Health in America—The Sum of Its Parts
Authors: J. Michael McGinnis
Journal: JAMA (2002)

THE LATE SPEAKER OF THE HOUSE TIP O’NEILL IS OFten remembered for his observation that “all politics is local.” That observation also applies to progress in public health, where priorities, capacity, and results vary widely from place to place. Recently, the anthrax outbreak dramatically underscored shortfalls in the US public health system, the failure to support that system, and the consequences that can follow being caught unprepared for a health emergency. But, just as important, public health is also about the ability of state and local agencies to monitor and attend to the everyday health problems that all Americans face, regardless of where they live. In this issue of THE JOURNAL, Nelson and colleagues report on trends at the state level regarding key factors in preventing disease and promoting health. The authors assess how state prevalences varied from 1991 through 2000 for the health risk factors of cigarette smoking, binge alcohol use, physical inactivity, obesity, and safety belt use; for screening for breast cancer (ie, mammography), cervical cancer, colorectal cancer, and elevated cholesterol levels; and for receipt of vaccination to prevent influenza and pneumococcal disease. Their report reveals the spotty nature of accomplishments in these basic prevention challenges, as well as insights on performance in achieving the health goals established in Healthy People 2000, the United States’ prevention initiative. The Healthy People 2000 initiative was announced in 1990 by the US Public Health Service and the Department of Health and Human Services. The product of a 3-year process of analysis and consultation, it presented a series of measurable health goals and objectives as targets of opportunity for the 1990s. It continued the target-setting process begun a decade earlier and now has been extended to its third decade as Healthy People 2010. From its inception, the Healthy People process has had multiple objectives: specifying health gains within the nation’s reach; rallying involvement and action from multiple sectors at the national, state, and local levels; and promoting development of improved health data collection and monitoring necessary to track progress and adjust strategies. The current report suggests mixed results on each of these dimensions. If Healthy People provided a vision, Nelson and colleagues provide what amounts to a reality check. The good news is that states have made substantial and relatively uniform progress with respect to adult immunizations for influenza and pneumonia, screening mammography for breast cancer, and safety belt use. But the results for physical activity, tobacco use, binge drinking, and screening for elevated blood cholesterol levels varied substantially among the states. For example, Nelson and colleagues report a static pattern over the decade with respect to smoking, with the statistically significant decrease in smoking prevalence for 1 state countered by increases in 14 states. Physical activity profiles apparently improved in 11 states but worsened in 3 states and were unchanged in 34. The prevalence of obesity increased across all states. Progress in cholesterol screening was uneven, with 13 states demonstrating increases in screening and 5 showing declines. Of the targets established in Healthy People 2000, the best result was for influenza immunization, with 48 states meeting the national goal of 60% immunized by 2000. The Healthy People 2000 targets and state performance on the other prevention priorities are as follows: less than 15% of the population using tobacco, 1 state; less than 15% physically inactive, 0 states; more than 60% of women receiving mammography, 47 states; more than 85% of women receiving cervical cancer screening, 41 states; more than 75% receiving cholesterol screening, 16 states; and greater than 60% receiving pneumococcal immunization, 8 states. Data reported by Nelson and colleagues for safety belt use, binge alcohol use, obesity, and colorectal cancer screening assessed slightly different aspects of the issues than the Healthy People 2000 targets, which aimed for greater than 85% automobile occupant protection by any means (safety belts, inflatable air bags, or child passenger restraints); less than 32% binge drinking among college students; less than 20% of the population overweight (body mass index, 27.5 kg/m) as opposed to obese (body mass index, 30 kg/m), and more than 40% of adults older than 50 years having ever received proctosigmoidoscopy (as opposed to a focus on those who had received proctoscopy, sigmoidoscopy, or colonoscopy in the past 5 years). Among these, good results were likely achieved for the au-