kind of
occupational  health hazard:   carcinogenic  agents,
pulmonary or  other physical  disease incitant, or
job-related pressures of noise, crowding, stress or
boredom which can have adverse psychological effects.

  Each year 100,000 Americans die from occupa-
tional illnesses and almost 400,000 new cases of
occupational  disease are recognized, according to
National  Institute for Occupational  Safety and
Health estimates.  And the actual extent of occupa-
tional disease is probably much greater because the
link between job and disease is often unrecognized
or unreported.

  Occupational exposures  to toxic chemicals--as
well as such physical  hazards as excessive noise,
radiation,  sunlight   and   vibration--can  produce
chronic lung disease, cancer, degenerative disease
in a number of vital organ systems, birth defects,
and genetic  changes that may be transmitted to
future generations.   Some hazards also increase
frequency of stillbirths,  spontaneous  abortions,
reduced fertility, and sterility.

  These health effects are often linked with par-
ticular jobs.   For example,  workers engaged in
manufacturing   the  pesticide  dibromochloropropane
have experienced an infertility rate twice to three
times  as great  as for the general population.
Examples of job exposure to carcinogens are noted in
Chapter 6.  Of nearly 34,000 chemicals in the work-
place which have reported toxic effects, over 2,000
have been reported to be potential human carcinogens.

  Yet, despite risks of serious disease or injury,
most workers are unprotected.   Worksite exposure
standards have been established for only a few toxic
substances.

g-11


  Nine of every 10 American industrial workers are
not adequately protected from exposure to at least
one of the 163 most common hazardous  industrial
chemicals, according to a recent occupational hazard
survey.

  And now under careful review is a recent esti-
mate that, if the full consequences of both present
and recent past  occupational exposures are taken
into account, perhaps 20 percent of all cancers may
be related to  carcinogens   encountered in  the
workplace.

  Not all  occupational   hazards  are found in
factories or   exposure to   toxic   substances.
Work-related injuries kill about 13,000 Americans
each year and affect nine million more so severely
that they require  medical care or are at least
temporarily unable to work.

  People in  mining,  agriculture (including
forestry and fishing),  and construction are six,
three,  and three times respectively, more likely to
die from a work-related injury than other private
sector  workers.   And work-related problems   are
reported by a wide  variety of employee groups,
including   medical   technicians,   cosmetologists,
flight  attendants,  dentists,   air   traffic   con-
trollers, and many others.

Health Protection Measures

  Occupational   hazards   can  be controlled by
modifying   work  environments,  patterns of  job
performance, or both.

  Altering the work environment--plant, processes,
materials used--is the most effective. Protection
against hazards can  be facilitated by requiring
appropriate  engineering  controls,  particularly as
new plants are built.

  For success, prevention strategies must rely
heavily on  employer   efforts   and  support from
employees, unions, and government regulatory bodies.

9-12


  Worker protection may also require special pro-
tective equipment when other means are unavailable--
and careful monitoring of workers exposed to hazards
in order to ensure that safety controls are effec-
tive.   Sometimes, however,  conditions and circum-
stances hamper efforts to protect workers.  Personal
protective equipment, for example, often is uncom-
fortable and encumbering.

  Effective protection also depends on the design
and maintenance of equipment and proper training of
employees.

  It must be recognized that higher pay for
hazardous jobs may lead employees to choose imme-
diate financial benefit over long-term safety and
health protection.  And the concentration of indus-
tries with hazardous conditions in certain geogra-
phic areas,  or their location in otherwise economic-
ally depressed communities, or their presence as the
only industry in  a community gives  workers, in
effect, no opportunity to choose a safer job.

  Furthermore, development of hazard control tech-
nology has lagged behind the growth in industrial
use of hazardous chemicals and sources of physical
energy such as microwaves, nuclear energy, lasers,
and ultrasound.

  Even when controls are available, there are few
incentives  for employers  to install or maintain
them.  Positive incentives that could be provided
include low-cost loans, tax benefits, and technical
assistance.  Regulation is a negative incentive but
occupational safety standards, important to preserv-
ing the health of millions of workers, should be
strongly and consistently enforced.

  It was recognition of the increasingly compel-
ling importance of assuring worker protection that
led to passage in 1970 of the Occupational Safety
and Health Act.

  The Act established the Occupational Safety and
Health Administration (OSHA) in the Department of

9-13


Labor,   with  responsibility   for  mandating   and
enforcing health and safety standards for the
workplace and for educating workers about potential
hazards.  Scientific support for the Administra-
tion's work is provided by the Department of Health,
Education  and Welfare's  National   Institute for
Occupational Safety and Health.

Pressures on OSHA are often conflicting, with
some groups urging fewer and less restrictive stan-
dards and others requesting faster and more aggres-
sive  action.  Clearly,  enforcement of the Act,
especially for  workers facing significant  health
hazards--asbestos workers, textile workers, chemical
workers,  and many  others--deserves high national
priority.

Health Promotion Measures

  Many firms and some government agencies have
taken  steps to  provide  worksite  programs for
promoting health through health education, physical
fitness activities,  and preventive medicine.   Some
provide  screening for  hypertension,  high blood
cholesterol,  and heart disease.   Some conduct or
refer employees to groups to help them stop smoking
or lose weight.

  Encouraging results have come from a number of
programs, and indicate the utility of establishing
these programs for employees from the assembly line
to the executive suite.

  Some companies have become concerned about
stress in and out of the workplace and are insti-
tuting measures  to help employees deal with its
adverse effects.  Training in meditation and other
relaxation techniques,  and seminars on how to cope
with stress at home and at work are examples of
measures provided by some companies.  Many employ
company psychologists or psychiatrists, or pay for
such services outside the firm.  The extent to which
such efforts actually reduce stress is still under
study.

9-14


  Beyond helping employees handle the pressures of
work,  a few firms try to modify the nature of the
work.  Some redesign jobs and organizational struc-
tures to try to make jobs more meaningful and ful-
filling.  For example,  instead of assembly lines
which require each worker to deal with smaller and
smaller elements of a whole, some employers allow
workers to assemble entire products.

  Among   other  experimental    measures  showing
promise are programs that allow workers to work in
small face-to-face groups with a good deal of
autonomy.  The groups may be responsible for a given
level of output but decide among themselves how to
accomplish their goal,  including deciding which
hours to work.   Supervisors  concentrate less on
giving detailed orders and more on making sure the
groups have the resources they need.

  Although they do not  solve every problem of
occupational   stress,   such    measures   have   the
potential to decrease job dissatisfaction and its
costly consequences--absenteeism, employee turnover,
alcoholism, waste of materials, sabotage, and plant
shutdowns--and    presumably    thereby    increase

productivity.

Gaps and Needs

  Despite  increasing  research into occupat
safety and health, many gaps exist.

iona

1

  Inadequate data make it difficult to determine
accurately   the   extent of  occupational   health
problems   and   to measure  the effectiveness of
prevention efforts.

  Because of long latency periods before disease
develops,  knowledge is  lacking about the risks of
the approximately 1,000 new chemicals introduced
each year and how they may interact.

  One problem in collecting statistical data about
occupational exposures is the variety of ways in
which  people   come in   contact   with   hazardous

9-15


agents--by ingestion, inhalation, skin contact, or
some combination of these.

  Another problem is lack of recorded information
about the intensity,  duration and combinations of
exposures.

  The difficulties are compounded by concerns for
confidentiality--of employers  over trade secrets,
and of workers  and occupational physicians   over
personal health records.  Often, too,  workers are
not told the names, particularly the common names,
of chemicals with which they work or simply do not
know of toxic substances to which they are or were
exposed.  And when they do know, they may prefer to
face possible health risks rather than the prospects
of job loss.

  Among critical areas that need study are the
role of occupational exposures in producing birth
defects and the special problems of women exposed to
hazardous substances. Others include:  occupational
causes of respiratory disease, alone or in combina-
tion with smoking; the role of job stress and expo-
sure to physical and chemical agents in cardiovas-
cular disease; and the behavioral changes induced by
chronic exposure to low levels of chemicals; the
health effects of occupational exposure to such
physical  agents as  heat and radiation and the
interaction between these and chemical agents; and
methods for analyzing thresholds of exposures to
hazardous workplace conditions.

  Finally,  we need to learn what combinations of
regulations and incentives work best to bring about
changes in both employer and employee attitudes and
practices to reduce known occupational risks.

  That the work environment can play a major role
in compromising  health has been known for many
decades.  It is time now for substantially increased
efforts  to control known hazards,   treat those
afflicted,  and develop techniques to identify and
prevent harm from materials and processes not now
recognized as dangerous.

9-16


  It is time, too, to act on the recognition that
the workplace not only should not contribute to
physical or mental disease, but is also a legitimate
and highly useful place for promoting health.

Accidental Injury Control

  More than 100,000 Americans lost their lives to
injuries  in 1977--nearly half of them from motor
vehicle  accidents,  the rest from falls, burns,
poisonings and other causes.   In 1977, too, 65
million   people   suffered   non-fatal   accidental
injuries, requiring medical treatment--and in terms
of  damage,  injury  and  lost productivity,   the
estimated cost of accidents in 1977 was $62 billion.

  The leading cause of death beween ages one and
44, accidents account for roughly 50 percent of
fatalities for those 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.

  Educational  approaches  advocating  changes in
behavior have been generally ineffective in pre-
venting accidents among those at highest risk--young
children,  teenage males,  problem drinkers, and the
elderly.

  More effective measures involve changing the
manmade environment to reduce risk for those unable
to take adequate precautions.   Such efforts are
certainly   not  unprecedented.   Examples   include
insulated tools,  childproof medication containers,
lead-free paints, and automobile airbags.

Motor Vehicle Accidents

  Highway accidents in 1977 killed 49,000 people
and led to 1,800,OOO disabling injuries.  The total
cost, as estimated by the Department of Transporta-
tion was more than $43 billion.

  Teenagers and young adults--the 15 to 24 year
olds--have the highest motor vehicle death rate of

9-17


any grow,  accounting for one-third of all motor
vehicle deaths.

   Like  many  other  types of  accidents,  motor
vehicle crashes traditionally have been blamed on
human error,  and prevention  strategies have con-
sisted primarily of driver education programs.   But
more recently,  injury control experts have identi-
fied a range of factors in vehicle collisions which
occur with imbalances between the demand of the
highway system,  the characteristics of individual
vehicles,  and the age and other characteristics of
the driver.

  Moreover,  it appears that injuries often can be
prevented or reduced even when collisions occur. A
number of preventive strategies emerge--some aimed
at preventing collision,  others at minimizing their
consequences,

  Many collisions obviously can be prevented by
reducing vehicle numbers and miles traveled by auto-
mobile through encouraging people to travel by air,
rail or bus--all safer modes of transportation.

  Similarly, lower speed limits, if observed,
would reduce both the number and severity of
crashes--and, for several years after it was imposed
in 1974, the national 55 mph speed limit saved an
estimated 4,000 to 5,000 lives each year.

  The greatest risk factor for fatal accidents is
driver alcohol use.  In about 50 percent of drivers
involved in fatal crashes, blood alcohol levels have
been   found to   be excessive.   Although  driver
education and strict penalties such as mandatory
license suspension  have the potential to reduce
alcohol-related accidents, those measures have not
been very effective to date. Clearly important are
the general preventive measures to reduce problem
drinking discussed in Chapter 10.

  Vehicle design is another major factor in high-
way injury and death.  To reduce crash impact on
driver  and passengers,  automobile bumpers,  front

9-18


ends, and steering columns can be designed to absorb
energy.  Passenger compartments can be better de-
signed to withstand accidents, with protruding knobs
and handles eliminated and hard surfaces padded.
Although some of  these design features  have been
adopted, most cars are not designed to fully protect
occupants from injury in crashes that occur at legal
let alone high speeds.

  Combined lap and shoulder belts can almost halve
the likelihood of serious injury or death, and
although all passenger vehicles sold in the United
States are equipped with seat belts, fewer than 20
percent of drivers use them.

  Current Federal law requires that by 1983 all
new cars contain devices that automatically protect
front seat passengers  in frontal collisions.   The
devices--such as airbags and belts that are auto-
matically positioned when the car door is closed--
promise   substantial   protection.    The   National
Highway Traffic  Safety   Administration  recently
reported  a fatality rate  for one type of car
equipped with automatic belts only half that for the
same type equipped with conventional safety belts.

  If no child died in an automobile accident, the
death rate for children could be reduced by fully
one-fifth.  Now,  about 1,000 youngsters under age
five die, and more than 50,000 suffer serious injury
each year.

  A number of devices specially designed for
children provide the best protection.   Their use
should begin with a newborn's trip home from the
hospital.  In the absence of the special restraints,
adult seat belts are better than nothing.  Beyond
reducing risk of serious injury or death, use of
restraints may help ensure that children acquire a
lifelong habit of wearing protection.

  Yet--in the face of evidence showing their
effectiveness--a 1974 survey by the   Insurance
Institute for Highway Safety found proper restraints
  use for only seven percent of almost 9,000
iissengers under age 10.

g-19


  Because efforts to convince most people to use
child restraints have not been successful, it is
important that passive protection devices be devel-
oped with children in mind.

An additional action is suggested by the success
that changing school hours to non-rush hours has had
in some European countries in helping to reduce
automobile-related deaths for children.

  The motorcycle helmet has proved to be the most
effective device for protecting riders from death or
serious injury in a collision.  Riders using safety
helmets have less than half as many moderate to
severe head injuries and three to nine times fewer
fatal head injuries.

  Although helmets are worn 90 to 99 percent of
the time in States which require them, they are used
less than 60 percent of the time in States which
have repealed such laws.

  Motorcyclists  often contend that helmet laws
infringe  on personal liberties--and opponents of
mandatory laws argue that since other people usually
are  not  endangered,  the individual motorcyclist
should be allowed personal responsibility for risk.

  But the high costs of disabling and fatal
injuries,  the burdens on families, and the demands
on medical care resources are borne by society as a
whole.  And society has a legitimate concern for
protecting the individual.

  In Colorado, Kansas and South Dakota--states for
which pre-  and post-repeal crash data are avail-
able--head injuries  rose and fatal head injuries
doubled after helmet laws were repealed.

  The interstate highway system has achieved a
halving of death rates compared to all other roads
by eliminating crash-precipitating features such as
sharp  curves,  steep grades,  blind intersections,
uncontrolled access, and lack of physical separation
between opposing traffic lanes.

g-20


  Other measures for preventing death and injury
include removing  fixed objects or shielding such
structures as bridge abutments with energy-absorbing
barriers,  locating essential signs and poles at
sufficient distance from traffic, and designing
guardrails to guide vehicles away from hazards.

  The importance of these measures is underlined
by the fact that almost half of all motor vehicle
deaths involve only one vehicle.

Firearms

  Second only to motor  vehicles as a cause of
fatal injury,  firearms in 1977 claimed some 32,000
lives.  About 13,000 deaths were homicides; 2,000
resulted from firearm accidents; 16,000 people took
their own lives with firearms; the remaining 1,000
deaths were of undetermined cause.   Estimates of
non-fatal firearm injuries--many of them permanently
disabling--range from 18,000 to more than 100,000.

  Although homicides committed with firearms have
recently declined after  a lo-year period during
which the rate doubled, FBI statistics show that in
1976 firearms were used in about 63 percent of
homicides,  almost half of which were committed with
handguns.

  Meanwhile, firearm suicides have risen, increas-
ing by 25 percent between 1970 and 1976, while sui-
cides by other methods increased three percent.

  Measures that could reduce risk of firearm
deaths and injuries  range from encouraging safer
storage and use to a ban on private ownership.

  Evidence from England suggests that prohibiting
possession of handguns would reduce the number of
deaths and injuries, particularly those unrelated to
criminal   assaults.   Both assaults   and   suicide
attempts  are less  likely to be fatal without
firearms-- and firearm accidents would decrease.

9-21


  About 20 percent of American households contain
a handgun.  Even if reducing handgun availability
did not substantially reduce the number of murders
committed during violent crimes,  it would likely
reduce both accidental deaths and murders of passion
involving family members and acquaintances.

  For those who feel compelled to keep handguns,
certain  safety measures  can be useful--security
locks,  use of non-lethal (wax) bullets, and weapon
storage in a location separate from ammunition and
inaccessible to children.

Falls

  Fifteen thousand Americans are killed and about
14 million are injured each year by falls.

  Fatal falls occur primarily in the home but are
also  a prominent cause of work-injury deaths,
especially among construction workers.  People over
age 75 account for about 60 percent of the deaths
resulting from falls and an even greater proportion
of the hospital days and disability.

  Preventing such deaths and injuries requires
preventing the falls themselves by attention to
safer walking surfaces and footgear, better illu-
mination, handrails, and window guards--or reducing
the potential for injury by minimizing the distances
people fall (lower beds for the elderly) or modi-
fying the surfaces they fall against (softer floors,
rounded edges and corners on furniture).

  Substantial reductions in injuries from falls
can be achieved through elementary and inexpensive
changes in housing and furniture design.

Burns

  Each year more  than a million Americans are
burned, 60,000 severely enough to require hospitali-
zation.  About 5,000 deaths result from fires--pre-
dominantly house fires-- and an additional 2,500 are
from other burns such as electrical and scalds.

9-22


  Fifty-six percent of fatal residential fires--
and a  substantial  number  of burn  injuries--are
cigarette-related,  often due to smoking in  bed.
Even in the non-fatal incidents, the consequences
are often tragic:  painful recovery, disfigurement,
and disability.

  Many deaths and injuries from residential fires
could be prevented through a number of measures:
effective fire or  smoke detection  systems;  less
flamnable  furnishings   and  structural  materials;
buildings designed for ease of escape; developing
and practicing fire evacuation procedures; and less
smoking.

  Deaths and injuries from ignited clothing have
been greatly reduced in the past decade, partly
through changes  in fabrics and styles, but the
problem still warrants attention.  Other preventive
measures  are available but seldom used:   matches
that burn with less heat and go out when dropped,
and fabrics whose weave,  finish,  composition or
chemical treatment makes them less likely to ignite,
melt or burn.

  Scalds which cause about 40 percent of hospital
admissions for burns,  often occur in showers and
bathtubs.  They could be prevented if water heaters
in homes, nursing homes, dormitories, and hotels
were  modified with automated cut-offs so water
temperatures remain below those likely to scald.

  A recent study for the Consumer Product Safety
Comnission indicates that this approach, even though
it requires larger  hot water storage facilities,
saves both money and energy.

Poisoning

  Once a leading cause of death for young
children,  poisoning has decreased significantly as
paint lead content has been reduced and drugs and
household products have been packaged in childproof
containers.

9-23


  Of 4,000 fatal poisonings in 1977, less than one
percent  involved children under five.   Even as the
number of children increased between 1968 and 1976,
childhood deaths from poisoning dropped from 284 in
1968 to 105 in 1976.

  Still,  some two million ingestions of poten-
tially dangerous  substances by American children
come to the attention of health professionals every
year.

  Poison Control Centers, now active in a number
of localities, provide immediate information on
poison  antidotes   and  other  emergency   measures.
Helpful precautionary measures include storing toxic
substances separately from food supplies, ensuring
that safety caps are fastened, and refraining from
introducing medicine to children as "candy."

  Currently, treatment of lead poisoning makes use
of chemicals that bind to the metal in the body and
help in its removal.

  But more important  is primary prevention of
potentially lethal lead poisoning by removal of
airborne lead from the environment and rehabili-
tation of old housing with lead-free paint.   Public
health screening of high-risk children is important
to prevention of adverse health effects, since lead
poisoning is usually asymptomatic.

Drug Reactions

  Some 70,000 prescription  drugs (with 2,000
individual ingredients) are now on the market, along
with 200,000 over-the-counter preparations.   Each
year 15 to 20 new chemical entities are introduced.
In 1977, 1.4 billion prescriptions were filled at a
cost of about $8 billion.

  Adverse reactions --ranging  from moderate rashes
or nausea to birth defects or death--can occur with
almost any drug.  For some drugs, reactions are
frequent enough to warrant warning labels.

9-24


  The potential for adverse reactions, coupled
with the volume and frequency of drug use, requires
the Food and Drug Administration to oversee regular
premarket screening and testing for user protection.

Product-Related Accidents

  A broad range of consumer products used at home
or in the workplace can cause injury, either because
of faulty construction or inappropriate and careless
use.

  In 1976, product-related accidents caused about
30,000 deaths and 37 million injuries, according to
Consumer Product Safety Commission estimates.

  Among the leading causes of injuries were glass,
bicycles,  skateboards,  nails,  knives,  playground
equipment, furniture,  and construction and flooring
materials.

  Measures to reduce injuries and deaths can start
with product design and engineering standards--and
the education of those developing the designs and
standards.  They can include improved construction
and packaging; testing and development of protective
devices;  inspection procedures to ensure safety
prior to  marketing or  operation;   and   better
instruction of operators of machinery as well as
more complete and clear information provided for
consumers and users.

  Because unsafe toys, electrical devices, and
home swimming pools injure many chidren, toys with
sharp edges or small and swallowable parts should be
discarded, electrical outlets should be covered, and
swimming pools fenced.

   Increased  protection   for   children  requires
better surveillance of injuries so their causes can
be clearly understood   and  preventive   measures
applied.  It also requires  teaching safe behavior
and providing barriers that separate children from
as many hazards as possible.

9-25


Recreational Accidents

  The population at risk for recreational acci-
dents has grown steadily as the amount of leisure
time available to Americans has increased.

  According to the National Safety Council, acci-
dents other than motor vehicle, work and home acci-
dents caused approximately 21,500 deaths in 1976,
with most  occurring in  recreational or  leisure
settings.

  Disabling injuries  in that year numbered some
2,700,OOO and about 100,000 sports team injuries
were serious enough to require medical attention.
Some 7,000 drownings also occur each year, mostly
during water sports such as swimming and boating.

  Safety measures can help.   Children can be
taught to float and swim at early age and should
learn water safety measures. Adults can avoid water
sports  when  intoxicated (in  almost one-third of
adult drownings,  there are high blood levels of
alcohol).  Young people participating in team sports
can be taught safety measures and ways to prevent
injuries as part of their training.  Better protec-
tive equipment can be developed.  Football helmets,
for example, which caused 12 percent of all injuries
sustained by 9,000 high school players, should be
designed to reduce injuries to other players.

  Modification of surroundings can help in some
cases.  Again,  in football it is estimated that
seven percent of hospitalized players are injured as
the result of striking a fixed obstacle outside the
playing field and that 95 percent of such injuries
could be prevented by establishing an obstacle-free
zone around the playing field.

Much can be done to prevent unnecessary injuries
annually suffered by Americans.

Fluoridation of Community Water Supplies

  With   tooth  decay  affecting  95 percent of
Americans,  it is the most common health problem,

9-26


costing an estimated $2 billion yearly for treat-
ment.  Adverse consequences include pain, infection
and tooth loss.

   Fluoridation is one of the most effective--and
cost-effective--preventive    measures   known. By
making teeth less susceptible to decay through
increasing resistance to the action of bacteria-
produced acid (it may have an antibacterial effect
as well), optimal  level fluoridation of drinking
water can prevent 65 percent of decay that would
otherwise occur.   And it can do so for 10 tc 40
cents per person per year, depending upon the size
of the community.

  Currently,  less than half of Americans have
access to fluoridated water.   About a third are
served by fluoride-deficient community water  sys-
tems.  An additional 35 to 40 million are on indi-
vidual (noncommunal) water systems with undetermined
fluoride content.

  Where community water supplies are not fluori-
dated or where there is no central  source of
drinking water,  as in many rural areas, other means
may be used.  In some localities, school drinking
water is fluoridated--a help in reducing decay but
less  effective  than  community-wide  fluoridation
since it does not reach pre-school children and is
not available to any child when school is not in
session.

  Fluoride mouth rinses are effective but require
regular,  continued use for maximum benefits. In
carefully  controlled   clinical  studies,   fluoride
rinsing has produced 35 percent decay reduction.

  If dietary fluoride  supplements   are  given
conscientiously from birth on a daily basis, the
protection against decay approaches that of water
fluoridation.

  Fluoride applied directly to teeth twice a year
by a dental professional in a school program or
dentist's office also is effective as is daily use
of an appropriately formulated fluoride toothpaste.




                 9-27


  But none of these approaches is as effective or
economical as fluoridated drinking water.

  Part of the delay in fluoridation of community
water supplies stems from concerns of some groups
that it may pose a hazard to health.   But substan-
tial research over the past 35 years has produced no
evidence to support this concern.

  It is important that every community ensure pro-
vision of  fluoridated drinking water for   its
citizens.

Infectious Agent Control

Some 291 million iilnesses from infectious
disease occurred in the United States in 1975--more
than one for every person.  Because of them, each
year at least 156 million work days are lost and the
cost for treatment and lost productivity is esti-
mated at $24 billion annually.

  In a typical year,  the Center for Disease
Control  investigates,   upon  request,  about 1,700
outbreaks of infectious diseases throughout the
country.

  Most of the deaths and illnesses related to
infectious diseases are due to the viral, bacterial
and other microbial agents of influenza, pneumonia,
the comnon cold,  urinary tract infections, gastro-
enteritis, hepatitis, childhood infectious diseases,
sexually transmissible diseases, tuberculosis,  and
hospital-acquired infections.

  There has been substantial success, as noted
earlier,  in minimizing the  infectious diseases as
threats  to life.   In 1977, only influenza and
pneumonia together continued to rank as one of the
10 leading causes of death.

  But new diseases appear and even familiar
diseases may change periodically, making existing
protective measures ineffective.

9-28


  Legionnaires'  disease is an example of a newly
identified infection.  The emergence of strains of
gonococcal bacteria resistant to penicillin, and the
periodic shifts in strains and virulence of influ-
enza viruses,  are examples of changes in familiar
diseases.

  These changes demand close monitoring and sur-
veillance of infectious disease incidence.

  Surveillance--a basic tactic for disease con-
trol--requires four activities.

0   finding cases  of disease or  significant
  exposures through the efforts of physicians
  and other health workers;

o   reporting cases to a responsible health
  authority, generally a public health offi-
  cial--traditionally done by physicians, but
  now also done by schools and industries;

0   analyzing  and  interpreting  the reported
  information to determine its implications;
   and

a   responding appropriately to the interpreted
   information with measures to control the
  source of the problem.

  Examples of response measures include an immuni-
zation campaign  in the face of a polio outbreak,
closing a restaurant found to be serving contami-
nated food,  and providing substitute water supplies
until a polluted source can be purified.

  Today,  about five percent of all  patients
admitted to hospitals acquire an  infection while
there,  incurring an added $1 billion in treatment
charges.  It is anticipated that stronger surveil-
lance and control techniques now available can
reduce incidence of these infections by 20 percent.

  The United States has the most sophisticated
infectious   disease  surveillance  system in   the

9-29


world--and it is possible to target surveillance for
many conditions-- infectious and non-infectious--that
are either preventable or  amenable to effective
intervention.

**********

  In a broad prevention strategy, the concept of
health protection must extend beyond traditional
disease control   measures  to include protection
against environmental and occupational hazards and
reduction of accidental injuries.

  These hazards are threats to all Americans,
regardless of age, health status, or socioeconomic
factors.

  Yet many accidents can be prevented, toxic
agents  can be reduced, occupational  safety and
health programs can be implemented, community water
supplies can be readily fluoridated, and infectious
diseases can be effectively controlled and in some
cases eliminated.

  A commitment to safety and elimination of
hazards--by everyone from government officials to
parents to children-- would  save millions of Ameri-
cans from needless pain and disability.

9-30


  CHAPTER 10
HEALTH PROMOTION

  Medical care begins with the sick and seeks to
keep them alive, make them well, or minimize their
disability.

  Disease prevention begins with a threat to
health--a disease or environmental hazard--and seeks
to protect as many people as possible from the
harmful consequences of that threat.

  Health promotion  begins with people who   are
basically healthy and seeks the development of
community and individual measures which can help
them to develop lifestyles that can maintain and
enhance the state of well-being.

  Clearly,  the three are complementary, and any
effective national health strategy must encompass
and give due emphasis to all of them.

  Beginning in  early childhood and throughout
life,  each of us makes decisions  affecting our
health.  They are made,  for the most part, without
regard to, or contact with, the health care system.
Yet their cumulative impact has a greater effect on
the length and quality of life than all the efforts
of medical care combined.

  Many factors  increasing the risk of premature
death can be reduced without medication.  In fact,
as we have noted,  the striking decline in heart
disease death rates in this country since the
mid-1960s has coincided with reductions in several
risk factors:  cigarette smoking by men, consumption
of high fat products,  average serum cholesterol
levels, and the number of people with untreated high
blood pressure (Figure 10-A).   During the same
period in Europe,  neither personal risk factors nor
heart disease death rates declined.

10-l


FIGURE 10-A

PERCENT DECREASES IN RISK FACTORS
  FOR CORONARY HEART DISEASE*

Risk Factor

Approximate
Percent     Time
Decrease     Period

Cigarette smoking (X who smoke)
Men

26      1964-1975

Women                                   8
Per capita consumption of:
Tobacco                                  22      1963-1975
Fluid milk and cream
Butter              :i
Eggs                                     13
Percent with high cholesterol (260 mg/lOO ml plus):
Men age 45-54                              6     c1962-cl975
Men age 55-64
Women age 45-54            ;z
Women 55-64                               29

Percent hypertensives untreated:
In U.S.                                 10     cl 962-c] 974
In 14 U.S. cities**                         25

*NOTE: Coronary heart disease deaths (to which these risk factors are
    related) declined by 20 percent in the period 1968-1976.
**Part of a special National Heart, Lung, and Blood Institute study
program.

10-2


  Consider, too, the strikingly lower cancer rates
among certain groups of Americans compared to those
for the general population.

  Seventh Day Adventists neither smoke nor drink,
and about half follow a milk, egg and vegetable
diet.  For this group, not only is their cancer
incidence,  for those cancers strongly related to
smoking and drinking,  less than one seventh that of
the general population;  even their cancer incidence
at other sites is  only half to three-fourths as
high.  Similarly, Mormons,  who also abstain from
smoking and alcohol, have lower cancer rates.

  And there are the promising results coming from
recent efforts to organize community resources for
health promotion.

  Notable examples  include the Stanford Heart
Disease Prevention Program and the Multiple Risk
Factor Intervention Trial (MRFIT), both funded by
the National Heart, Lung, and Blood Institute.

  The Stanford program, begun in 1972, has been
monitoring the rates of cigarette smoking,   serum
cholesterol levels, and uncontrolled hypertension in
three Northern California communities.  Two of the
three employed active risk reduction activities,
including messages designed for television, radio,
newspapers  and other media.   In one of these two
communities,   face-to-face  counseling   also   was
provided for a sample of high risk individuals.

  Within a two-year period in the two experimental
communities,  overall heart disease risk fell by
about 25 percent.  In both, there were reductions in
average serum cholesterol and a six percent lowering
of systolic blood pressures.  A substantial reduc-
tion (net decrease of 35 percent) in smoking was
achieved  only  among the high-risk individuals
receiving counseling.  In the community without an
active information program, overall risk for heart
disease actually increased during the first two
years of the study.

10-3


  The Multiple Risk Factor Intervention Trial
program also seeks to change behaviors with respect
to smoking, serum cholesterol, and high blood pres-
sure.  It is a multicenter clinical trial in 22 com-
munities to determine whether, for men at high risk,
concentrated program  based on counseling and
dairected simultaneously toward the three risks will
result in a significant reduction in heart disease
deaths.

  Although final study results will not be avail-
able until 1983, preliminary data are especially
encouraging with respect to the numbers of partici-
pants who have stopped smoking and those whose high
blood pressure is under control.  Moderate choles-
terol reduction also has been achieved.

  Abroad,  promising  results have come from a
program in the province of North Karelia, Finland,
which has the highest documented heart disease rate
in the world.

  In the early 7Os,  more than half of the men in
North Karelia smoked;  they also  had extremely
elevated cholesterol levels and high consumption of
animal   fats   and   dairy   products;   untreated
hypertension was comnon.

  Concerned about their high heart disease rate,
North Karelians developed a massive health promotion
campaign designed  to help the 250,000 province
residents  control  their blood pressure, reduce
cholesterol  intake,   and  stop  smoking.   Efforts
included promotion of low-fat dairy products and
low-fat sausages  by local industries, training of
local residents as health personnel, and extensive
media coverage.

  After five years, there was a 21 percent drop in
cigarette smoking among middle-aged people and a 35
percent decline among young women.  Butter consump-
tion dropped dramatically and 29 percent of the
population was using low-fat milk.   The number of
men  with  high blood pressure declined by 25
percent.  Among women, the decline was 50 percent.

10-4


  And,  significantly,  preliminary results yet to
be confirmed show a drop of 14 percent in heart
attack incidence and a 40 percent drop in the inci-
dence of stroke among North Karelians aged 30 to 64.

  Here at home too, after the University of
Southern California Medical Center ravamped its
diabetic care system--by installing a telephone
hotline for information and advice, making available
counseling by physicians  and nurses,  and issuing
pamphlets  and posters  to promote the service--
emergency room visits per patient were halved and
the   incidence of   diabetic   coma  decreased by
two-thirds.

  Relatively simple community health education
programs, now increasing in number, can indeed make
contributions.

  This chapter deals with five types of behaviors
which affect health and are targets for health
promotion programs:  smoking, alcohol and drug use,
nutrition,  exercise and fitness, and management of
stress.

Smoking Cessation

  Cigarette smoking is clearly the largest single
preventable cause of illness and premature death in
the United States.

  It is associated,  as Section II noted, with
heart and blood vessel diseases; chronic bronchitis
and emphysema;  cancers of lung,  larynx,  pharynx,
oral cavity, esophagus, pancreas, and urinary blad-
der;  and with other ailments ranging from minor
respiratory infections to stomach ulcers.  Smoking
during pregnancy also increases risks of complica-
tions of pregnancy and retardation of fetal growth.

  Cigarette smokers have a 70 percent greater rate
of death from all causes than nonsmokers, and to-
bacco is associated with an estimated 320,000 prema-
ture deaths a year.   Another 10 million Americans
currently suffer from debilitating chronic diseases
caused by smoking.

10-5


  A remarkable aspect of these statistics is that
smoking presumably is voluntary, and theoretically
a77 of this damage is therefore preventable.

  Moreover,  a large portion of a smoker's excess
risk for heart disease disappears within two years
after quitting-- and  within 10 to 15 years an ex-
smoker's chance of early death from a heart attack
is no greater than that of someone who never smoked.
If, in fact, a77 Americans stopped smoking, coronary
deaths could be reduced by approximately 30 percent,
with a saving of more than 200,000 lives a year.
And people who have smoked for many years can reduce
their risk of lung and urinary bladder cancer if
they stop.

Changing Trends

  In 1950, when the Nation first became generally
aware of an association between smoking and lung
cancer, there were about 18,000 lung cancer deaths.
In 1964, the year of the first Surgeon General's
Report on Smoking and Health, there were over 45,000
lung cancer deaths.  An estimated 92,000 deaths from
lung and related respiratory system cancers occurred
in 1977.

  The 1964 Surgeon General's Advisory Committee
Report concluded that cigarette smoking was a cause
of lung cancer  in men  and was associated with
coronary  artery disease,  chronic bronchitis, and
emphysema.   Since then,  cigarette smoking's rela-
tionship to these diseases--and to still others--has
become clearer.  A comprehensive review of the evi-
dence linking smoking with a wide variety of health
problems--with  particular   attention to  special
smoking-related problems for women,  children and
workers --is presented in the 1979 Surgeon General's
Report on Smoking and Health.

  The public's reaction to the risks of smoking
can be measured by changes in cigarette consumption.
In the early 195Os, consumption declined in response
to the first scientific reports.  It rose again,
then dropped when the Surgeon General's Report was

10-6


published in 1964,  then rose a second time but
dropped again between 1968 and 1970 as more tele-
vision advertisements against smoking were aired.

  All in all,  more than 30 million smokers have
quit since the first Surgeon General's Report, and
the proportion of adult smokers has declined from
about 42 percent  in 1965 to a little more than
one-third today.  A large share of the decline is
due to a drop in the proportion of men who smoke,
but the percentage of women who smoke has decreased
negligibly and there has been a doubling of the rate
at which adolescent women (12 to 18 years) smoke.

  Though the recent decline in the proportion of
men who smoke is encouraging, an associated decline
in cancer death rates may not appear for some years
because cancer takes many years to develop. But the
fall-off of heart disease deaths is undoubtedly due
in part to the shift.

  On the other hand,  if the proportion of women
who smoke does  not decrease  and current trends
continue,  experts predict that lung cancer will
surpass breast cancer as the leading cause of cancer
mortality among women by 1983.

  Meanwhile,  approximately  4,000 children   and
adolescents become cigarette smokers each day.
While girls in the 1960s were smoking at about half
the rate of boys, they now smoke as much. More than
20 percent of 12 to 17 year olds and about one-third
of all 18 year olds now are regular smokers.

Approaches to the Problem

  Much more can and must be done to educate the
public about the risks of smoking.

  Although Americans know about the relation be-
tween smoking and lung cancer, surveys show that
they have yet to become aware that smoking-related
cardiovascular diseases claim even more lives.  And
few believe they personally will suffer any harmful
effects.

10-7


  Physicians and dentists could be more helpful.
Surveys show that only two-thirds of doctors and
one-third of dentists routinely inquire about their
patients'  smoking habits.   Only 25 percent of
smokers  say their physicians have told them to
quit.  Most physicians and dentists apparently wait
until a serious smoking-related symptom or ailment
has appeared, yet studies show that if doctors
advise patients not to smoke, as many as 25 percent
will quit or reduce the amount they smoke.

  Most people say they intended to smoke for only
a short time and we77 over half of new smokers
confidently expect to stop within five years.   The
reality, however,  is that once started the smoking
habit is extremely difficult to overcome.  About 90
percent of all current smokers have expressed a
desire to quit.

  To help smokers quit, many clinics, techniques,
and devices have been developed over the past 20
years and different methods have succeeded to some
extent with different individuals.  But reverting
back to smoking is a major problem for many people
and   effective  techniques   are   needed to  help
ex-smokers avoid tobacco.

  Actually, 95 percent of smokers who successfully
quit do so on their own.  And four factors seem to
be of major importance in their success:   health
concerns (including symptoms); a desire to set an
example for others;  a desire for self-control; and
aesthetic reasons such as breath odor and loss of
taste for food.

  These motivations should therefore be stressed
in  anti-smoking  literature,  advertisements,   and
broadcast  announcements, as  well as  in special
information campaigns  directed to such high risk
groups  as pregnant women,  industrial workers in
especially  hazardous  occupational  settings,   and
persons with health problems likely to be worsened
by smoking.

10-8


  Special efforts should be directed to children
and adolescents.   School health education curricula
are   needed to  help a  child make  intelligent
decisions  about smoking-- as well as about other
behavior affecting  health--and to help reinforce
those decisi.ons  against peer pressure  and other
forces that impel them toward serious risk-taking
behavior.

  Effective curricula already in existence need to
be more widely used.   Educational activities must
begin at the earliest possible point in school and
continue  systematically  throughout   the   child's
educational experience.

  The best of these programs emphasize not only
knowledge of the human body but also how it works
and how behavior  affects it.  They also impart
attitudes of persona7 responsibility for protecting
one's own health and means of coping with pressures
and uncertainties.

  Efforts for teenagers must be designed to help
them deal with their own values and attitudes toward
smoking and with their own sense of maturity.  They
should be aimed at helping them develop the ability
to resist group pressures toward smoking and at
reinforcing the concept that, in fact, smokers are
the minority-- not majority--both in their own age
group and among adults.

  One approach,  which makes positive use of the
peer pressures that influence youthful behavior, is
deploying students themselves as health educators.
Such peer instruction programs have shown substan-
tial promise in preliminary trials.

  Some have suggested use of economic sanctions
such as increased taxes to discourage smoking.  This
iS  a complex political   and  economic  issue  not
readily accomplished.   But the effect of price
changes--particularly of   dramatic   changes--on
consumption merits further investigation.


  Development  of lower tar cigarettes has been
urged as a means of reducing hazards.  And smokers
can take a first step toward quitting and hazard
reduction by using low tar and nicotine cigarettes.
They can also reduce hazards by not smoking to the
end of a cigarette,  by taking fewer puffs on each
cigarette,  by reducing inhalation and, gradually,
the number smoked daily.

  While gradual   reduction is  better than no
reduction at all, it should be noted that generally
smokers who quit all at once have better success
than those who try to quit in steps.

  Also,   there is  no known   safe  cigarette--
including the low tar  and nicotine varieties--nor
any safe level of smoking for any type of cigarette.
The smoker who continues to smoke, even in reduced
amounts, still runs a significantly greater risk of
illness and death than the nonsmoker.

  Finally,  the rights of nonsmokers should be
recognized  and  supported.   Measurable levels of
nicotine have been found in the blood and urine of
non-smokers exposed to tobacco smoke.  Such exposure
may present a special health hazard for people with
certain diseases.  Breathing the smoke of others can
lead to unsafe carbon monoxide levels, allergic
reactions,  and exacerbation of conditions such as
asthma   and   bronchitis.   For  infants,   risk of
respiratory infections increases when parents smoke.

  Legislation has been introduced in every state
to restrict smoking in public places.  Steps are
being taken to restrict smoking in government
buildings  and facilities  as well as on  buses,
airplanes, and passenger trains.

  Despite all the difficulties,  efforts to in-
crease the number of nonsmokers should become much
more energetic.  The World Health Organization notes
in a recent report:  "The control of cigarette smok-
ing could do more to improve health and prolong life
in (developed) countries than any other single
action in the whole field of preventive medicine."

10-10


Reducing Misuse of Alcohol and Drugs

  Alcohol and other psychoactive substances exact
a substantial toll of premature death, illness, and
disability in the United States.

Alcohol

  Because of   its   overuse  and general   social
acceptance  throughout American  society,   alcohol
accounts for a significant share of the Nation's
medical care cost burden.

  Alcohol misuse is a factor in more than 10
percent of a77 deaths in the United States--about
200,000 a year.   It is associated with half of a77
traffic deaths, many involving teenagers.   Cir-
rhosis, which ranks among the 10 leading causes of
death,  is largely attributable to alcohol consump-
tion.  Alcohol use is also associated with cancer,
particularly of the liver, esophagus and mouth.
Primary liver cancer  is almost exclusively attri-
buted to alcohol consumption. People who drink and
also smoke cigarettes have even greater increases in
esophageal   cancer  rates.  And excessive drinking
during pregnancy can produce infants with severe
abnormalities, including mental retardation.

  Nor is the death and injury toll only for alco-
holics or problem drinkers. Accidents, in particu-
lar,  often involve the occasional drinker who is
temporarily out of control.

  Per capita consumption of alcohol by Americans
increased during the 1960s--a trend generally attri-
buted to the lowering of the legal drinking age in
many States,  an increase among young people con-
suming alcohol,  and increasing use of alcohol by
women.

  The proportion of heavy drinkers in the popu-
lation grew substantially in the 1960s to reach the
highest recorded level since 1850, though it has
leveled off in recent years.  Drinking is greatest
in the younger years and declines after age 50.

10-11


  Currently,  average consumption of alcohol for
all persons older than 14 is 30 percent higher than
15 years ago-- about 2.6 gallons of ethanol annually,
representing a total of 28 gallons of beer, plus 2.5
gallons of distilled spirits and 2.25 gallons of
wine.

  Ten million adult Americans--seven percent of
those 18 years or older--are estimated to be
alcoholics or problem drinkers.

  Of all adults who drink, more than a third have
been classified as either current or potential
problem drinkers, with women making up one-fourth to
one-third of the latter.  Youthful problem drinkers,
aged 14 to 17 (intoxicated at least once a month)
are estimated to number more than three million,
between 20 and 25 percent of the age group.

  The social and economic burdens associated with
alcohol   are enormous.  Those who abuse drinking
affect not only themselves  but their 40 million
family members as well.   Alcohol abuse and alco-
holism are estimated by the Alcohol, Drug Abuse and
Mental Health Administration to have cost the Nation
nearly $43 billjon in 1975, including health and
medical  costs,   lost  production,   motor   vehicle
accidents,  violent crimes, fire losses, and social
response programs.

Drugs

  Although there is no question that drug misuse
is a major problem,  reliable information on actual
prevalence is hard to obtain. Much depends on self-
reporting and many problems occur among transient
populations likely to be missed in any survey.

  Moreover,  interpretation of surveys is compli-
cated by lack of agreement on what frequency of use
of drugs constitutes abuse.

  Heroin addiction, the most serious drug problem
in the United States,  appears to be declining. In
1978,  there were an  estimated 450,000 addicts,

10-12


compared with an estimated 550,000 in 1975. It
should be noted that the decline parallels demo-
graphic changes in the number of young adults.

  The toll from highly addicting heroin includes
premature death and severe disability, family dis-
ruption,  and crime committed to maintain the habit.
The heroin user is at very high risk of overdose
death, of hepatitis and other  infections from
contaminated equipment and impurities in the drug,
and from chronic undernutrition because money is
spent on heroin instead of food.  Preventing con-
sequences  of overdose and infection in  users is
virtually impossible since there is no control over
the strength and purity of the drug or the means of
administration.

  Central nervous system depressants and stimu-
lants with potential for abuse include many drugs
ordinarily prescribed for their medical value. At
least one million Americans are believed to misuse
barbiturates or other sedative-hypnotic drugs and
30,000 are estimated to be addicted to them.

  Excessive doses of depressants over a long
period can result in both physical and psychological
dependence, with abrupt withdrawal (particularly of
barbiturates) leading to convulsions which may pro-
duce permanent disability or even death. Overdosing
with barbiturates --intentional  and accidential--is a
leading cause of drug overdose fatalities but has
declined somewhat as physicians have changed pre-
scribing practices.   Combinations  of barbiturates
with  depressants,  particularly  alcohol,
increase the chance of death.          greatly

  Cocaine is a stimulant which--despite its high
cost--has become very popular for its propensity to
induce euphoria  and reduce feelings  of fatigue.
Some 10 million Americans have tried cocaine at
least once and one to two million are current users.
Although physical  dependence  does  not develop,
psychological dependence may.   Some deaths due to
toxic reactions to cocaine have been reported.

10-13


  Hallucinogens, which distort perception of real-
ity,  can cause potentially fatal toxic reactions.
And their unpredictable psychic effects may result
in unintentionally dangerous behavior.  One halluci-
nogen,  PCP (phencyclidine hydrochloride), has a
well-deserved street reputation as a "bad" drug, yet
many people use it regularly, and in 1977 it was
associated with at least 100 deaths and more than
4,000 emergency room visits.

  Other illicit drugs-- with less harmful physical
and social consequences-- are in more widespread use.

   There are  some 16 million current marijuana
users.  Among males  20 to 24 who have ever used
marijuana,  perhaps 17 percent are daily users.
Among high school seniors recently surveyed, about
10 percent reported daily use. Of special concern
is the relationship of marijuana to automobile
accidents; especially when used in combination with
alcohol,  and by teenagers and young adults who are
at high risk of accidents.

  One of the dominant concerns about use of mari-
juana and other psychoactive drugs is the reduction
in motivation and performance they may produce when
used  chronically,  particularly  by children and
adolescents.

Prevention Programs

  Helping people to stop or avoid starting misuse
of alcohol or drugs will not be easy--particularly
among population groups in which social and economic
factors are prominent contributors to .abuse of alco-
hol and drugs,  and therefore complicate potential
interventions.

  For the broad range of alcohol and drug pro-
blems, strategies for intervention differ; but there
are some comnon elements.  They include: prevention
through  education that starts early and extends
throughout life; altering the social climate of
acceptability; reducing individual and social stress
factors; and law enforcement.

10-14


  One reason recent alcohol education efforts have
had little success in changing children's behavior
is that their moralistic nature has not always
matched parental behavior or the favorable image
afforded alcohol use in television advertising and
programming.  Such dichotomy creates confusion in
young minds.

  Similarly, efforts to educate young people about
drug abuse dangers have met with skepticism--and, in
fact, on occasion, the excitement and drama employed
to discourage a drug's use have created an incentive
to try the drug.

  Educational strategies directed against drugs
themselves appear to be less effective than those
built around the concept of individual responsi-
bility for the daily decisions that can affect
health.

  Young people who gain an understanding of how
body systems work and how their personal choices
affect their well-being are better prepared to make
wise choices about alcohol and drug use.   For this
reason,  comprehensive   school   health   education
programs directed toward strengthening children's
decision-making capabilities may hold particular
promise.

  Moreover,   because   peer   pressure, as   noted
earlier, has profound influence on youth behavior,
educational programs that build on peer group coun-
seling are more  likely to be successful.   School
systems,  youth-related organizations such as the
Boys Club of America, Catholic Youth Organizations,
4-H and   the  scouts,   and  churches  and  other
community-based organizations can help develop such
programs.

  These programs serve many purposes.  They open
communication channels between adolescents and the
health community;  they teach young people tangible
skills and give  them important information, thus
increasing their sense of self-worth; they also
provide needed community services.

10-15


  Our society needs to find more socially con-
structive outlets for the interests and energies of
children and adolescents.   While urbanization and
farm mechanization have moved rapidly, alternative
activities for the work once required have not been
adequately developed.  Challenging work for young
people is important for more than economic reasons;
it helps build self-respect and a better outlook for
the future.

  The media can be important in creating a social
climate that encourages  sound health-related per-
sonal decisions.  In recent years, television has
reduced its emphasis on the social acceptability of
smoking--only, ironically, to have lighting a ciga-
rette replaced in part by pouring a drink as a typi-
cal stage routine.

  Labeling policies for alcohol and prescription
drugs may provide an important means for conveying
information which will help users to avoid harmful
affects.  Product labels may be especially useful
for informing expectant mothers of the potential
effects of ingested substances on the fetus.

  Help and support  must be offered to those
already  suffering   from   misuse  problems.    For
alcohol-related   problems,   Alcoholics  Anonymous,
similar organizations  for families of alcoholics,
and workplace-based programs may be successful.

  Health professionals need to play a more active
role.  A physician who diagnoses cirrhosis has no
difficulty in recorrmending against alcohol use but
may miss earlier opportunities to make the recom-
mendation when the advice could make a difference.

  Physicians  and pharmacists   can  also be very
important in reducing availability of legal drugs
which may be abused.  Physicians need to exercise
more caution when prescribing psychoactive drugs,
and pharmacists should check with physicians when in
doubt about prescriptions.

lo-16


  Finally,  legislation  and law enforcement can
help.  The experience of some jurisdictions indi-
cates that social practices may be substantially
modified through vigorous enforcement of laws such
as those against driving while intoxicated, and
careful study of the efficacy of such measures is
warranted.

Improved Nutrition

  Although evidence keeps mounting that certain
food factors and current dietary habits may be
linked with health problems as diverse as heart
disease,  tooth decay, obesity and some types of
cancer,  consumers often find it difficult to make
informed choices about food.

  Most know that good nutrition can make a sub-
stantial contribution to health and development of
infants and children and that healthy eating pat-
terns should be firmly established in adolescents
and young adults.  Most also are aware that good
nutrition  is particularly  important for pregnant
women and the elderly.

  But food choices are influenced by many complex
factors and the consumer is often bombarded with an
overload of somewhat confusing--and even conflict-
ing-- information from books,  newspapers,  magazine
articles, and advertising.

  Most diet deficiency diseases prevalent early in

the century are now rarely seen.   But iron defi-
ciency in children and women of childbearing age
remains a public health concern.

  And although  less than one percent of the
American people can be considered undernourished in
the traditional sense,  data from the first Health
and Nutrition Examination Survey by the National
Center for Health Statistics show a trend toward low
calorie intake among certain adults over age 45, and
particularly among women over 60.   If the trend
continues, it is possible that some diet deficiency
diseases may reappear.

10-17


  Nevertheless,  today's  nutrition problems are
still more likely to be associated with eating too
much and with imbalance in the kinds of foods eaten
than from eating too little.

The Obesity Problem

  Thirty-five percent of women between ages 45 and
64 with incomes below poverty level and 29 percent
of those with incomes above are considered obese,
according to the National Center for Health Statis-
tics.  The comparable figures for men are five and
13 percent.

  Obesity is clearly related to diabetes, gall-
bladder disease, and high blood pressure.   In asso-
ciation with other risk factors, it can contribute
significantly to heart disease.   In addition to the
physiological problems, obesity may have serious
social consequences for the young person growing up
in a society which prizes slimness  and athletic
ability.

  A genetic component may be involved in some
obesity.  But the social environment of the family--
eating and exercise habits and a tendency to view
food as a "reward" --is of great importance.  And, as
noted in Chapter 4,  obese children are three times
more likely to be obese adults than children who are
not overweight.

  There is no quick,  easy solution to obesity.
Among adults,  it has proved very difficult to re-
verse on a lasting basis.

  Permanent weight loss  has been found somewhat
easier to achieve by people who inventory their food
intake,  avoid situations that would entice them to
overeat,  and gradually change their eating  and
exercise habits.  Many nutritionally sound diets are
available for weight control, but people should be
extremely skeptical about fad diets promising rapid,
painless weight reduction.

lo-18


  Obesity is not the only nutrition-related health
problem.   Cardiovascular disease and cancer are
other public  health concerns that may be diet-
related.

Nutrition and Cardiovascular Disease

  A good case can be made for the role of high
intake of cholesterol and saturated fat, usually of
animal origin,  in producing high blood cholesterol
levels which are associated with atherosclerosis and
cardiovascular diseases.

  Animal studies have shown that reducing serum
cholesterol can slow down the atherosclerotic dis-
ease process.

  And,  in man,  studies have shown:  people in
countries where diets are low in saturated fats and
cholesterol have lower average serum cholesterol
levels and fewer heart attacks; that Americans who
habitually eat less fat-rich diets (vegetarians and
Seventh-Day Adventists, for example) have less heart
disease    than    other   Americans;    and    that
atherosclerotic plaques in certain arteries may be
reversed by cholesterol-lowering diets.

  The weight of the evidence, therefore, now sug-
gests that Americans who have been consuming high
fat diets should attempt to reduce serum cholesterol
by  changing  eating  patterns.   Moreover,   these
changes should begin at an early age.  Not only
adults but children in countries with low coronary
heart disease rates have much lower serum choles-
terol levels than many of our children have.

  Many issues still need to be resolved.  Among
the most interesting are those concerned with high
and low density lipoproteins (see Chapter 6). While
it appears that a higher ratio of high-density to
low-density lipoproteins carries a lower risk for
heart disease,  the effect of diet upon the ratio
still is under study.

10-19


  Some investigations indicate that the ratio is
favorably influenced by lean body weight, regular
vigorous exercise, smoking avoidance, consumption of
small amounts of alcohol, and a diet with relatively
more vegetables,  fish and white meats than red
meats.   But further research is needed before
definite statements can  be made about diet and
lipoproteins.

  High dietary salt intake may produce high blood
pressure,  particularly in  susceptible  people.
Unequivocally, studies  in genetically predisposed
animals show a cause-effect relationship between
high   salt  intake  and  elevated blood pressure.
Studies in man also suggest such a relationship and
show,  too,   that when  hypertension is  present
controlling salt intake can help combat it.

  A prudent approach,  given present knowledge,
would be to limit salt consumption by cooking with
only small  amounts,  refraining from adding salt
to food at the table,  and avoiding salty prepared
foods.  Careful label reading will reveal whether
salt or a sodium compound has been added to a
packaged food.

Diet and Cancer

  The association between diet and cancer is more
tenuous than between diet and heart disease.

   Because  populations   with   different  dietary
patterns have differing cancer rates--and emigrants
assuming the patterns of their adopted country soon
also assume new cancer rates--there has been much
research into the possible diet-cancer association.

  Studies in human populations have suggested a
number of possibilities:  that high consumption of
animal protein may be linked to colon cancer; that
low consumption of fiber from plant sources may also
be linked to colon cancer; and that high consumption
of fats.  both saturated and unsaturated, may be
                          hormone-related
                            All of these
                          ion.

1 inked
cancers
possibi

*to colon cancer  and to
of the ovary and prostate.
lities need further investigat

lo- 20


Healthy Nutrition

  Individual   nutritional  requirement  variations
make exact dietary standards impossible to estab-
lish.  Variations also occur in the same person at
different  times--during   pregnancy,   with  aging,
during acute or chronic illness, or with changes in
physical activity.

  But given what is already known or strongly sus-
pected  about the relationship between diet and
disease, Americans would probably be healthier, as a
whole, if they consumed:

0   only sufficient calories to meet body needs
   and   maintain   desirable  weight (fewer
  calories if overweight);

0   less saturated fat and cholesterol;

0   less salt;

0   less sugar;

0   relatively more complex carbohydrates such
    as   whole  grains,  cereals,   fruits   and
  vegetables; and

0   relatively  more fish,  poultry,  legumes
b,t" - 9 beans, peas, peanuts), and less red
         .

  Adequate, balanced nutrition can be obtained by
eating-- in quantities sufficient to maintain desir-
able weight--a wide  variety of foods  each day,
including  meat or  meat  alternates,  fruits  and
vegetables,  cereal  and bread-type products, and
dairy products.

  The processing of our food also makes a
difference.  The American food supply has changed so
that more than half of our diet now consists of
processed foods   rather  than fresh  agricultural
produce.  Because of this change, we need more
complete nutrient composition data about our food

10-21


supply, particularly as related to some of the newer
essential   "trace  minerals"   such as  molybdenum,
manganese, chromium, and selenium.

  The quantities of these trace minerals have not
previously been a  nutritional   concern   because
practically everybody consumed a variety of fresh or
minimally processed foods.   Increased  attention
therefore also needs to be paid to the nutritional
qualities of processed food.

Better Nutrition Education

  Food choices are determined in part by the
nutritional knowledge of the person who buys or
prepares the food.   Other factors include avail-
ability, personal and family likes and dislikes, and
marketing and advertising practices.   These factors
should be addressed in educational initiatives to
promote good food habits.

  Until now, nutrition education has provided
information rather than instruction in the skills
that can be used to improve dietary habits.

  Such skills should be taught in formal and
informal nutrition education programs for people of
all ages.  And these programs should consider what
too often has also been neglected in the past:  the
differences in food preferences found in different
cultural groups.

  Teachers,  in particular,  need to receive train-
ing in nutrition;  and nutrition should be an inte-
gral part of the school curriculum.

  More can also be done in medical care settings.
Although  education   about  nutritional   intake is
essential and often provided for patients suffering
with health problems  such as diabetes or kidney
disease, it is uneven in quality.

  And although pediatricians, obstetricians and
other health workers often include some form of
nutrition  education as  part of their care of

10-22


infants, mothers, and pregnant women, rarely do they
take advantage of this opportunity to build nutri-
tional knowledge and positive attitudes for future
decision-making.

  Training in nutrition for physicians and other
health professionals should have high priority, and
nutrition training and services should be promoted
in hospitals and clinics.

  Sound nutrition information should also involve
the media.  Food advertising,  particularly on tele-
vision,  has a powerful influence on food choices.
Many foods are promoted for their convenience and
ease of preparation or for their taste, rather than
for nutritional value.  Convenience and good taste
are important considerations, but a balanced presen-
tation should also consider nutritional value.

  Results in the Stanford Heart Disease Prevention
Program suggest  that structured campaigns  using
multiple media sources can positively affect food
selections to reduce, for example, consumption of
products high in cholesterol or salt.

  Education efforts must be augmented by direct
food assistance to segments of the population find-
ing it difficult to meet basic nutritional needs.

  Certain older adults--for example, those with
chronic diseases, acute illnesses, or particular
genetic or lifestyle patterns--absorb nutrients less
efficiently.  But the primary problem for many of
the elderly and other  age groups is poverty and
fixed incomes.

  A number  of Federal food distribution and
supplemental food programs have been established to
provide poor people with better diets.  Among them
are the nutrition services programs  (including
congregate and home-delivered meals), the Food Stamp
Program,  and the Special Supplemental Food Program
for Women, Infants, and Children administered by the
Department of Agriculture.  Measures are needed to

lo-23


strengthen these programs and to assist people in
using them.

Exercise and Fitness

  For more than a generation, American living has
become increasingly sedentary. Most of us drive or
ride to work and most other places.  Work itself,
for much of the labor force, involves relatively
little, if any, vigorous physical activity.  Even in
recreation, people commonly have tended to be spec-
tators, not participants. The relative lack of phy-
sical activity has led to a decline in physical
fitness among youth and adults alike.

  Within the past half dozen years or so, however,
there has been a promising resurgence of interest in
physical exercise and fitness.  A 1977 Gallup Poll
found nearly half of American adults saying that
they exercise regularly to keep fit. Millions par-
ticipate in tennis, bicycling, swinnning, calisthen-
ics  and other forms  of exercise.  Running, in
particular,  has become a very popular pastime even
though it is in reality confined to a relatively
small,  and highly visible,  portion of the popula-
tion. (According to the National Center for Health
Statistics, five percent of Americans over age 20,
and 10 percent of men aged 20 to 44 run.)

Health Effects

  Physical fitness  activities affect health in
many ways.

  People who exercise regularly report that they
feel better,  have more energy,  often require less
sleep.  Regular exercisers often lose excess weight
as well as improve muscular  strength and flexi-
bility.  Many also experience psychological benefits
including   enhanced  self-esteem,  greater   self-
reliance,  decreased anxiety,  and relief from mild
depression.

  Moreover, many adopt a more healthy lifestyle--
abandoning  smoking,  excessive drinking,  and poor
nutritional habits.

lo-24


  Sustained exercise improves the efficiency of
the heart and increases the amount of oxygen the
body can process in a given period of time.
Compared to non-exercisers, people who engage in
regular physical activity have one and a half to two
times   lower   risk of  developing   cardiovascular
disease, and an even lower risk of sudden death.

  While not yet definitively proven, the role of
exercise in preventing heart disease is attractive
and plausible.  An example of the growing evidence
supporting the association between exercise and
reduced cardiovascular risk comes from a study of
17,000 Harvard alumni.  The physically active among
them had significantly fewer heart attacks than the
more sedentary.  Those who expended less than 500
calories a week in exercise developed heart disease
at about twice the rate of those expending 2,000 or
more calories a week (approximately 100 calories are
used for each mile run or walked).   Regular,
vigorous exercise was found to reduce risk of heart
disease independently of other risk factors such as
cigarette smoking or high blood pressure.

  The kind of physical  activity probably most
beneficial to the cardiovascular system is sometimes
called aerobic--exercise requiring large amounts of
oxygen for energy production.   Examples include
brisk walking, climbing stairs, running, cross-
country skiing, and swimming.

  An average of 15 minutes or more of aerobic
exercise is thought to produce beneficial effects
which are further increased when the exercise is
done vigorously.

  A reasonable goal for any individual ought to be
15 to 30 minutes of exercise at least three times a
week.  A beginner should start slowly and people
over 40 should be examined by a physician first.

  Non-aerobic activities,  such as weight training
and calisthenics,  are useful for enhancing muscle
tone, strength and flexibility.  But they are often
intermittent and less vigorous, and therefore may be

lo-25


less effective in reducing risk for cardiovascular
disease.

  The risk may be reduced by regular, sustained
exercise in several ways.  Such activity may cause
the blood pressure of a hypertensive individual to
fall an average of 10 points and may also lower
serum  cholesterol   while  raising the  level of
desirable high-density lipoproteins.   It can also
get rid of excess weight.  Walking or running a mile
daily--or swimming one-quarter mile--can lead to a
reduction of more than 10 pounds in a year.

  Aerobic exercise, when carefully prescribed, has
been found useful for patients with chest pain
:tt:cks
an ina pectoris) and those recovering from heart
     enabling them to  increase the amount of
activit; they can perform free of chest pain.

  Such exercise has also been shown to be useful
in treatment of other diseases.   Asthmatics and
people with chronic obstructive lung disease often
can improve their respiratory capacity.   Diabetics
can lower their blood sugar levels and insulin
requirements,  and overweight adults who have become
diabetic often are freed of any indications of the
disease when they achieve normal weight through
exercise and diet.

Gaps and Needs

  Despite a doubling of the percentage of those
who exercise,  most participants do not exercise
often or vigorously enough to achieve maximum health
benefits.

  Participation rates are higher among whites than
minorities;  among males than females; among younger
than older persons; among the more educated than the
less educated;  among professionals than blue-collar
workers;  among the affluent than the poor; and among
suburbanites than city dwellers.

  For children and adolescents, too often exercise
involves an emphasis on team sports in which much of

lo-26


the time a player is inactive, and which are rarely
engaged in later in life.  More valuable would be
properly conducted physical education programs that
could help promote  lifetime habits of vigorous
exercise as well as contribute to child growth and
development.

  Most older people do not exercise regularly.
Yet suitable exercise programs can help them in many
ways:  by reversing the replacement of muscle by fat
associated  with  inactivity;  maintaining a  good
posture and muscular strength required for efficient
movement in  daily  activities;  improving  joint
mobility for the better balance skills needed for
safety; and stimulating cardiorespiratory endurance.

  Some people who exercise began on their own or
because they were  influenced by a friend.   Other
motivating   influences   include  school,  employee
health   fitness   programs,   health  professionals,
media, and government programs.

  In the early 196Os,  responding to the emphasis
by President John F. Kennedy through his Council on
Youth Fitness, many schools undertook more extensive
fitness programs  and a number of States began to
require daily physical education for school children.

  But since the late 196Os, many school physical
education programs have had to cut back for lack of
adequate State and local funding.  Many States today
have only limited requirements for physical educa-
tion and no requirements at all for some grade
levels.   It has become even more important for
parents to see that their children are exercising
adequately.

  During the past few years, an increasing number
of employee fitness programs have been developed in
business   and  government.    Some  companies   have
full-time fitness directors in charge of programs.
In the most successful activities, participation
rates range up to 40 percent, with benefits accruing
to management as well as to workers who, feeling
better, often may work better.

lo-27


  Health professionals have largely ignored active
promotion of suitable exercise for their patients.
A recent survey found 80 percent of patients not
remembering that their physicians had ever recom-
mended exercise.  When exercise was recommended, it
was  usually of  nonvigorous  nature with limited
value.   More   interest   and  concern by  health
professionals  could do much to get more people
exercising.

On a national level, government involvement has
largely been through the President's Council on Phy-
sical Fitness and Sports.  Since 1956, the Council
has provided impressive leadership in drawing atten-
tion to the importance of exercise and fitness. It
has assisted in development of employee health pro-
grams, public information programs, and special pro-
jects designed to increase participation in fitness
and sports activities.

  But what is needed is a substantial national
effort involving  all levels of both public  and
private sectors.

Stress Control

  Stress is normal, inevitable; a part of life.
It is experienced in family relationships, school,
work,  traffic, shopping, financial and other prob-
lems.  And everyone develops means of coping--more
or less effectively.

  Some means of coping are beneficial--as, for
example, when the response is an effort to improve
performance.

  But there are destructive responses such as
excessive alcohol use, resorting to drugs, violence,
reckless behavior, depression, and other forms of
mental illness.

  There are indications that stress can be related
to cardiovascular disease and deaths, gastrointes-
tinal disorders,  and other diseases and physical
health problems as well as much mental illness.

lo-28


  Studies have indicated that stress in the home,
for  example,   can  increase a  child's   risk of
streptococcal  throat infection--and an expectant
mother's risk of pregnancy complications.

  One revealing  study assessed pregnant women,
married,  of similar age, race, and social status,
all of whose babies  were delivered in the same
hospital.  The finding:  those women undergoing a
great deal of social stress and lacking strong
social supports-- measured by closeness of ties with
husband, family, and community--had almost three
times the frequency of complications of pregnancy or
delivery.

  People   under   stress   experience   measurable
changes in body functions:  a rise in blood pressure
and secretion of adrenaline and other hormones at
higher levels.  The changes are basically defensive,
mobilizing body energies to meet a threat.

   But when  stress --or an individual's reaction to
it --is  excessive,  physiologic changes can be so
dramatic as to have serious physical and emotional
consequences.

Reducing the Harmful Consequences of Stress

  Two strategies are needed to minimize destruc-
tive stress consequences:  preventing or reducing
stress itself and improving individual stress-coping
skills.

  Opportunities for stress prevention exist in the
work setting.  Many jobs are dull, boring, or dan-
gerous.  Many people work under unpleasant circum-
stances--noise, polluted air, cramped quarters.  The
fear of losing one's job is an important source of
stress.

  Many of these factors, as noted earlier, can be
eliminated or reduced.  The work environment can be
improved.  Job assignments  can be better tailored
to individual   interests   and  capabilities.   Such

10-29


improvements may pay dividends in increased produc-
tivity and decreased absenteeism and job turnover
rates as well as reduced stress for the individual
workers.

  In the community setting, stress for individuals
and groups often can be reduced through helping
networks, neighborhoods, and community organizations.

  The recent report of the President's Commission

on Mental Health noted the significance of support
systems in fostering a sense of security and as an
effective treatment measure for people suffering
problems associated with both physical and mental
health.

  There is extensive evidence of the importance of
a sense of neighborhood or belonging for people and
of the meaningful roles in people's lives played by
neighborhood institutions such as churches, schools,
ethnic  clubs,  fraternal  organizations,  community
organizations, and others.

  In a pluralistic society, people meet needs and
solve problems in varied ways.  And a neighborhood-
based  approach--with  community  support  systems
designed to address diverse individual needs--can be
critical to individual well-being.

  Strengthening neighborhood networks can help
people in many ways:  to gain a sense of control
over their lives;  reduce alienation from society;
improve capacity to solve new problems; and maintain
the  motivation to   overcome  handicaps or   the
frustrations comnon in modern society.

  With adequate day care programs, for example,
stressful  pressures on working mothers can be
reduced.   The stressful consequences of unwanted
teenage pregnancy and motherhood can be substan-
tially reduced by programs that enable the young
women to complete their educations and qualify for
satisfactory employment.

10-30


  Racial and ethnic tensions can be eased through
comunity action to improve cooperation and under-
standing.  Young people at highest risk of becoming
school dropouts can be identified and programs can
be designed  to anticipate and help meet their
needs.  Elderly people  in need of support after
retirement or loss of a spouse can be identified and
helped through community services.

  Efforts to improve coping skills must begin with
an understanding of the events most difficult to
handle emotionally.

  Extensive research in this area has generally
confirmed folk wisdom.  The death of a spouse, the
serious illness of a child, the loss of a job,
family disruption and divorce, and other catas-
trophic changes over which the individual has little
or no control, are the stresses most likely to cause
psychosomatic disorders or other emotional problems,
and their consequences.

  Since stressful events are not always prevent-
able,  preparation for dealing with them needs to
begin early.  Emphasis should be given to building
coping skills in children and young people.   Too
often,  stress has been addressed only after the
problem  is fully developed--by treatment of the
alcoholic,  the drug abuser,  the acutely depressed
person,  and by penalties for criminal  offenders.
Much more attention should be given to preparing
people to deal in  less destructive ways with
unavoidable stresses.

  To help young people and adults deal with
critical   stresses as  they  arise, a  number of
self-help and mutual support activities have been
developed in communities across the country. Many
evolved from the crisis intervention centers of the
late 1960s.  They deal with a wide range of stress-
generated or  stress-related problems:  alcoholism,
pregnancy, divorce, suicide attempts, rape, terminal
illness,  death of a child, death of a spouse, and
many others.

10-31


  There are in addition self-help, mutual aid
groups for the handicapped; drug abusers; parents of
handicapped children;  parents who abuse their chil-
dren; young people in search of jobs and identity;
widows; old people; patients who have heart attacks,
colostomies or  mastectomies;  gamblers;  smokers;
drinkers;  overeaters;  and many more.  These groups
constitute a significant community resource.

  Although the group programs may vary in effec-
tiveness,  their rapid spread indicates they may be
responding to social needs not completely filled by
families, churches, schools, or health and mental
health professionals.

  Helping to prevent  suicide is a particularly
important task.

  Health professionals who see people at high
risk--and the families and friends of such people--
may be able to assist by carefully assessing their
emotional status and providing, or referring them
to, appropriate help.

  Guns, alcohol, barbiturates and other drugs with
lethal potential are used in a large proportion of
suicide attempts.  Their availability and use could
be controlled more effectively.

  Suicide also can be prevented by indirect means.
Notably,  in England,  when the carbon monoxide con-
tent of gas piped to homes was reduced, suicides as
well as accidental deaths dropped sharply.   And
while what had been the most common means of com-
mitting suicide was virtually eliminated, there was
no compensating increase in suicide by other means.

  A vital part of community strategy to reduce
harmful stress consequences is to assure that people
know about available services--and that services are
truly accessible in terms of location and hours of
operation.  This applies to hotlines and sources of
professional  counseling as well as self-help and
other supportive services.

10-32


  For this,  local media,  telephone directories,
churches,  civic organizations,  and other outreach
channels can be used.

  And there must be an effort to have services
offered in ways that assure that no stiga attaches
to their use.

  Not least of all,  there should be educational
efforts by health professionals, schools, and all
community groups  and services to underscore the
importance of the family as a potential resource for
individuals trying  to cope with stressful situa-
tions.  How families develop communications between
parents and children,  offer support to a troubled
member,  and care for needs  and views of family
elders can either trigger or intensify stress on the
one hand, or, on the other, help significantly to
ameliorate it.

  To be sure,  stress is inevitable with living.
But excessively stressful factors in the environment
can be assessed; many can be reduced or removed; and
families and educational, social service, and other
support programs can help people cope effectively
with those that remain.

  Exactly how much can  be achieved by strong,
multi-faceted community programs to deal with stress
is difficult to predict.   But certainly it is
important to test the extent to which such programs
can reduce the individually and socially devastating
effects of failure to cope adequately:  homicides,
suicides,  substance  abuse,  accidental deaths and
injuries,  and disease.

  Even relatively minor  reductions would amply
repay the investment.

**********

  Collectively, smoking, misuse of alcohol and
other drugs,  poor dietary habits, lack of regular
exercise,  and stress place enormous burdens on the
health and well-being of many Americans today.

10-33


  Identifying and implementing ways to help people
adopt more healthful habits will require a large
commitment from government, schools, media, health
professionals, and business and industry.

  It will be necessary, too, to work to reduce
pressures in our society which often lead people to
adopt unhealthy habits.

  Although helping people to understand the need
for and to act to change detrimental lifestyles
cannot be easy,  the dramatic potential benefits
clearly make the effort worthwhile.

10-34


SECTION IV - CHALLENGE TO THE NATION


    CHAPTER 11
CHALLENGE TO THE NATION

   Americans  are becoming healthier people--but
more can be achieved.

  This report has described and documented the
potential for better health at each stage of life.
It has set forth specific goals to be attained over
the next decade,  and a full agenda of possible
actions to be taken.

  To reach these goals will require a national
effort and the commitment of people extending far
beyond what we traditionally consider the health
sector.  No single segment of society can accomplish
them alone. Unnecessary death and disability can be
prevented--and better health can be maintained--only
through  a partnership that involves the serious
commitment of individual citizens,the communities in
which they live,  the employers for whom they work,
voluntary agencies, and health professionals.

  Government agencies at all levels must encourage

and bolster their efforts.

  How to move expeditiously toward the goals of
prevention is the challenge for the years to come.

The Obstacles

  Expectations for programs in disease prevention
and health promotion must be geared to realities.
Social factors,  personal attitudes, economics, and
the knowledge base all are potential restraints to
progress.

  Socioeconomic factors.   The critical influence
of adequate income, housing, diet, education, and
healthful workplaces in shaping the health of our
people deserves continuing and serious attention.

11-1


Without adequate resources to solve problems in
these areas,  the health of vulnerable population
groups is at risk.

  The Director General of the World Health Organi-
zation has said that economic development and health
are   indivisible.    This   holds   true   for   the
disadvantaged in our population.

  Fundamental social and economic improvement is
essential to better health for Americans.

  Personal attitudes.   Formidable obstacles also
exist on other fronts.  Prominent among them are
individual attitudes toward the changes necessary
for better health.   Though  opinion polls  note
greater   interest  in healthier  lifestyles, many
people remain apathetic and unmotivated.

  Illness is often still viewed as a matter of
random chance, not to be averted but to be tolerated
and accepted.

  Some consider activities to promote health
moralistic rather than scientific; still others are
wary of measures which they feel may infringe on
personal liberties.

  However,  the scientific basis for suggested
measures has grown so compelling, it is likely that
such biases will begin to shift.

  Economics.  Resistance may also be expected from
certain industries.  The threat of economic loss due
to decreased use of a product, or to requirements
for sometimes costly measures to protect workers and
the public,  can lead to vigorous opposition to
efforts to promote health or prevent disease and
disability.

Knowledge.  The knowledge base for prevention
activities IS growing dramatically, but there is
still a need to learn more.   Better measures are
needed to:  further identify causes of diseases;
detect and test potential hazards; provide people

11-2


with  information  which will  motivate  them  and
provide them with the skills to control behaviors
they are trying to change.

  More accurate techniques must be developed with
which to estimate program costs and measure program
effectiveness.

Opportunities for Action

  We cannot afford to wait for perfect solutions
before beginning to act.  Many specific measures are
available   and   must be   taken to   facilitate
opportunities for better health.

  Appendix I summarizes the measures which can be
taken to enhance our prospects for better health at
the major life stages.  Responsibility for facili-
tating these actions falls to people at many levels.

  Individuals.  Each of us has a tremendously
important role,  as noted throughout this report.
Personal lifestyles are responsible for a large
share of unnecessary disease and disability in the
United States.

  People decide day by day and hour by hour what
foods to eat, how much to consume, whether or not to
smoke a cigarette  or take a drink of alcohol.
Greater or lesser amounts of physical activity are
chosen.  Various ways  of coping with stress are
developed.

  Important decisions  are also made about what
services to seek, what conditions to be screened for.

  People can determine not only what services to
use,  but the nature of those services as well.
Individual participation in comnunity decisions can
affect the availability of health services,  the
quality of the environment, and other issues with
health implications.

  Each of these decisions influences the length of
people's lives and their capacity to enjoy it.

11-3


  Families.   An individual's  responsibility ex-
tends to others as a parent, a marriage partner, and
a neighbor.  One person's choice in health behavior
can affect the choices of others.

  The role as exemplar and guide is particularly
critical for the parent who is shaping the health
practices of another generation.   Parents can en-
hance the opportunities for their children's health
by fostering healthy personal habits, by ensuring
availability and use of appropriate childhood health
services,  by participating in sound and enjoyable
recreational  activities,  and by encouraging the
development of effective  health curricula in the
school systems.

  Health professionals.  Physicians, nurses, and
other health professionals have a particular oppor-
tunity and obligation  to provide information and
services  necessary to promote better health and
prevent disease.

  People continue to note that they would be more
likely to try to change their behaviors if their
physicians strongly recommended such changes.   Yet
health professionals  often find themselves too
pressed by duties related to diagnosis and treatment
to capture the opportunity they have to influence
the behavior,  and therefore the health, of their
patients.

  These professionals need to be trained to view
themselves as educators and models, as well as
practitioners of a particular discipline.

  Health institutions.  Hospitals and other health
institutions, likewise,  need not only be concerned
with the sick.

  Some  hospitals   are   now  actively  providing
preventive services and organizing community health
promotion efforts.  Some Health Maintenance Organi-
zations,  structured with incentives to keep their
members healthy,  have also helped expand preventive
services.

11-4


  Other incentives to good health can be provided
by insurance companies through offering preferential
rates on life and health insurance to groups engaged
in health promotion programs at the worksite.

  Schools.   More than 40 million children and
youth spend most of their day in school.  No group
is   more  able  than  school   teachers  to provide
information  and instruction that can help young
people make decisions that promote good health.

  Comprehensive school health education activities
can:  enhance a child's skills and personal deci-
sion-making;  promote understanding of the concepts
of health and the causes of disease;  and foster
knowledge about the ways in which one's health is
affected by personal decisions related to smoking,
alcohol and drug use, diet, exercise,  and sexual
activity.

  Business and labor.  Business leaders, working
with their labor counterparts,  can make substantial
contributions to   health  through   programs   and
services  provided   for  employees,   and  through
responsible manufacturing and marketing practices
which embrace health concerns.

  The worksite may provide an appropriate setting
for health promotion as well as health protection
activities.   A number  of companies  have already
shown  leadership in providing employee fitness
programs and encouraging worker participation, but
more can be done.

  Furthermore,  business practices in advertising
products may play a key role in influencing consumer
behavior.

  To date, the net effect in many areas of adver-
tising--particularly for food products, over-the-
counter drugs, tobacco,  and alcohol--has generally
not been supportive of health promotion objectives.
But, as some companies are now recognizing, in an
increasingly   health   conscious   climate   health
promotion can result in excellent corporate public

11-5


relations,  as well as save money, through programs
to improve the health of their own employees.

  Communities.  Most communities have substantial
resources,  sometimes  unrecognized,  for prevention
and health promotion.

  Included in these resources are the networks of
voluntary agencies, media broadcasters,  and civic
and religious programs.  All can provide a variety
of useful services and help to create a climate of
interest in better health.

  Certainly   the  voluntary  organizations   have
played the major role to date in drawing people's
attention to important health issues.

  Public forums provided by media sources, such as
television, radio, newspapers, and magazines, and by
commercial enterprises such as grocery and depart-
ment stores, can also be used creatively to facili-
tate the deployment of health promotion and disease
prevention measures.

  Government.  The American system for delivering
health care services is pluralistic, and government
at all levels--Federal, State, and local--operates
direct care services for many beneficiary groups.

  Federal and State governments have other impor-
tant responsibilities in disease prevention  and
health promotion:  to provide leadership in setting
priorities and goals for prevention activities; to
help expand the knowledge base through research and
data collection; to assure that preventive services
are provided to high risk groups on a priority
basis;  to determine and enforce health and safety
standards protecting people; and, if necessary, to
provide economic incentives to encourage health and
safety.

  Federal facilities provide care to veterans,
American Indians, the armed forces, merchant seamen,
and others.  State and local governments operate
systems serving the mentally ill, the disadvantaged,

11-6


and other groups.  Through grants and contracts,
government helps to support health care delivered
through a   still  greater  variety of  agencies.
Finally, through such programs as Medicare and
Medicaid, government helps pay the bills for health
care delivered in virtually every facility in the
United States.

  All provide potential means to deliver preven-
tive services.

  The importance of local governmental units to
successful prevention programs is unquestioned.  The
past successes of prevention and public health have
been predominantly community based.

  Local sanitation measures, purification of com-
munity  water  supplies,  surveillance  and mainte-
nance of epidemics have all been community matters.
More  recently,   fluoridation of  community  water
supplies   has   been  the greatest single measure
promoting dental health, though many conunities
lack its benefits.

  Local government,  assisted and supported by its
State and Federal counterparts, can establish and
enforce   important   regulations--rodent   control,
housing  codes  which   address   such  problems as
lead-based paint,  air and water pollution control,
and laws requiring immunization as a prerequisite to
attending school.

**********

  The diversity  of participants  in prevention
activities is both necessary and desirable.   What
has been lacking up to now, however, has been a
mechanism for coordinating these various efforts and
bringing focus and direction to new ones to fill
gaps.

  Responsibility for  implementing the newer ap-
proaches to health promotion and disease prevention
has for the most part rested everywhere, and thus
nowhere.

11-7


  However, opportunities may be emerging to link
and coordinate the resources available at various
levels.   Many governors,  county  officials,   and
mayors are in the process of developing mechanisms
to meet new needs in prevention.

  Furthermore,  the 205 newly-created health sys-
tems  agencies  and State health planning bodies
provide a potential means of fostering the actions
outlined in this report to respond to the needs and
characteristics of their respective populations.

  What is most apparent is that the effort must be
truly a collective one.   While the measures are
readily within our capabilities, their realization
will require diligence, determination, and coopera-
tion.

  If the commitment is made at every level, we
ought to attain the goals established in this re-
Port,  and Americans who might otherwise have suf-
fered disease and disability will instead be healthy
people.

11-8


APPENDIXES


         APPENDIX I
MEASURES FOR BETTER HEALTH--A SUMMARY

  Throughout this report a number of specific
measures have been identified as important to im-
proving the health of individuals.   Summarized in
this Appendix are the principal recommendations for
healthier infants, children, adolescents and young
adults, adults and older adults.

  In most cases,  issues which span several age
groups are discussed for the age group at greatest
risk for the problem addressed.  However, for those
issues in which the nature of the problem varies by
life stage (e.g., nutrition), the recommendation is
repeated with a different emphasis for each age
group.

HEALTHY INFANTS

  Education for parenthood.  People who are well
informed about the care reauired by infants can bet-
ter plan and prepare for' parenthood.  Prospective
parents can seek education for parenthood classes
through physicians, hospitals, and community organi-
zations.  Schools can offer preparation for parent-
hood to children and teenagers.

  Genetic counseling.   Prospective parents who
havewily disorders such as Down
syndrome,  Tay-Sachs disease,  sickle cell anemia,
hemophilia,  muscular dystrophy, or serious mental
disorders should seek special counseling.   Health
professionals can provide this information to their
patients and make appropriate referrals for genetic
services.

  Prenatal care.  Good prenatal care is essential
for a healthy pregnancy.   Medical care, dietary
assistance  and counseling is  important for all
expectant mothers.  Mothers with social and economic

AI-1


barriers to such care can be targeted by outreach
and follow-up programs.

  Prenatal nutrition.  Pregnant women have extra
needs for iron, protein, calcium, and calories and
may need to be -provided with dietary suggestions
and/or supplements.  Nutritional guidance and ser-
vices are available from health professionals and
service agencies.

  Prenatal maternal habits.  To reduce the poten-
tial for adverse effects on the developing fetus,
women should avoid tobacco and alcohol during preg-
nancy.  Counseling and appropriate services can help
expectant mothers who wish to avoid these risks.
Similarly,  physicians should avoid prescribing use
of medications and exposure to radiation by pregnant
women, unless warranted by special circumstances.

  Amniocentesis.  A test (amniocentesis) sampling
the intrauterine fluid at about the 16th week of
pregnancy can determine whether certain serious
birth defects exist in the fetus. Expectant mothers
at higher risk include those who:  are 35 and over;
have a history of multiple spontaneous abortions; or
have a family history of Dam syndrome, neural tube
defects,  inherited metabolic disorders, multiple
birth defects,  or sex linked inherited disorders.
Detection of an abnormality may require a personal
decision about an abortion.

plet~refa..;m f$edinc#.   Breast milk is the most com-
           in ant nutrition and is recommended
for full-term newborn babies, unless there are
specific problems or breast feeding is unsuccessful.
If a nursing mother is healthy and well nourished,
fluoride and possibly Vitamin D may be the only
supplements needed by the baby.   After about four
months iron may also have to be added.  Solid foods
should not be introduced hastily into the baby's
diet--rather they should be phased in gradually.

  Pediatric care.   Regular,  comprehensive pedi-
atric care can help assure the early detection of
preventable   problems,   and  provide   preventive

AI-Z


services such as immunizations (see below).   In ad-
dition to a detailed examination after birth, every
baby should be examined before leaving the hospital
or within 10 days of birth, and again at approxi-
mately two, four, six, and nine months of age.

   Immunizations.   Childhood diseases that can be
prevented by vaccinations continue to be a threat to
infant health.  Babies should be immunized for diph-
theria,  pertussis, tetanus,  and polio at ages two
months, four months, and six months (polio immuni-
zation is optional at six months). They should also
receive  the recormiended  childhood  immunizations
thereafter.

  Social services.  Some families require special
support services to enhance the healthy growth and
development of their children.   Such services in-
clude high quality day care, improved foster care
and adoption programs,  as well as services to assist
families in which a parent may suffer from chronic
disabling disease, mental illness, alcoholism, or
drug abuse.

HEALTHY CHILDREN

  Early childhood development. A stimulating and
healthy environment during the early part of life
can  enhance a  child's growth  and development.
Programs such as Head Start, which provide compre-
hensive services for children, including day care,
health care, nutrition,  education and counseling,
have produced important gains in child development,
particularly for families with low incomes.

  Special support services.  Special sources of
support should be available through community agen-
cies and health care providers to assist children
and families under particular stress.   Foster care
programs and practices should be designed to in-
crease the opportunities for children to grow up in
a stable and healthy environment.

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  Injury reduction.   Accidents  are the single
greatest threat to children's health.  People can
reduce children's risk of injury and death by:

0   having the child secured in an approved
  child carrier, safety harness or seat belt
  when riding in an automobile;

0   storing toxic agents out of reach, away
  from food,  and in special containers with
  fastened safety caps;

@   ensuring against access to knives and guns;

0   carefully  supervising young  children at
  play, particularly when they are near water
  or streets;

e   instructing the child what to do in situa-
   tions of  special  risk (e.g., stoves,
  matches, electrical sockets, traffic).

  Pediatric care.  Some childhood problems can be
prevented or ameliorated through the provision of
certain medical sevices.  Examples of such services
include:  identification and treatment of vision and
hearing problems; assessment of developmental skills
important to learning;  immunizations (see below);
and early diagnosis  and treatment of childhood
infections.   Children should, therefore, receive
routine pediatric evaluations at least every two to
three years.

  Immunizations.  Children should be immunized for
diphtheria, pertussis, tetanus, and polio at ages
two months, four months, six months, 18 months, and
four to six years (polio immunization is optional at
six months),  and for measles, mumps, and rubella at
age 15 months.

  Nutrition   and   exercise.   Acquiring  healthy
eatinq and exercise habits in childhood may have
lifelong benefits.  An appropriate balance of food
intake and physical activity promotes normal weight.
Excessive intake of salt, sugar, and fats should be

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avoided.  Parents and schools can emphasize these
points  through  instruction,  meal  planning,   and
physical  education programs emphasizing lifelong
exercise activities.  Nutrition supplements can be
provided to children in high risk families.

habits.
  Healthy       Preparing young children for
peer group pressures with regard to smoking, alcohol
use, drug use, and sexual activity can enhance their
ability to   deal   with   those   pressures   later.
Parents, schools,  and health professionals are all
important to the provision of comprehensive health
education which can help children to acquire skills
to   cope  with  problems  they will   confront as
teenagers.

  Fluoridation.   The most effective and efficient
way to prevent tooth decay is through fluoridation
of- community water supplies.  If the water supply is
not fluoridated, alternative fluoride sources can be
provided through school-based fluoride mouth rinse
or tablet programs,  fluoride rinsing services from
dentists, fluoride tablets for home use.

  Dental care.  Children should be taught proper
tooth brushing and flossing techniques at early
ages,  and should begin regular visits to a dentist
by age three.  Sweets in the diet should be limited
to prevent tooth decay.

HEALTHY ADOLESCENTS AND YOUNG ADULTS

  Roadway safety.   Autombile accidents are the
leading cause of death among young people. A
substantial number of injuries and deaths could be
avoided through careful,  defensive driving habits.
Especially important are avoiding driving after
drinking (or riding  with a driver who has been
drinking) or use of mood-altering drugs; obeying
traffic laws; and using seat belts or, for cyclists,
helmets.   These  efforts   can  be reinforced by
Federal, State,  and local measures to set and
enforce safety regulations and lower speed limits,
and to improve roadway and vehicular design.

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  Smoking, alcohol, and drug use.  Experimental
behavior by young people can lead to dependence or
misuse of certain substances.   Collective measures
can be taken by parents, teachers, health profes-
sionals,  and community organizations  to provide
adolescents and young adults with information and
skills  necessary to help  them avoid cigarette
smoking or harmful use of alcohol or drugs.

  Nutrition and exercise.  Changes in values and
social pressures may encourage adolescents to eat
snack foods that do not contain adequate supplies of
essential nutrients.  Yet,  good eating habits and
regular,  vigorous exercise are important to still
growing  adolescents.  During their growth spurt,
teenagers need more calories, and particularly more
protein, calcium, and iron.

  Family planning.   Unwanted  pregnancy is a
distressing problem for adolescent and young adult
women in this country.  Families, schools, health
professionals,  and social organizations can ensure
that information about birth control measures is
provided to young people of both sexes, and that
family planning services  are easily accessible to
those who are sexually active.  Services (including
continued schooling) can also be made available in
the community for young women who become pregnant
and are in need of care and advice.

  Sexually   transmissible   diseases.   Sexually
transmissible diseases that affect large numbers of
young people are preventable.  Families, schools,
health professionals  and social organizations can
help provide information, confidential counseling,
and   treatment  to prevent   the  transmission of
venereal diseases.  Periodic screening for disease
which may not be symptomatic can be obtained from
private  physicians   and  community  clinics,   and
encouraged for sexually active young people.  Clinic
personnel,   sex  educators,   and  family planning
services counselors can stress the value of condoms
in reducing the spread of disease and can emphasize
the importance of informing partners immediately if
disease is discovered.

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  Wnunization.  Young people should receive a
booster immunization for diphtheria and tetanus at
age 15.

  Mental health.  Young people frequently experi-
ence  periods of  frustration,  uncertainty,   and
confusion,  and should be encouraged to talk over
problems with people with whom they can be open.
Alert and sensitive friends, family members, clergy,
or counselors at school or work can be helpful
during periods of stress, anxiety, depression or
uncertainty.  Hotlines may also be helpful. Mental
health professionals may be needed if conditions
persist.

   Firearms.  Handguns are involved in a substan-
tial number of homicides, suicides and accidental
deaths in this country.  Actions at the individual,
community,  and governmental   levels  can provide
measures to reduce the availability of handguns.

HEALTHY ADULTS

=I?-  Cigarette smoking is the principal
preventa e cause of chronic disease and death in
this country.   Public education efforts at the
Federal, State, and local levels, as well as health
professionals, can provide information about the
health hazards of smoking and suggestions on how to
stop.  Those who cannot quit on their own may
benefit from one of the organized smoking cessation
clinics.  Those who are unable or unwilling to stop
ought to smoke brands low in tar and nicotine, to
inhale less,  to smoke their cigarettes only half
way,  and to reduce gradually the number of ciga-
rettes smoked.

  Alcohol.  Misuse of alcohol leads to accidental
injumily disruption, and chronic disease for
millions of Americans.  It is important that people
realize   the  dangers--particularly   for  pregnant
women--when alcohol is used excessively.   Indivi-
duals  (or their families)  with  alcohol-related
problems may find effective assistance from health
professionals, the clergy, community groups such as

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Alcoholics Anonymous, or programs run by various
businesses to   assist  employees   with  drinking
problems.

  Nutrition.   Good nutrition is an essential
component of good health.   People  should adopt
prudent dietary habits, consuming:

o   only sufficient calories to meet body needs
  (f ewer  calories  if the person is   over-
  weight);

0   less saturated fat and cholesterol;

0   less salt;

o   less sugar;


0   relatively more complex carbohydrates, such
    as  whole  grains,  cereals,   fruits   and
  vegetables; and
0   relatively   more  fish,  poultry,  legumes
         beans, peanuts), and less red

Employers,  food advertisers, grocery stores, and
health and social service agencies can add to the
promotion of healthy nutritional habits by providing
the information and access to foods necessary to a
good diet.

  Exercise.  Regular exercise can bring physical
and  psychological   benefits.   Adults  should be
encouraged to exercise vigorously--if possible, at
least three times a week for about 15 to 30 minutes
each time.  Caution should, however, be taken to
initiate activity gradually, and anyone over 40, or
with a health problem of any kind, should consult a
physician  before beginning a vigorous exercise
program.  The importance of regular and sustained
exercise for adults should be stressed in public
information programs  and by health professionals.
Communities  and employers   can  encourage fitness-
related programs,  including,  where practical, the
provision of  facilities or  pathways to   make

AI-8


bicycling, running,  and other exercise safer and
more convenient.

  Environmental health.   Toxic  agents in   our
environment can present health hazards which may not
be detected for years.  Private and public actions
at all levels are important to protect against pos-
sible environmental hazards.  Individuals can sup-
port the monitoring of industrial and agricultural
production processes to reduce exposure to poten-
tially toxic agents.

  Worksite health and safety.  The occupational
setting is important both as a source of potential
health hazards and a site for health promotion
activities.  Health programs  at the worksite can
provide information and protection related to all
potential workplace hazards for employees, including
stress,  as well as offer activities and services to
promote healthier lifestyles.  People should both
encourage these programs and take advantage of them.

millii;nP~r~sion.. High blood pressure affects
       Americans and is a major contributor to
heart disease and stroke.   Adults should have a
screening exam for high blood pressure at least
every five years,  and every two to three years if
over age 40.  If hypertension is discovered, and
medication prescribed,  it is important that people
follow their therapeutic regimens carefully.

to iF-=  The Pap smear is an important tool
  etect cervical cancer at early stages.   Women
should have three Pap smears taken one year apart
beginning at age 20, or at the beginning of sexual
activity.  Thereafter, a Pap smear should be taken
every three years to age 35, then every five years
to age 60, then every three years.  Screening fre-
quency should be increased if any abnormalities are
found, or if a woman is taking oral contraceptives
or estrogen therapy.

  Breast examination.   Self-examination is the
most effective way to detect breast cancer at an
early treatable stage.   Women should examine their

AI-9


own breasts monthly, after the menstrual period, for
early signs of cancer (lumps, abnormal discharge,
irregular  size).   Post-menopausal   women   should
select a specific day of the month for such self-
examination.  Health professionals and public health
education programs can provide information and
instruction on breast self-examination, and increase
their efforts to disseminate this important informa-
tion.  Periodic screening by mamnography is not
needed until after age 50, except for women who have
already had cancer in one breast, and after 40 for
women with a family history of breast cancer.

  Cancer signs.  Some cancers present signs at
early stages  in which the chances for successful
treatment are greater.  People should watch for
early signs of cancer and consult a physician if any
are noticed.  In addition to the signs for breast
cancer noted above,  other cancer signs  include:
changes in bowel or bladder habits; a sore that does
not heal; unusual bleeding or discharge; difficulty
swallowing;  change in a wart or mole; or nagging
cough or hoarseness (American Cancer Society's seven
cancer signs).

  Mental health.  Many people suffer from various
forms of emotional disorders or mental illness. It
is quite comnon for people to become, at one time or
another,  uncotnnonly  anxious,  depressed, or have
difficulty coping with a life event.   Professional
assistance may be helpful if particular difficulty
is encountered and may be available through health
professionals, employers, local media, community
organizations,  hospitals, telephone hotlines, and
other outreach organizations.

  Dental care.  People frequently lose their teeth
prematurely because of poor dental and gum care.
Adults should take care of their teeth with daily
brushing   and  flossing   and an   annual   dental
examination.

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HEALTHY OLDER ADULTS

  Work and social activity.  Employment and/or
volunteer  opportunities   are  important for older
people accustomed to working. Maintaining an active
social life is also important to their good health.
Older people should remain active socially, avoid
isolation, and maintain ties with family members and
friends.  Community health and social organizations
can facilitate group activities for older people,
when possible, in corrfnunity centers.

  Exercise.  Regular physical activity for older
adults   can  provide  physical   and  psychological
benefits,  as well as help maintain flexibility and
balance important to preventing falls. Older adults
should therefore engage in exercise, such as daily
walks, regularly.

  Nutrition.  Older people have certain special
dietary  needs.   Regular,   nutritious  meals   are
important and particular care should be taken to
include vegetables, sources of iron, calcium, and
fiber, and use more fish, poultry, and legumes than
red meat as sources of protein in the diet.

  Preventive services.  Some problems associated
with aging can be detected and corrected at early
stages.  Older adults should have health check-ups
at least every two years until age 75, and every
year thereafter.  The following should be performed
each time:  blood pressure check (with follow-up and
treatment,  if warranted),  hearing and vision exam,
breast exam for women, urinalysis, and hematocrit
(measurement of red blood cells).  At less frequent
intervals women should have Pap smears,  and all
should have stool examined for blood.  When pos-
sible, these and other preventive services such as
foot care,  dental care and dietary guidance should
be provided at a single location.

  Medication.  Older people frequently receive too
much medication.  Often, fewer kinds of medications
and lower dosages will suffice.  Patients should ask
their physicians to regularly review the medications

AI-11


they are taking.  They should also request that
medication be prescribed by its generic name,
whenever feasible.

   Immunization.  Every year, many older adults die
or are incapacitated unnecessarily due to influenza
or pneumonia.  Older people can consult their physi-
cians about immunization against these diseases.

acci$!%$%$Sy Falls are the leading cause of
           and death among older adults.
People and agencies responsible for housing for the
elderly can provide such home safety measures as
ample lighting, sturdy railings and steps, non-slip
floor surfaces,  and fire protection and detection
measures.

  Services to maintain independence.   For those
whose activity 'IS limited, often relatively minor
services  can help older people maintain their
independence.  People should encourage programs and
services to help avoid unnecessary institutionali-
zation.  Examples include programs for:   safe and
affordable housing; dietary assistance through group
meals and home meals;  communications and transpor-
tation services; recreation and education opportuni-
ties;  in-house services such as homemaker, visiting
nurse and home health aides care; reading aids; and
access  to advice and services from appropriate
health professionals.

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       APPENDIX II
SOURCES OF ADDITIONAL INFORMATION

  Additional information about various health pro-
motion and disease prevention activities is avail-
able from a number of sources.   This section lists
representative sources of information,  grouped by
the 15 activity areas  introduced in Section III.
Both government  agencies and private,  non-proifit
groups are listed.  These agencies and organizations
comprise  only  a portion  of the total possible
sources.  Many other qualified sourcs of such infor-
mation  exist,  including State and local health
agencies which generally provide a comprehensive
repository of consumer-oriented health information.
Most groups listed offer free or low cost litera-
ture.  The Surgeon General does not necessarily en-
dorse the statements or viewpoints of the organi-
zations listed.

PREVENTIVE HEALTH SERVICES

Family Planning

a   National Clearinghouse for Family Planning
   Information

6110 Executive Blvd., Suite 250
Rockville, Maryland 29852
(301) 881-9400

0   Planned Parenthood Federation of America,
   Inc.

810 Seventh Avenue
New York, New York 10019
(212) 541-7800

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0   National Family Planning and Reproductive
  Health Association, Inc.

Suite 350
425 Thirteenth Street, N.W.
Washington, D.C. 20004
(202) 783-1560

0  American College of Obstetricians and
  Gynecologists

Resource Center
Suite 2700
1 East Wacker Drive
Chicago, Illinois 60601
(312) 222-1600

Pregnancy and Infant Care

0   Office of Maternal and Child Health

     Program Services Branch
     Bureau of Comnunity Health Services
      Health Services Administration
     Room 7A20, Parklawn
      5600 Fishers Lane
     Rockvillc, Maryland 20857
     (301) 443-4273

0   National Foundation -- March of Dimes

     Public Health Education Department
      1275 Mamaroneck Avenue
     White Plains, New York 10605
     (914) 428-7100, ext. 298

0   American College of Obstetricians and
  Gynecologists

Resource Center
Suite 2700
1 East Wacker Drive
Chicago, Illinois 60601
(312) 222-1600

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0   American Academy of Pediatrics

      1801 Hinman Avenue
     Evanston, Illinois 60204
     (312) 869-4255

Immunizations

0   Center for Disease Control

Bureau of State Services
Technical Information Services
Center for Disease Control
Atlanta, Georgia 30333
(404) 452-4021

@   National Institute of Child Health and
  Human Development

Office of Research Reporting
Room 2A34, Building 31
National Institutes of Health
Bethesda, Maryland 20205
(301) 496-5133

Sexually Transmissible Diseases

0   Center for Disease Control

      Bureau of State Services
      Technical Information Services
      Center for Disease Control
     Atlanta, Georgia 30333
     (404) 452-4021

a   American Social Health Association

      260 Sheridan Avenue
     Palo Alto, California 94306
     (415) 321-5134

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o   National Operation Venus

      1213 Clover Street
    Philadelphia, Pennsylvania 19107
     (800) 523-1885

High Blood Pressure and Heart Disease

0   National High Blood Pressure Information
   Center

Suite 1300
7910 Woodmont Avenue
Bethesda, Maryland 20014
(301) 652-7700

0   National Heart, Lung, and Blood Institute

     Public Inquiries Office
     Room 4A21, Building 31
     National Institutes of Health
     Bethesda, Maryland 20205
     (301) 496-4236

0   American Heart Association

      7320 Greenville Avenue
     Dallas, Texas 75231
     (214) 750-5300
     (or local chapters)

0   Consumer Information Center

      Consumer Information Center
     Pueblo, Colorado 81009
     (303) 544-5277, ext. 370

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HEALTH PROTECTION

Toxic Agent Control

0   Center for Disease Control

     Chronic Diseases Division
     Bureau of Epidemiology
     Building 1, Room 5127
      Center for Disease Control
     Atlanta, Georgia 30333
     (404) 329-3165

0   Environmental Protection Agency

      Office of Public Awareness
     Environmental Protection Agency
     401 M Street, S.W.
      Mail Code: A-107
     Washington, D.C. 20460
     (202) 755-0700

0   National Institutes of Health

     National Institute of Environmental
        Health Sciences
      Post Office Box 12233
     Research Triangle Park,
       North Carolina 27709
     (919) 541-3345

0   American Lung Association

     1740 Broadway
     New York, New York 10019
     (212) 245-8000
     (or local chapter)

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Occupational Safety and Health

0   Occupational Safety and Health
  Admlnlstratlon

Office of Public and Consumer Affairs
U.S. Department of Labor (Room N3637)
200 Constitution Avenue, N.W.
Washington, D.C. 20210
(202) 523-8151

o   Clearinghouse for Occupational Safety
   and Health

National Institute for Occupational
Safety and Health
Center for Disease Control
Robert A. Taft Laboratory
4676 Columbia Parkway
Cincinnati, Ohio 45226
(513) 684-8326

a   National Safety Council

     444 North Michigan Avenue
     Chicago, Illinois 60611
     (312) 527-4800

0   American Industrial Hygiene Association

     475 Wolf Ledges Parkway
      Akron, Ohio 44311
     (216) 762-7294

0   American Occupational Medical Association

Suite 2240
150 North Wacker Drive
Chicago, Illinois 60606
(312) 782-2166

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Accidental Injury Control

0   Consumer Product Safety Commission

      Consumer Education and Awareness
        Division
      5401 Westbard Avenue
     Washington, D.C. 20207
     (202) 492-6576
     (or local Poison Control Centers)

0   Department of Transportation

     General Services Division (NAD-42)
     National Highway Traffic Safety
        Administration
     Department of Transportation
     400 Seventh Street, S.W. (Room 4423)
     Washington, D.C. 20590
     (202) 426-0874
       ATTN:  E. Kitts

0   National Safety Council

     444 North Michigan Avenue
     Chicago, Illinois 60611
     (312) 527-4800

0   American Red Cross

     National Headquarters
      18th and E Streets, N.W.
     Washington, D.C. 20006
     (202) 857-3555

Community Water Supply Fluoridation

a   Center for Disease Control

     Dental Disease Prevention Activity
      (E107)
      Center for Disease Control
     Atlanta, Georgia 30333
     (404) 262-6631

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0   National Institute of Dental Research

     Public Inquiries Office
     Room 2C34, Building 31
      National Institutes of Health
     Bethesda, Maryland 20205
     (301) 496-4261

0   American Dental Association

       Bureau of Health Education
        and Audiovisual Services
      American Dental Association
     211 East Chicago Avenue
     Chicago, Illinois 60611
     (312) 440-2593

Infectious Agent Control

0   Center for Disease Control

Public Inquiries
Management Analysis and Service Office
Building 4, Room B2
Center for Disease Control
Atlanta, Georgia 30333
(404) 329-3534

0   National Institute of Allergy and
   Infectious Diseases

Office of Research Reporting
and Public Response
Room 7A32, Building 31
National Institutes of Health
Bethesda, Maryland 20205
(301) 496-5717

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HEALTH PROMOTION

Smoking Cessation

o  Technical Information Center for Smoking
   and Health

Office on Smoking and Health
Department of Health, Education, and

Welfare (Room 1-16, Park Building)
5600 Fishers Lane
Rockville, Maryland 20857
(301) 443-1690

0  Office of Cancer Communications

      National Cancer Institute
     Room lOA18, Building 31
      National Institutes of Health
     Bethesda, Maryland 20205
     (301) 496-5583

0   American Cancer Society

     Public Information Department
      777 Third Avenue
     New York, New York 10017
     (212) 371-2900, ext. 254
     (or local chapter)

0   American Lung Association

     1740 Broadway
     New York, New York 10019
     (212) 245-8000
     (or local chapter)

0   American Heart Association

7320 Greenville Avenue
Dallas, Texas 75231
(214) 750-5300
(or local chapter)

AII-9


Reducing Misuse of Alcohol and Drugs

0   National Clearinghouse on Alcohol
   Information

Post Office Box 2345
Rockville, Maryland 20852
(301) 468-2600

0   National Clearinghouse on Drug Abuse
   Information

Room lOA53, Parklawn Building
5600 Fishers Lane
Rockville, Maryland 20857
(301) 443-6500

m   National Council on Alcoholism

       733 Third Avenue
     New York, New York 10017
     (212) 986-4433

m   Alcoholics Anonymous

     General Services Office (6th Floor)
      468 Park Avenue South
     New York, New York 10016
     (212) 686-1100
       ATTN:  Public Information Department

Improved Nutrition

m   Food and Drug Administration

Office of Consumer Communications
(HFG-10)
Food and Drug Administration
Room 15832, Parklawn Building
5600 Fishers Lane
Rockville, Maryland 20857
(301) 443-3170

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U.S. Department of Agriculture

Human Nutrition Center - SEA
Room 421A
U.S. Department of Agriculture
Washington, D.C. 20250
(202) 447-7854

Consumer Information Center

Consumer Information Center
Pueblo, Colorado 81009
(303) 544-5277, ext. 370

Nutrition Foundation

Suite 300
888 Seventeenth Street, N.W.
Washington, D.C. 20006
(202) 872-0778

National Nutrition Education Clearinghouse

Suite 1110
2140 Shattuck Avenue
Berkeley, California 94704
(415) 548-1363

Exercise and Fitness

0   President's Council on Physical Fitness and
  Sports

Department of Health, Education
and Welfare (Room 3030 Donohoe)
400 Sixth Street, S.W.
Washington, D.C. 20201
(202) 755-7947

0   American Alliance for Health, Physical
  Education, Recreation, and Dance

Promotions Unit
1201 Sixteenth Street, N.W.
Washington, D.C. 20036
(202) 833-5534

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a   American College of Sports Medicine

      1440 Monroe Street
     Madison, Wisconsin 53706
     (608) 262-3632

Stress Control

0  National Clearinghouse for Mental Health
   Information

National Institute of Mental Health
Room llA21, Parklawn Building
5600 Fishers Lane
Rockville, Maryland 20857
(301) 443-4515

0   Mental Health Association

      1800 North Kent Street
    Arlington, Virginia 22209
     (or local chapters)
     (703) 528-6405

0   Public Affairs Committee, Inc.

Room 1101

381 Park Avenue South
New York, New York 10016
(212) 683-4331

0   Blue Cross and Blue Shield Associations

      Public Relations Office
      840 North Lake Shore Drive
    Chicago, Illinois 60611
     (312) 440-5955

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GENERAL INFORMATION SOURCES

Public Health Service

0   Bureau of Health Education

     Building 14
      Center for Disease Control
     Atlanta, Georgia 30333
     (404) 329-3111

0   Office of Health Information and Health
  Promotion

Office of the Surgeon General
Department of Health, Education,

and Welfare (Room 7218 HHH)
200 Independence Avenue, S.W.
Washington, D.C.
(202) 472-5370

National Organizations

0   National Association of Community
  Health Centers, Inc.

Suite 420
1625 Eye Street, N.W.
Washington, D.C. 20006
(202) 833-9280

0   National Center for Health Education

     211 Sutter Street (4th Floor)
     San Francisco, California 94108
     (415) 781-6144

State and Local Levels


   o   Contact your family physician


   0   Contact your local health department

0   Contact your county's cooperative
   extension service

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ACKNOWLEDGEMENTS

Preparation of this report was coordinated by the
U.S. Public Health Service's Office of Disease Pre-
vention and Health Promotion, directed by J. Michael
McGinnis, M.D.,  Deputy Assistant Secretary for
Health.  Contributions were made by a wide variety
of agencies and individuals, listed below.  Special
acknowledgement should be given to the Institute of
Medicine of the National Academy of Sciences, which
developed a series of scientific background papers
for the report,  as well as to the Center for Disease
Control   and   the   National   Center   for   Health
Statistics,  which contributed substantially to the
development of the data and tables contained in the
report.

Participating Agencies.   The  following   Federal
agencies contributed to preparation and review of
the report:

Public Health Service (HEW)

Alcohol, Drug Abuse, and Mental Health
Administration

Gerald Klerman, M.D., Administrator

Center for Disease Control
William H. Foege, M.D., Director

Food and Drug Administration
Donald Kennedy, Ph.D., Commissioner

Health Resources Administration
Henry A. Foley, Ph.D., Administrator

Health Services Administration
George I. Lythcott, M.D., Administrator

AIII-1


National Center for Health Statistics
Dorothy P. Rice, Director

National Institutes of Health
Donald S. Fredrickson, M.D., Director

Office of Health Planning and Evaluation
James Mongan, M.D., Deputy Assistant
Secretary for Health

Office of Population Affairs
Irvin M. Cushner, M.D., Deputy Assistant
Secretary for Health

Office of Public Affairs
Michael F. White, Director

Office of Research, Statistics and Technology
Ruth S. Hanft, Deputy Assistant Secretary
for Health

Office on Smoking and Health
John M. Pinney, Director

Department of Agriculture

M. Rupert Cutler, Ph.D.
Assistant Secretary for Conservation,
Research and Education

Carol Tucker Foreman
Assistant Secretary for Food and Consumer
Services

Department of Labor

Eula Bingham, Ph.D.
Assistant Secretary for Occupational Safety
and Health

Department of Transportation

Joan Claybrook, Administrator
National Highway Traffic Safety
Administration

AIII-2


Department of the Treasury

Richard J. Davis
Assistant Secretary for Enforcement and
Operations

Consumer Product Safety Commission

Susan B. King, Chairman

Environmental Protection Agency

Douglas M. Costle, Administrator

Contributors.  The following individuals contributed
materials to the development of the manuscript:

Irwin L. Auerbach, Program Analyst,
Environmental Protection Agency

Norman W. Axnick, Director, Office of Program
Planning and Evaluation, Center for Disease
Control, U.S. Public Health Service

Clement Barbaza, Printing and Reproduction
Management Branch Chief, Office of Management,
Office of the Assistant Secretary for Health,
U.S. Public Health Service (production
assistance)

Katharine Bauer, Senior Advisor, Office of
Health Information, Health Promotion and
Physical Fitness and Sports Medicine, U.S.
Public Health Service

Alexander Cohen, Ph.D., Chief, Behavioral and
Motivational Factors Branch, Division of
Biomedical and Behavioral Science, National
Institute for Occupational Safety and Health,
Center for Disease Control, U.S. Public Health
Service

AIII-3


Ralph Cosham, Editorial Consultant, Office of
Health Information, Health Promotion and
Physical Fitness and Sports Medicine, U.S.
Public Health Service

Audrey T. Cross, Nutrition Policy Coordinator,
Office of the Secretary, U.S. Department of
Agriculture

Paul Danaceau, Editorial Consultant, Office of
Disease Prevention and Health Promotion, U.S.
Public Health Service

Winthrop N. Davey, M.D., Director, Bureau of
Training, Center for Disease Control, U.S.
Public Health Service

Ervin E. Duggan, Special Assistant to the
Secretary, Department of Health, Education, and
Welfare

Lawrence Farer, M.D., Director, Tuberculosis
Division, Bureau of State Services, Center for
Disease Control, U.S. Public Health Service

Barry Felrice, Acting Associate Administrator
for Plans and Programs, National Highway Traffic
Safety Administration, Department of
Transportation

Allen Forbes, M.D., Director, Nutrition and
Consumer Sciences, Food and Drug Administration,
U.S. Public Health Service

David Fraser, M.D., Chief, Special Pathogens
Branch, Bacterial Diseases Division, Bureau of
Epidemiology, Center for Disease Control, U.S.
Public Health Services

Frank Frodyma, Operations Research Analyst,
Occupational Safety and Health Administration,
Department of Labor

AIII-4


Lawrence Galton, Editorial Consultant, Office of
Disease Prevention and Health Promotion, U.S.
Public Health Service

John C. Greene, D.M.D., Deputy Surgeon General,
U.S. Public Health Service

Michael B. Gregg, M.D., Deputy Director, Bureau
of Epidemiology, Center for Disease Control,
U.S. Public Health Service

Stephen W. Havas, M.D., Medical Advisor, Office
of Health Information, Health Promotion and
Physical Fitness and Sports Medicine, U.S.
Public Health Service

John W. Horm, Statistician, Demographic Analysis
Section, Biometry Branch, National Cancer
Institute, National Institutes of Health, U.S.
Public Health Service

Juel Janis, Ph.D., Special Assistant to the
Assistant Secretary for Health and Surgeon
General, U.S. Public Health Service

Vicki Kalmar, Professional Associate, Division
of Health Promotion and Disease Prevention, The
Institute of Medicine, National Academy of
Sciences

Martha Katz, Special Assistant to the Acting
Deputy Assistant Secretary for Health, Office of
Disease Prevention and Health Promotion, U.S.
Public Health Service

Samuel S. Kessel, M.D., Robert Wood Johnson
Foundation Fellow, Office of the Assistant
Secretary for Health, U.S. Public Health Service

Ronald J. Kostraba, Technical Services
Specialist, Administrative Services Center,
Office of Management, Office of the Assistant
Secretary for Health, U.S. Public Health Service
(cover design)

AIII-5


J. Michael Lane, M.D., Director, Bureau of
Smallpox Eradication, Center for Disease
Control, U.S. Public Health Service

Seth N. Leibler, Ed.D., Deputy Director, Bureau
of Training, Center for Disease Control, U.S.
Public Health Service

Frank S. Lisella, Ph.D., Program Development
Branch, Environmental Health Services Division,
Bureau of State Services, Center for Disease
Control, U.S. Public Health Service

Brian J. McCarthy, M.D., Family Planning
Evaluation Division, Bureau of Epidemiology,
Center for Disease Control, U.S. Public Health
Service

J. Donald Millar, M.D., Director, Bureau of
State Services, Center for Disease Control, U.S.
Public Health Services

Sanford Miller, Ph.D., Director, Bureau of
Foods, Food and Drug Administration, U.S. Public
Health Service

Catherine Milton, Special Assistant to the
Assistant Secretary for Enforcement and
Operations, Department of the Treasury

John E. Mounts, Publications Branch Chief,
National Center for Health Satistics, U.S.
Public Health Service

Elena 0. Nightingale, M.D., Ph.D., Director,
Division of Health Promotion and Disease
Prevention, The Institute of Medicine, National
Academy of Sciences

Godfrey P. Oakley, Jr., M.D., Chief, Birth
Defects Branch, Chronic Diseases Division,
Bureau of Epidemiology, Center for Disease
Control, U.S. Public Health Service

AIII-6


Horace G. Ogden, Director, Bureau of Health
Education, Center for Disease Control, U.S.
Public Health Service

Jennifer Peck, Social Science Analyst, Bureau of
the Census, Department of Comnerce

Earl S. Pollock, Sc.D., Chief, Biometry Branch,
National Cancer Institute, National Institutes
of Health, U.S. Public Health Service

Thomas W. Poore, Chief, Text Preparation
Section, Publications Branch, National Center
for Health Statistics, U.S. Public Health Service

Kate Prager, Sc.D., Statistician, Mortality
Statistics Branch, Division of Vital Statistics,
National Center for Health Statistics, U.S.
Public Health Service

Robert Proctor, Public Affairs Officer, Office
of Public Affairs, U.S. Public Health Service

Robert L. Ringler, Ph.D., Deputy Director,
National Institute on Aging, National Institutes
of Health, U.S. Public Health Service

Don Robinson, Printing Specialist, Printing and
Reproduction Management Branch, Office of
Management, Office of the Assistant Secretary
for Health, U.S. Public Health Service
(production assistance)

Harry Rosenberg, Ph.D., Chief, Mortality
Statistics Branch, Division of Vital Statistics,
National Center for Health Statistics, U.S.
Public Health Service

Lisbeth Bamberger Schorr, Chairperson, Select
Panel for the Promotion of Child Health

Roger Sherwin, M.D. Associate Professor,
Department of Epidemiology and Preventive
Medicine, University of Maryland

AIII-7


James W. Stratton, M.D., Medical
Officer/Prevention Planning, Office of Program
Planning and Evaluation, Center for Disease
Control, U.S. Public Health Service

Susan B. Toal, M.P.H., Instructional Systems
Specialist, Bureau of Training, Center for
Disease Control, U.S. Public Health Service

Dennis D. Tolsma, M.P.H., Program Analysis
Officer. Office of Prooram Planninq and

Evaluation
Public Hea

     Center for"Disease Cot&-o
    !th Service            1


     ler, M.D., Director, Family
     Division, Bureau of Epidem i
      Disease Control, U.S. Pub1 i


William Walton, III, Acting Director,

Carl W. Ty
Evaluation
Center for
Service

, U.S.

Planning
OlWY,
c Health

Office of

Strategic Planning, Consumer Product Safety
Commission

Basil Whiting, Deputy Assistant Secretary,
Occupational Safety and Health Administration,
Department of Labor

Ronald W. Wilson, Chief, Health Status and
Demographic Analysis Branch, Division of
Analysis, National Center for Health Statistics,
U.S. Public Health Service

David Wu, Program Analyst, Office of Health
Information, Health Promotion and Physical
Fitness and Sports Medicine, U.S. Public Health
Service

Reviewers.  The following individuals provided
review and comments for the development of the
manuscript:

Herbert K. Abrams, M.D., M.P.H., Director of the
Arizona Center for Occupational Safety and
Health, Arizona Health Sciences Center,
University of Arizona

AI1 I-8


Duane Alexander, M.D., Assistant to the
Director, National Institute of Child Health and
Human Development, National Institutes of
Health, U.S. Public Health Service

John R. Ball, M.D., J.D., Senior Policy Analyst,
Office of Science and Technology Policy,
Executive Office of the President

Robert Benedict, Commissioner, Administration on
Aging, Office of Human Development Services

George A. Bray, M.D., Nutrition Coordinator,
U.S. Public Health Service

Lester Breslow, M.D., M.P.H., Dean, School of
Public Health, Center for the Health Sciences,
University of California at Los Angeles

John H. Bryant, M.D., Deputy Assistant Secretary
for International Health, U.S. Public Health
Service

Benjamin T. Burton, Ph.D., Associate Director,
National Institutes of Arthritis, Metabolism,
and Digestive Diseases, National Institutes of
Health, U.S. Public Health Service

Kathy Buto, Policy Coordinator, Executive
Secretariat, Office of the Secretary, Department
of Health, Education, and Welfare

C. Carson Conrad, Executive Director,
President's Council on Physical Fitness and
Sports, U.S. Public Health Service

Richard Cotton, Executive Secretary, Department
of Health, Education, and Welfare

Charles L. Cox, Assistant to the Director of the
Bureau of Radiological Health, Food and Drug
Administration, U.S. Public Health Service

James F. Dickson, III, M.D., Senior Advisor for
Environmental Affairs, U.S. Public Health Service

AIII-9


Allen Duncan, Assistant for Program Operations,
Office of Health Affairs, Food and Drug
Administration, U.S. Public Health Service

Kenneth Flieger, Special Assistant to the Acting
Associate Cowiissioner for Health Affairs, Food
and Drug Administration, U.S. Public Health
Service

Calvin Frederick, Ph.D., Chief, Disaster
Assistance and Emergency Mental Health Section,
Division of Special Mental Health Programs,
National Institute of Mental Health, Alcohol,
Drug Abuse, and Mental Health Administration,
U.S. Public Health Service

Peter L. Froner, M.D., Deputy Director,
National Heart, Lung, and Blood Institute,
National Institutes of Health, U.S. Public
Health Service

Carol W. Garvey, M.D., Acting Chief Medical
Officer, Office of Primary Care, Bureau of
Community Health Services, Health Services
Administration, U.S. Public Health Service

Stephen E. Goldston, Ed.D., M.S.P.H.,
Coordinator for Primary Prevention Programs,
National Institute of Mental Health, Alcohol,
Drug Abuse, and Mental Health Administration,
U.S. Public Health Service

David A. Hamburg, M.D., President, The Institute
of Medicine, National Academy of Sciences

Stephen P. Hersh, M.D., Assistant Director for
Children and Youth, National Institute of Mental
Health, Alcohol, Drug Abuse, and Mental Health
Administration, U.S. Public Health Services

Richard N. Hill, Acting Director, Health Effects
and Science Policy, Office of Toxic Substances,
Environmental Protection Agency

AIII-10


Mary Jane Jesse, M.D., Director, Division of
Heart and Vascular Diseases, National Heart,
Lung, and Blood Institute, National Institutes
of Health, U.S. Public Health Service

George M. Kirqnan, Director, Office of Program
Planning and Evaluation, National Institute of
Environmental Health Sciences, National
Institutes of Health, U.S. Public Health Service

Charles Krautharrrner, M.D., Special Assistant to
the Administrator, Alcohol, Drug Abuse, and
Mental Health Administration, U.S. Public Health
Service

George A. Lamb, M.D., Associate Professor,
Department of Preventive and Social Medicine,
Harvard Medical School

Mildred K. Lehman, Director, Office of
Communications and Public Affairs, Alcohol, Drug
Abuse, and Mental Health Administration, U.S.
Public Health Service

Mark H. Lepper, M.D., Vice-President of
Evaluation, Rush Medical Center, Chicago,
Illinois

Charles U. Lowe, M.D., Director, Office of Child
Health Affairs, U.S. Public Health Service

Bernard R. McColgan, Chief, Prevention Branch,
National Institute on Drug Abuse, Alcohol, Drug
Abuse, and Mental Health Administration, U.S.
Public Health Service

Carolyn G. McHale, Head, Program Information
Section, National Eye Institute, National
Institutes of Health, U.S. Public Health Service

Laura A. Miller, Special Assistant to the
Secretary, Department of Health, Education, and
Welfare

AIII-11


Lulu Mae Nix, Ed.D., Director, Office of
Adolescent Pregwncy Programs, Office of the
Assistant Secretary for Health, U.S. Public
Health Service

Mark Novitch, M.D., Acting Associate
Commissioner for Health Affairs, Food and Drug
Administration, U.S. Public Health Service

Gilbert S. Omenn, M.D., Ph.D., Associate
Director for Human Resources and Social and
Economic Services, Office of Science and
Technology Policy, Executive Office of the
President

Seymour Perry, M.D., Associate Director for
Medical Applications of Research, National
Institutes of Health, U.S. Public Health Service

Blandina Ramirez, M.D., Commissioner,
Administration for Children, Youth and Families,
Office of Human Development Services

Renie Schapiro, M.P.H., Staff Fellow, Office of
Health Affairs, Food and Drug Administration,
U.S. Public Health Service

Marvin Schneiderman, Ph.D., Associate Director
for Science Policy, National Cancer Institute,
National Institutes of Health, U.S. Public
Health Service

John R. Seal, M.D., Deputy Director, National
Institute of Allergy and Infectious Diseases,
National Institutes of Health, U.S. Public
Health Service

Cliff Sessions, Deputy Assistant Secretary for
Public Affairs, Department of Health, Education,
and Welfare

AIII-12


Zekin Shakhashiri, M.D., Special Assistant to
the Chief, Office of Program Planning and
Evaluation, National Institute of Neurological
and Communicative Disorders and Stroke, U.S.
Public Health Service

Laurel C. Shannon, Special Assistant to the
Associate Administrator for Planning,
Evaluation, and Legislation, Health Resources
Administration, U.S. Public Health Service

L. David Taylor, Deputy Assistant Secretary for
Management Analysis and Systems, Office of the
Secretary, Department of Health, Education, and
Welfare

Howard R. Veit, Director, Office of Health
Maintenance Organizations, Office of the
Assistant Secretary for Health, U.S. Public
Health Service

Graham W. Ward, M.P.H., Chief, Health Education
Branch, Office of Prevention, Education, and
Control, National Heart, Lung, and Blood
Institute, National Institutes of Health, U.S.
Public Health Service

Lois G. Whitley, Deputy Director, Division of
Prevention, National Institute on Alcohol Abuse
and Alcoholism, Alcohol, Drug Abuse, and Mental
Health Administration, U.S. Public Health Service

Sidney C. Wolverton, Acting Associate
Administrator for Program Coordination, Alcohol,
Drug Abuse, and Mental Health Administration,
U.S. Public Health Service

Z U. S. WVEIWMWT PRINTING OFFICE : 1979 297-780

AIII-13