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PROMOTING HEALTH/PREVENTING DISEASE
OBJECTIVES FOR THE NATION

Fall 1980

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service

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Department of Health and Human Services
Patricia Roberts Harris, Secretary

Public Health Service
Julius B. Richmond, M.D., Assistant Secretary
for Health and Surgeon General

Ofﬁce of Disease Prevention and Health Promotion
J. Michael McGinnis, M.D., Deputy Assistant Secretary
for Health

Center for Disease Control
William H. Foege, M.D., Director

Health Resources Administration
Henry A. Foley, Ph.D., Administrator

 

For sale by the Superintendent of Documents. U.S. Government Printing Ofﬁce
Washington, DC. 20402

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:3 C DEPARTMENT OF HEALTH 81 HUMAN SERVICES Public Health Service

 

Office of the Assistant Secretary
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Washington DC 20201

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I am pleased to share with you Promoting Health/Preventing Disease:
Objectives for the Nation. Our national strategy for achieving further
improvements in the health of Americans was established in Healthy People,

a document that notes our accomplishments in prevention, identifies the
major health problems, and sets national goals for reducing death and
disability. This volume sets out specific and measurable objectives for
fifteen priority areas that are key to achieving our national health
aspirations. We appreciate the work of so many people to define quantifiable
objectives against which we can assess the effectiveness of our efforts.

Achievement of these objectives by 1990 is a shared responsibility, requiring
a concerted effort not only by the health community, but also by leaders

in education, industry, labor, community organizations and many others.

These challenges for the eighties demand creative approaches and by working
together we can realize our aspirations and really make a difference.

ﬁﬂamgg
%B. Richmond, .D.

Assistant Secretary for Health
and Surgeon General

 

CONTENTS

page page
INTRODUCTION AND OVERVIEW . . . . 1 FLUORIDATION AND DENTAL
PREVENTIVE HEALTH SERVICES HEéAiTg-CI 0.66.5] ................... :1
HIGH BLOOD PRESSURE CONTROL . 5 P 1 ° es -----------------
Speciﬁc Objectives ................. 7 SURVEILLANCE AND CONTROL OF
FAMILY PLANNING _______________ 11 INFECTIOUS DISEASES ............ 57
Speciﬁc Objectives ................. 13 Speciﬁc Objectives ----------------- 58
PREGNANCY AND INFANT HEALTH. 15
Speciﬁc Objectives ................. 17 HEALTH PROMOTION
IMMUNIZATION .................. 21 SMOKING AND HEALTH ........... 61
Speciﬁc Objectives ................. 22 Speciﬁc Objectives ----------------- 63
SEXUALLY TRANSMITTED DISEASES 25 MISUSE OF ALCOHOL AND DRUGS 67
SpeCIﬁc Objectives ----------------- 26 Speciﬁc Objectives ................. 69
HEALTH PROTECTION NUTRITION ...................... 73
TOXIC AGENT CONTROL .......... 31 Speciﬁc Objectives ................. 75
Speciﬁc Objectives ................. 34 PHYSICAL FITNE AND E RCISE V
OCCUPATIONAL SAFETY AND Speciﬁc Objectivefs XE ' :3
HEALTH ......................... 39 """""""""
Speciﬁc Objectives ................. 41 CONTROL OF STRESS AND VIOLENT
ACCIDENT PREVENTION AND BEHAVIOR .. . .. .................... 83
INJURY CONTROL ................ 45 sPeelﬁc Oblectlves ----------------- 85

Speciﬁc Objectives ................. 47 ACKNOWLEDGEMENTS .............. 87

 

INTRODUCTION AND OVERVIEW

The Purpose and the Process

In 1979 the ﬁrst Surgeon General’s Report on Health
Promotion and Disease Prevention, Healthy People, was
issued. That report chronicled a century of dramatic gains
in the health of the American people, reviewed present
preventable threats to health, and identiﬁed ﬁfteen priority
areas in which, with appropriate actions, further gains can
be expected over the decade. The report established broad
National goals—expressed as reductions in overall death
rates or days of disability—for the improvement of the
health of Americans at the ﬁve major life stages. Speciﬁ-
cally, the goals established were:

0 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.

0 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.

0 To improve the health and health habits of adoles-
cents 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.

0 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.

0 To improve the health and quality of life for older
adults and, by 1990, to reduce the average annual
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.

This volume, Promoting Health/Preventing Disease, sets
out some speciﬁc and quantiﬁable objectives necessary for
the attainment of these broad goals. Objectives are estab-
lished for each of the 15 priority areas identiﬁed in the
Surgeon General’s report: high blood pressure control;
family planning; pregnancy and infant health; immuniza-
tion; sexually transmitted diseases; toxic agent control;
occupational safety and health; accident prevention and
injury control; ﬂuoridation and dental health; surveillance
and control of infectious diseases; smoking and health;
misuse of alcohol and drugs; physical ﬁtness and exercise;
and control of stress and violent behavior. A number of
different objectives are speciﬁed for each of the 15 areas.
Taken together the targets established in Promoting
Health/Preventing Disease, when attained, should permit
the realization of the overall National goals set down in the

Surgeon General’s report.

The objectives are the result of a year long eﬁort involv-
ing more than 500 individuals and organizations from both
the private and governmental sectors. First drafts were
drawn up by 167 invited experts at a conference held in
Atlanta, Georgia, on June 13 and 14, 1979, sponsored by
the then Department of Health, Education, and Welfare.
The conference, organized into work groups for the 15
subject areas, was a joint effort of the Center for Disease
Control and the Health Resources Administration, coordi-
nated by the Ofﬁce of Disease Prevention and Health Pro-
motion of the Ofﬁce of the Assistant Secretary for Health.

An invitation for public comment on these drafts was
published in the Federal Register and the volume contain-
ing them was also circulated widely to people and agencies
concerned with the various subjects. During the fall of
1979 the objectives and reports were revised according to
the suggestions received. In early 1980 the revised objec-
tives were circulated within the Department of Health and
Human Services, to other relevant Federal agencies, and
to Atlanta conference work group chairpersons to elicit
further comment. Final revisions were made in the spring
of 1980.

Because the process received such a substantial con-
tribution from the 1979 Atlanta conference, it merits
special note. The conference participants and invited ob-
servers were all knowledgeable about some aspect of risk
reducing actions that can improve the opportunities for
health. The chairpersons and members of each of the 15
work groups were expressly selected to provide a mix of
backgrounds which could bring to the task not only tech-
nical expertise and consumer and professional viewpoints,
but also practical experience with planning and program
implementation. Thus, participants Were drawn from a
variety of aﬁiliations—providers, academic centers, State
and local health agencies, voluntary health associations,
and many others.

To facilitate the discussions, each work group member
received a draft background paper, prepared by staﬁ of
an HEW ofﬁce with program responsibility in the relevant
prevention activity. Other HEW activities in setting goals
and standards for prevention were taken into account both
in the background papers and in work group discussions,
particularly the National Health Planning Goals called for
by Section 1501 of PL. 93-641, presently under develop-
ment by the Health Resources Administration, and the
Model Standards for Community Preventive Health Serv-
ices called for by Section 314 of PL. 95—83, whose

development was coordinated by the Center for Disease
Control.*

While the objectives were developed under Public
Health Service sponsorship, and are consistent with Fed—
eral policies, they are far wider in purpose and scope. They
are intended to be National—not Federal—objectives. To
realize the potential for reducing the rates of premature
death and disability to the levels set forth here requires
a truly National commitment, including, but going far
beyond, that of government.

To achieve these objectives demands actions by Ameri-
cans in all walks of life, in their roles as concerned indi-
viduals, parents, and as citizens of their Nation and of
States and local communities. Sustained interest and action
is required not only by physicians and other health pro-
fessionals, but also by industry and labor, by voluntary
health associations, schools, churches, and consumer
groups, by health planners, and by legislators and public
ofﬁcials in health departments and in other agencies of
local and State governments and at the Federal level.

While the diagnosis and treatment of disease are the
primary responsibility of health professionals and health
organizations, actions to reduce the risks of disease or
injury extend far beyond health services per se. The range
of preventive activities is broad. Included are key preven-
tive services, such as immunization, delivered to indi-
viduals by physicians, nurses, other health professionals,
and trained allied health workers. Also important are
standards, voluntary agreements, laws and regulations,
such as engineering standards, safety regulations and toxic
agent control, to protect people from hazards to health in
their living, travel and working environments. In addition,
and perhaps most important for today’s health threats,
there are activities that individuals may take voluntarily
to promote healthier habits of living and activities that
employers and communities may take to encourage them.

This document is designed for the use of leadership in
the wide range of private and public sector organizations
with important roles in these various areas. At a time in
the Nation’s history when budgets become ever tighter,
legislators, public ofﬁcials and governing boards of indus-
try, foundations, universities and voluntary agencies are
beginning to re—examine their traditional bases for allo—
cating their limited health—related resources. It is antici-
pated that in the years to come policy makers will be able
to use the objectives in this volume to track the Nation’s
successes or failures in prevention.

The Reports

Each of the reports focuses on one of the 15 prevention
areas and is presented in a standard format allowing a
review of:

0 the nature and extent of the problem, including
health implications, status and trends;

*Readers who want to place disease prevention priorities in the
perspective of overall national health policy should refer to the
draft National Health Planning Goals, forthcoming from the
Health Resources Administration which address broad health
status and health system considerations. Readers who want more
speciﬁcs on how to put prevention measures to work are referred
to Model Standards for Community Preventive Health Services,
issued in 1979 by the Center for Disease Control.

0 prevention/promotion measures illustrative of ap-
proaches in education and information, services,
technology, legislation and regulation, and economic
incentives, followed by observations on the relative
strength of these measures;

0 speciﬁc national objectives for:

— improved health status

— reduced risk factors

— improved public/ professional awareness
— improved services/protection

— improved surveillance/evaluation;

0 the principal assumptions that underlie the framing
of the objectives;

0 the data necessary for tracking progress.

Discussion of the objectives is limited to some extent by
the need to distill often comprehensive and complex issues
into a short outline form as well as by limitations in the
knowledge base. In some instances, for example, it is not
possible to relate the magnitude of a targeted problem to
a speciﬁc disease incidence—e.g., the prevalence of a par-
ticular carcinogen in the environment to an identiﬁable
level of cancer incidence. Also, the discussions of the
various intervention measures are offered principally as
checklists rather than as detailed blueprints with appro-
priate sequencing carefully established and presented.
They do not necessarily reﬂect Federal policy—rather they
represent a broader range of possible measures available
throughout the public and private sectors.

But these limitations are dictated by the character of the
existing data, as well as the necessity to tailor efforts to
local conditions. Given these considerations, the discus-
sions provide a concise review of the central issues rele-
vant to each area.

With respect to the objectives themselves, certain
premises are inherent. First, the stated objectives should
reﬂect a careful balancing of potentials for beneﬁts and
harm to the individuals or populations concerned. Second,
speciﬁc actions suggested should be in line with profes-
sional consensus on likely efﬁcacy of the action. Third,
continued biomedical, epidemiological and behavioral sci-
ence research, and systematic evaluation will result in
improved judgments.

The objectives focus on interactions and supports de-
signed primarily for well people; to reduce their risks of
becoming ill or injured at some future date. Thus, few of
the objectives deal with secondary prevention. Objectives
relating to the frequency and content of physical exami-
nations and other means of detecting early conditions
(such as cervical, breast and colon cancer, diabetes, vision
and hearing problems and dental caries) were deliberately '
excluded from consideration, despite their obvious im-
portance in signaling needs for intervention.

Finally, an attempt has been made to conﬁne objectives
to what might feasibly be attained during the coming
decade, assuming neither major breakthroughs in preven-
tion technology, nor massive infusions of new Federal
spending. For example, the goal for infant health is to
reduce the infant mortality rate to no more than 9 deaths
per 1,000 live births. In' theory the Nation should be able
to do much better. Several areas in western Europe, and
certain political jurisdictions within the United States

already have achieved rates of 5 per 1,000. Yet, the size
of the gaps that presently exist between the risks experi-
enced by pregnant women in different age, ethnic and
income groups of the population, and the limited resources
that now appear likely to become available to narrow those
gaps make 9 per 1,000 a more realistic objective.

In sum, the objectives were framed in the context of
current knowledge and the current aggregate level of pub-
lic and private resources for the 15 prevention areas.
While this parameter was not adhered to in every instance,
it promoted a greater measure of restraint—or realism—
on the process.

No effort has been made to establish priorities among
the 15 areas, or even among the various objectives Within
any given area. Given the nature of our pluralistic society
and the diversity of regional and local needs and capabil-
ities, both the setting of priorities and the choice of pro-
gram direction are best left to those responsible for
planning, coordinating, and implementing prevention
strategies—namely State and local health agencies, State
health planning and development agencies, health system
agencies, and governing boards of the wide range of pri-
vate sector organizations involved. ,

It is important to note that some themes can be identi-
ﬁed which group the activities of the 15 areas into sub-
categories with common elements. “Substance abuse,” for
example, links the areas of smoking and health and misuse
of alcohol and drugs. Common elements in these areas
include questions of addictive properties, neurochemical
action, long-term sequelae, age-related vulnerability, ef-
fectiveness of primary and secondary prevention measures,
and ethical issues attendant to behavior change. Each of
these issues should be considered not only on its own
merit, but also for its lessons for, and commonalities with,
the other abusive behaviors. Another example is the theme
of “reproductive health.” Family planning, pregnancy and
infant health, and sexually transmitted diseases are, of
course, all concerned with reproductive health, but ele—
ments are also found in the discussions of smoking and
health, misuse of alcohol and drugs, nutrition, toxic agent
control, occupational safety and health, and immunization.
Approaches to ensuring positive results of human repro-
ductive processes compel consideration of issues of sexual
attitudes and behavior, understanding of fertility and infer-
tility, decisions about pregnancy, activities and exposures
during pregnancy, obstetrical services, and follow-up care
of mother and infant. All are important factors in repro-
duction; central concerns of much of reproductive life.
Considering the spectrum of issues in the aggregate, rather
than a series of isolated events, has substantial merit.

Because such collective themes can be important to the
implementation of measures to address the identiﬁed ob-
jectives, program directors designing such measures and
setting priorities should search for the common elements
particularly germane to their program needs and resources.

Crosscutting Issues

A number of issues are common to most or all of the
reports: the problem of developing objectives in the face
of economic uncertainties, a rapidly changing science base,
the needs for more research and data, unpredictable shifts

in popular interests and values, trade-offs between health
and other societal interests, and ethical considerations in
attempts to inﬂuence changes in people’s customary habits.
Two are discussed below: data requirements and research
needs.

0 Data requirements—The most salient common fea-
ture across the 15 areas is the need for better data
both to proﬁle current status and to track progress
towards the established objectives. Statistical analyses
derived from reliable data, continuously reported and
coded according to universally accepted deﬁnitions
and conventions, are the sine qua non for establish-
ing the true nature of the problems preventive meas-
sures should address, as well as for charting trends
towards achieving the objectives. There is currently
great variability in the depth and reliability of data
available among the 15 areas. While statistical reports
relevant to the problem of smoking are quite com-
plete, virtually no data exist to estimate the problem
of unmanaged stress in the population, and its asso-
ciation with mental illness, cardiovascular disease or
violent behavior.

In some cases, the availability of baseline data and
ability to track progress have been relatively more
prominent than overall importance to health in shap-
ing the nature of objectives. The paucity of data is
particularly handicapping for State and local organi-
zations and agencies seeking to set and track progress
toward their own local priorities and objectives for
prevention. For the most part, birth and death sta-
tistics and local hospital discharge abstract analyses
remain their only guides. Results from the continu-
ing National surveys, such as the Health Interview
Survey (HIS) and the Health and Nutrition Exami-
nation Survey (HANES), while essential for tracking
change in the United States population as a whole,
are based on samples too small to permit analysis
applicable to small areas.

Surveillance systems developed to monitor the oc-
currence of infectious diseases provide models for
many of the speciﬁc objectives relating to the pre-
vention of other types of diseases and injuries. They
depend on systems through which the occurrence of
the particular condition or action will be reported
within some ascertainable limits of accuracy and
completeness. Whatever the source of the necessary
data—physicians, hospitals, highway patrols, or in-
surance claim systems—important issues concerning
the quality of the data must be addressed. Using data
from surveillance systems which are not based on
probability sample designs, or which are based on
voluntary reporting, carries risks in making National
estimates for tracking objectives. The level of volun-
tary reporting may differ markedly from one local
area to another and ﬂuctuates unpredictably at dif-
ferent points in time.

Scientiﬁc evaluation of the impact of risk reduc-
tion on trends in health status or in reduction of risk
factors is diﬂicult methodologically and collection of
the data required is expensive. To obtain valid results,
test and control populations of considerable size must

be followed over considerable periods of time, and a
multiplicity of variables must be systematically taken
into account.

We anticipate considerable improvements will be
made in our data capabilities over the next decade.
New methods now being developed will help State
health planning agencies, health systems agencies and
health departments use existing data more effectively
to establish base lines of prevention needs and oppor-
tunities. New efforts are underway to target new
subjects for National data collection efforts. By 1990
the Nation should have a considerably improved data
collection network and therefore be able to assess
the progress with greater reliability as well as to
establish new priorities based on new knowledge.

Research needs—The development of realistic objec-
tives for risk reduction obviously must take place
within the framework of whatever scientiﬁc knowl-
edge is currently available. Since for most areas the
state of the art is constantly changing, developing
objectives for a point in time ten years down the road
often means shooting at a moving target. For ex-
ample, when the initial section on high blood pressure
was drafted in June 1979, uncertainty about the
efﬁcacy of intervention in cases where blood pressure
was only slightly elevated (90 to 104 mm Hg diastolic
blood pressure without complications) led the work
group to caution that in such cases: “. . interven-
tion . . . is not yet of clearly proven beneﬁt.” Ten
months later, based on the results of a National study
sponsored by the National Heart, Lung and Blood
Institute, the statement was revised to read: “Based
on 1979 research results, intervention seems war-
ranted in a large proportion of this population.”

If the objectives developed are to be reﬁned and
improved, the continuing need for basic biomedical
research in most of the 15 subject areas of preven-
tion is clear. Were our understanding of biological
processes sufficient to develop vaccines to protect
individuals against the most prevalent sexually trans-
mitted diseases, tremendous opportunities for preven-
tion would unfold and the task would become much
easier. Similarly, epidemiological and biomedical
research-to identify major health risks from exposures
to toxic agents is fundamentally important. We need
new technologies to aid prevention in many areas——
the development of acceptable, reversible, male con-
traceptives, for instance. Many of these issues have
been addressed in the process of establishing National
research principles, directed by the National Insti-
tutes of Health.

Additionally, behavioral research is needed to learn
the basis for such addictions as smoking, overeating,
and dependence on alcohol and drugs. Research at
the interface between biomedical and behavioral
methodologies is required to'advance our knowledge
of the effects of stress on health, and of how to
control them. ‘

Social science research is needed to ﬁnd more effec-
tive ways to communicate to vulnerable and inac-
cessible populations, such prevention techniques as

lifestyle change measures to reduce their percentage
of low birth weight, high risk infants. Health services
research is required to learn how to maintain adher-
ence to health promotion measures over long time
periods, such as high blood pressure control regimens
and maintaining a balance between energy input from
food and output from exercise. Cost effectiveness
studies, too, could identify preferred measures in
some areas of prevention, despite the difﬁculties al-
ready noted in deﬁning the associated costs and
beneﬁts that limit the applicability of such analysis
to many prevention activities.

Finally, legal and public policy research is called
for in many areas of prevention, so that questions of
individual and collective rights and responsibilities,
and of trade-offs between economic and health
values, and of short run versus long run beneﬁts can
be systematically introduced into public debates.

Implementation

Implementation of the objectives for each of the 15
areas requires a pluralistic process involving public and
private participants from many sectors and backgrounds.
Health ofﬁcials andhealth providers must be joined by
employers, labor unions, community leaders, school teach-
ers, communications executives, architects and engineers,
and many others 1n efforts to prevent disease and promote
health. It 1s important to emphasize that, while the Federal
Government must bear responsibility for leading, catalyz-
ing and providing strategic support for these activities, the
effort must be collective and it must have local roots.

Accordingly, the objectives contained in this volume
must be viewed dynamically. They ought not to be con-
sidered rigid obligations, but as useful National guideposts
—to be altered to ‘ﬁt local conditions, or as our level of
understanding of the problems at hand changes. There will
be controversy. Issues often raised in connection with the
advocacy and adoption of prevention measures include:
the appropriate role of government in fostering personal
behavior change; the philosophy and psychology of throw-
ing responSibility for serious health problems back to the
victim; the role of business and industrial processes in
health and disease; the preferential treatment 0 certain
categories of people for insurance purposes; th role of
government in regulating health protection measures.

Despite such‘questions, the objectives presented in Pro-
moting Health/ Preventing Disease represent an important
component of a focused National prevention strategy.
Substantial gains to the health of Americans can be at-
tained if we have the will to apply what we know. From
the Federal perspective, work is already under way to
apply the capabilities of Federally sponsored programs to
the agenda set forth. If similar efforts are undertaken at
the State and local levels to design measures for imple-
menting locally-based Objectives, progreSs can be greatly
facilitated. To draw upon the last line of Healthy People,
“If the commitment is made at every level, We ought to
attain the goals established in this report, and Americans
who might otherwise have suffered disease and disability
will instead be healthy people. ”

HIGH BLOOD PRESSURE CONTROL

1. Nature and Extent of the Problem

High blood pressure is perhaps the most potent of the
risk factors for coronary heart disease and stroke——
and contributes as well to diseases of the kidney and
eyes. Because it is asymptomatic, a large number of
people are unaware of their condition. High blood
pressure is, however, only one of several risk factors
for heart disease and stroke. Other prominent factors
for heart disease include cigarette smoking, elevated
blood cholesterol levels, diabetes and obesity. It is
essential to recognize the multiple nature of these risks
and their proved or suspected interaction. Correspond—
ingly, both health professionals and the public need to
know more about approaches for dealing compre-
hensively with these multiple risk factors and how to
act on the basis of this knowledge. Control of high
blood pressure requires patients to adhere to regimens
over their lifetime. These may include various combi-
nations of pharmaceutical interventions and changes in
diet, exercise and stress management practices. (See
Smoking and Health, Nutrition, Physical Fitness and
Exercise, and Control of Stress and Violent Behavior.)

2. Health implications

0 Heart disease, the leading cause of death in the
US. population, was responsible for over
700,000 deaths in 1977; stroke led to 183,000
deaths in that year. Survivors are often severely
handicapped.

0 About 60 million people have elevated blood
pressures (above 140/90) and are at increased
risk for death and illness.

0 Of these, about 35 million people (15 percent
of the US. population) have high blood pressure
at, or above 160/95, which is the World Health
Organization deﬁnite determination of hyper-
tension. These people face excess risk of death
or illness from heart attack, heart failure, stroke,
and kidney failure, and are the primary targets
for control efforts.

0 Much of this excess risk is attributable to mild
high blood pressure (90 to 104 mm Hg diastolic
blood pressure without complications). Based
on 1979 research results, intervention seems
warranted in a large proportion of this popu—
lation.

0 Other important risk groups are: persons with
diastolic blood pressure over 104 (for whom
drugs have been proven beneﬁcial); populations
having a high prevalence (e.g., blacks and elder-

ly); persons with limited access to, or use of,
medical care such as young men and the poor.
Among special issues are the growing proportion
of elderly in the population, their high preva-
lence of high blood pressure, uncertainty about
the beneﬁt of treating isolated systolic blood
pressure and the sometimes unpredictable side
effects of drugs used to control high blood pres-
sure in older people.

Children present an opportunity, since pre-
cursors of high blood pressure may be identiﬁed
in them, but also present a dilemma as the
beneﬁt of early intervention in this population is
not known and a ﬁrm consensus on deﬁning
high blood pressure in youngsters has not yet
been reached. Changes in habitual diet may
prove useful in prevention.

b. Status and trends

Although blood pressure can be controlled, the
speciﬁc cause of 90 to 95 percent of high blood
pressure is not known. Thus, while short-term
emphasis must be placed on control, increased
understanding of the causes of hypertension
must be pursued to enable prevention of high
blood pressure in the long run.

High salt intake is associated with high blood
pressure in susceptible people; reduced salt in-
take is one measure for reducing high blood
pressure.

Many successful approaches to detection and
control (e.g., use of allied health personnel,
worksite care, patient tracking systems) are not
yet widely adopted or integrated into main-
stream care.

Although prevalence data indicate a problem of
great magnitude, incidence data for high blood
pressure and its complications do not exist to
aid improved planning of intervention strategies
for both primary and secondary prevention.
Men are only half as likely as women to have
their high blood pressure controlled.

Rural (non-SMSA) areas and urban inner city
areas have made less progress in high blood
pressure control in recent years than have metro-
politan areas.

Many health professionals are inattentive to
regimen adherence issues and lack skills to deal
with adherence.

School health education rarely addresses risk

factor control and lifestyle impact on health in
a satisfactory way.

The proportion of the population with high
blood pressure who are aware of their condition
and are successfully controlling it appears to
have doubled in the last 5 years, while the pro-
portion of this population who are unaware of
their condition has sharply decreased. However,
the proportion who are aware of their condition,
but whose high blood pressure remains un-
treated or uncontrolled, appears to have stayed
constant.

2. Prevention/Promotion Measures
Potential measures
0 Education and information measures include:

— continuing current efforts to heighten pro-
fessional and public awareness of possibil-
ities for blood pressure control, with mes-
sages targeted to groups at special risk, such
as black males, the elderly and users of oral
contraceptives; /

— informing the public that daily intake of over
5 grams of total salt (2 grams sodium) is
not essential for good health and may con-
tribute to the development of high blood
pressure in some people;

—— developing and distributing palatable recipes
for low sodium diets;

— raising public awareness that overweight
predisposes to high blood pressure and
weight control often assists blood pressure
control; avoidance of juvenile obesity is
especially important;

—— encouraging increased physical activity and
understanding that maintaining an appropri-
ate balance between the energy individuals
expend in their daily physical activity and
the amount of energy they consume through
the food they eat determines their success in
controlling weight;

— increasing public awareness of the fact that
stress reduction and exercise may be useful
adjuncts for some persons to provide a
healthy lifestyle and lessen the risk of hyper-
tension;

— increasing public awareness of multiple risk
factors and the interaction of risk factors;

—— alerting physicians on value of monitoring
the children of hypertensives with attention
to weight control and low salt intake;

— increasing professional school training in
behavioral / motivation skills;

— involving specialists in behavioral medicine
in teaching programs and assisting in patient
adherence to regimens;

— encouraging introduction/inclusion of
health-related content into the curricula of
public/private institutions which train food
preparation/ processing personnel;

— more active nutrition education in school
health and lunch programs for school chil-
dren and for the elderly;

—— inﬂuencing industry to take active steps to
promote high blood pressure control/pre-
vention among its employees and throughout
the Nation by changes in both products
(primarily reduced sodium content of proc-
essed foods) and marketing approaches;

— increasing awareness by employers and the
public of the potential for insurance prem-
ium cost savings associated with blood pres-
sure control, not smoking and weight control
among individual and group policy pur-
chasers.

0 Service measures include:

—— providing blood pressure checks routinely at
contact with health providers (e.g., physi-
cians, dentists, nurse practitioners) and
through programs staffed by suitably trained
non-professionals (e.g., ﬁremen);

— providing high blood pressure detection and
treatment services at the worksite with a
systematic program for follow-up;

— giving health providers instruction in tech-
niques to improve patient adherence to
blood pressure control regimens.

0 Technologic measures include:

—- increasing use of systems/policy analysis
methods in program planning at all levels;

—— reducing fat content (caloric density) and
sodium content of snack and highly proc-
essed foods;

— developing practical means to supply low
sodium content water to populations living
in “hard” water areas.

0 Legislative and regulatory measures include:

— promoting consumer choice through labeling
of foods for sodium and caloric content;

— seeking uniform National guidelines and
Federal agency (National Institutes of
Health, Department of Agriculture, and
Food and Drug Administration) policies for
nutrition (e.g., sodium consumption, total
dietary fat content);

— modifying State practice acts to provide for
expanded roles of allied health professionals
in the management/control of high blood
pressure.

0 Economic measures include:

— providing free or low cost access to blood
pressure checks during intervals between
physician examinations;

—— reducing economic barriers (e.g., reimburse-
ment, training costs) to use of allied health
personnel;

—- providing industry with tax incentives to en-

courage development of lower calorie, fat,
sodium-containing foodstuffs;

— reducing economic barriers to control
through reimbursement for antihypertension
prescription drugs.

b. Relative strength of the measures
0 Education and information measures:

— established impact; low technology imple-
mentation possible; wide acceptance of this
approach now exists; excellent cost/eﬁective
potential.

0 Service measures:
— effective with potential for signiﬁcant impact.

0 Technologic measures:

— use of systems analysis approach to planning
to facilitate more comprehensive/objective
problem analysis resulting in more eﬁective
plans;

— food content changes to allow greater con-
sumer choice; may inﬂuence a major source
of calorie self-abuse, and could be especially
relevant to school children among whom
adverse eating patterns have lasting effects.

0 Legislative and regulatory measures:
— not well evaluated as a behavioral tool,
slow to achieve results.
0 Economic measures:
— difﬁcult to achieve but usually effective when
accomplished. \

3. Speciﬁc Objectives for 1990 or Earlier

0 Improved health status

a. By 1990, at least 60 percent of the estimated
population having deﬁnite high blood pressure
(160/95) should have attained successful long
term blood pressure control, i.e., a blood pres-
sure at or below 140/90 for two or more years.
(High blood pressure control rates vary among
communities and States, with the range generally
being from 25 to 60 percent based on current
data.)

0 Increased public/ professional awareness

d. By 1990, at least 50 percent of adults should be
able to state the principal risk factors for
coronary heart disease and stroke, i.e., high
blood pressure, cigarette smoking, elevated
blood cholesterol levels, diabetes. (Baseline data
unavailable.)

e. By 1990, at least 90 percent of adults should be
able to state whether their current blood pres-
sure is normal (below 140/90) or elevated,
based on a reading taken at the most recent visit
to a medical or dental professional or other
trained reader. (In 1971—74, 55 percent of
people with high blood pressure greater than
160/95 were not aware of their condition.)

0 Improved services/ protection

f. By 1990, no geopolitical area of the United
States should be without an effective public pro-
gram to identify persons with high blood pres-
sure and to follow up on their treatment. (Base-
line data unavailable.)

g. By 1985, at least 50 percent of processed food
sold in grocery stores should be labeled to in-
form the consumer of sodium and caloric con-
tent, employing understandable, standardized,
quantitative terms. (In 1979, labeling for sodium
was rare; the extent of calorie labeling was
about 50 percent in the market place.)

— See Nutrition.

0 Improved surveillance/ evaluation systems

h. By 1985, a system should be developed to de-
termine the incidence of high blood pressure,
coronary heart disease, congestive heart failure
and hemorrhagic and occlusive strokes. After
demonstrated feasibility, by 1990 ongoing sets
of these data should be developed.

i. By 1985, a methodology should be developed to
assess categories of high blood pressure control,
and a National baseline study of this status
should be completed. Five categories are sug-
gested: (l) Unaware; (2) Aware, not under
care; (3) Aware, under care, not controlled;
(4) Aware, under care, controlled; and (5)
Aware, monitored without therapy.

0 Reduced risk factors
*b. By 1990, the average daily sodium ingestion (as 4. Principal Assumptions

measured by excretion) for adults should be 0 The etiology of high blood pressure is multifactorial

reduced at least to the 3 to 6 gram range. (In
1979, estimates ranged between averages of 4
to 10 grams sodium. One gram salt provides ap-
proximately .4 grams sodium.)

*c. By 1990, the prevalence of signiﬁcant over-
weight (120 percent of “desired” weight) among
the US. adult population should be decreased
to 10 percent of men and 17 percent of women,
without nutritional impairment. (In 1971—74,
14 percent of adult men and 24 percent of
women were more than 120 percent of “de-
sired” weight.)

*NOTE: Same objectives as for Nutrition.

and no research breakthrough will eliminate it as a
public health problem in the next decade.

The basic components of successful control pro-
grams will continue to be detection, evaluation,
treatment and/ or changes in lifestyle, and follow-up.
While there are still some uncertainties about the
quantitative relationship between sodium ingestion
and high blood pressure, it is important to begin
moving in the direction suggested by the data.
While there is not yet a true consensus as to what
constitutes dangerous levels of overweight for the
population as a whole, the stated targets provide the
pattern for a productive trend.

. Governmental efforts to control high blood pressure
will be continued and expanded.

0 Voluntary and private sector efforts to control high
blood pressure will be continued and expanded.

0 Health Systems Agencies will give high priority to
high blood pressure detection, treatment and con-
trol.

0 Implementation of the smoking, nutrition, and phys-
ical activity recommendations (see appropriate sec-
tions) will impact favorably on the prevention and
control of high blood pressure.

5. Data Sources
a. To National level only

0 Health and Nutrition Examination Survey
(HANES). Prevalence of hypertension by de-
mographic characteristics; blood pressure distri-
butions; some data on awareness and control
status. DHHS-National Center for Health Statis-
tics (NCHS). NCHS Vital and Health Sta-
tistics, Series 11, selected reports, especially No.
203, and Advance Data from Vital and Health
Statistics, selected reports. Periodic National
surveys, obtaining data from physical examina-
tions, clinical and laboratory tests and related
measurement procedures on National probabil-
ity sample of the U.S. civilian noninstitutional—
ized population. Data on adults currently avail-
able from the 1960-1962 Health Examination
Survey and the 1971—1974 HANES. 1971—1975
data are expected during 1980. 1976—1980 data
not yet available.

0 Health Interview Survey (HIS). Interview re-
ported data on prevalence of hypertension by
demographic characteristics, disability days as-
sociated with high blood pressure therapy and
regimen adherence, and other related topics.
DHHS-NCHS, NCHS Vital and Health Statis-
tics, Series 10, selected reports, especially No.
121, and Advance Data from Vital and Health
Statistics. Continuing household interview health
survey; National probability samples of the U.S.
civilian noninstitutionalized population. Special
survey on hypertension conducted in 1974. Data
on hypertension available from the 1972 and
1978 HIS will be published in the 1979 and
1980 survey reports.

0 National Ambulatory Medical Care Survey
(NAMCS). Patient visits to oﬂice-based private
practice physicians in the U.S. by patient and
physician characteristics, diagnosis (including
high blood pressure and its sequelae), patient’s
reason for the visit and services provided.
DHHS-NCHS. NCHS Vital and Health Statis-
tics, Series 13, selected reports and Advance
Data from Vital and Health Statistics. Continu-
ing survey, since 1973; National probability
sample of oﬁice-based physicians.

0 Hospital Discharge Survey (HDS). Patient stays
in short-term hospitals, by patient characteris-

tics, diagnosis (including high blood pressure
and its sequelae), survey and other procedures.
DHHS-NCHS. NCHS Vital and Health Statis-
tics, Series 13, selected reports. Continuing sur-
vey, since 1965; data from discharge records of
samples of patients in a National probability
sample of general and special short stay hos-
pitals.

National Disease and Therapeutic Index
(NDTI). Patient visits to ofﬁce-based private
practice physicians in the United States by
patient and physician characteristics, type of
visit, diagnosis (including high blood pressure
and its sequelae), whether blood pressure was
measured and actual measurement and prescrib-
ing behavior of the physician. IMS America,
Ltd., Ambler, Pennsylvania. Regular reports
from IMS, plus specially requested computer
tabulations. Continuing survey from a repre-
sentative sample panel of physicians in private
practice. Blood pressure measurements available
only since 1976. V

National Prescription Audit (NPA). Drug sales
(including hypertensive drugs), source of pre-
scription, payment status and prescriber type.
IMS America, Ltd., Ambler, Pennsylvania. IMS
reports. Continuing audit of pharmacies on IMS
panel.

Physician response to high blood pressure diag-
nosis. Physicians’ knowledge, attitudes and be—
havior toward high blood pressure; perceived
importance of high blood pressure diagnosis and
treatment practices. Surveys conducted for
DHHS-Food and Drug Administration (FDA)
and the National High Blood Pressure Educa-
tion Program (NHBPEP), National Heart,
Lung, and Blood Institute (NHLBI), National
Institutes of Health. DHHS Publication No.
(NIH) 79—1056, Diagnosis and Management of
Hypertension: A Nationwide Survey of Physi-
cians’ Knowledge, Attitudes and Reported Be-
havior. National survey 1977; follow-up surveys
anticipated.

The public’s view of high blood pressure. Public
knowledge, attitudes and reported behavior to-
wards high blood pressure. Surveys conducted
for NHBPEP-NHLBI, National Institutes of
Health. DHHS Publication No. (NIH) 77—356
(1973 survey), The Public and High Blood
Pressure: A Survey. 1979 survey to be pub-
lished. Periodic surveys; National probability
sample of the U.S. adult population.
Hypertension Detection and Follow Up Pro-
gram. State of knowledge among persons of high
risk of coronary and vascular diseases. DHHS-
NHLBI. NHLBI (NIH) Hypertension Task
Force Reports, Nos. 8 and 9. One time survey.

b. To State and/ or local level
0 National Vital Registration System

— Mortality. Deaths by cause, including hyper-

tension and hypertension-related sequelae,
by age, sex and race. DHHS-NCHS. NCHS
Vital Statistics of the United States, Vol. II,
and NCHS Monthly Vital Statistics Reports.
Continuing reporting from States; National
full count. (Many States issue earlier re-
ports.)

0 Hospitalized illness discharge abstract systems
— Professional Activities Study (PAS). Pa-

tients in short stay hospitals; patient charac-
teristics, diagnoses of hypertension and
hypertension-related sequelae, procedures
performed, length of stays. Commission on
Professional and Hospital Activities, Ann
Arbor, Michigan. Annual reports and tapes.
Continuous reporting from 1900 CPHA
member hospitals. Not a probability sample;
extent of hospital participation varies by
State.

— Medicare hospital patient reporting system

(MEDPAR). Characteristics of Medicare
patients, diagnosis, procedures by hospitals,
HSA areas. DHHS-Health Care Financing
Administration, Ofﬁce of Research, Demon-
stration and Statistics (ORDS). Periodic
reports 1975, 1976, 1977. Continuing re-
porting from hospital claim data, 20 percent
sample.

Other hospital discharge systems as locally
available.

Selected health data. DHHS-NCHS. NCHS Sta-
tistical Notes for Health Planners. Compilation
and analysis of data to State level. , ‘
Area Resource File (ARF). Demographic,
health facility and manpower data at State and
county level from various sources. DHHS-
Health Resources Administration, Area Re-
source File: A Manpower Planning and Re-
search Tool, DHHS—HRA—80—4, Oct 79. One
time compilation.

 

FAMILY PLANNING

1. Nature and Extent of the Problem

Family planning is based on the voluntary decisions
and actions of individuals. Its purpose is to enable
individuals to make their own decisions regarding
reproduction and to implement their decisions. Family
planning includes measures both to prevent unintended
fertility and to overcome unintended infertility.

a. Health implications

Family planning is a preventive health measure

which supports:

— maternal and infant health;

— the emotional and social health of indi-
viduals and the family.

Pregnancies among teenagers, among women .

who are unmarried, among women over the age
of 34 and among high parity women are all asso-
ciated with higher than average rates of ma-
ternal and/or infant morbidity and mortality.
They are also more likely than other pregnancies
to be unintended and unwanted.

Compared to pregnancies carried by women in
the most favorable childbearing years, teenage
pregnancies are associated with markedly in—
creased risks of maternal morbidity and mortal-
ity and of premature and other low birth weight
infants who have reduced chances of surviving
infancy and high rates of serious neurological
impairment.

Adolescent motherhood is associated with great-
er risk of lowered educational and occupational
attainment, reduced income and increased like-
lihood of welfare dependency.

Unwanted pregnancies impose psychological and
social costs that often continue throughout the
lifetimes of the mother and the child.

1). Status and trends

In 1978, about 545,000 babies were born to
unmarried American women, almost half of
whom were teenagers.

Although fertility rates for teenagers are declin-
ing in the United States, the rates continue to
exceed those in more than a dozen developed
countries. Both the birth rate and the number
of births for unmarried women are increasing;
unmarried mothers are more likely to have be-
gun prenatal care late in pregnancy and to
have made fewer prenatal visits than married

11

mothers; infants born to single mothers are more
likely to have a low birth weight.

Ten percent of babies born to married American
women between 1973—1976 resulted from con-
ceptions the mothers wished had never hap-
pened. An additional 25 percent resulted from
pregnancies which the mothers wanted to have
some time in the future but which occurred too
early in their lives.

Certain subgroups of our population have dis-
proportionately high risks of unintended preg-
nancy and childbearing. Examples include:

— unplanned births are almost twice as fre-
quent in poor as compared to nonpoor fami-
lies (52 percent of births that occurred dur-
ing the previous ﬁve years Were unplanned as
reported in 1976 by women with family in—
comes below the poverty level, compared
to 29.2 percentfor women with family in-
comes of 150 percent of poverty level or
higher);

-—- reports of black women in a 1973 survey
that one of every four of their births had
been unintended, versus reports by white
women that only one of every 10 of their
births had been unintended;

—— high rates of unintended pregnancy among
teenagers, women with language barriers
and/or illegal immigration status, women
living in rural areas on on Indian reserva-
tions and members of some religious groups.

More than a million American women have
pregnancies terminated by abortion every year.
The teenage populatidn accounts for aproxi-
mately one-third of these abortions.

The risk of death associated with temporary
methods of contraceptions, sterilization and
legal abortion is less than the risk of death
from childbearing, although the absolute num-
bers of deaths are about equal.

Many deaths associated with methods of con-
traception are preventable, including those asso-
ciated with:

— smoking by women who use oral contracep-
tives;

— oral contraceptives with unnecessarily high
estrogen content;

— legal abortions performed after the ﬁrst
trimester of pregnancy;

illegal abortion.

The psychological and biologic bases and under-
lying causes of a large proportion of infertility
cases are not understood and/or are not re-
mediable by medical treatment. Those treat-
ments which are available technically are costly
and are largely inaccessible to the poor.

2. Prevention/Promotion Measures

3. Potential measures

Education and information measures include:

providing content on human sexuality, re-
production, family planning and parenting
in the curricula of schools which train per-
sonnel for delivery of human services (i.e.,
professional schools for social workers,
clergy, nurses, nurse practitioners, teachers,
counselors, pharmacists and physicians);
providing content on human sexuality, re-
production and contraception within con-
tinuing education programs for graduate
level professionals involved in human serv-
ices;

incorporating into elementary and high
school educational programs a family life
curriculum which includes human sexuality,
reproduction, contraception and parenting
as well as approaches to decision-making
and values clariﬁcation—offering parents
opportunities to participate in parallel pro—
grams;

using a variety of approaches to inform
teenagers about prescription and nonpre-
scription contraceptives, including how they
work, their relative effectiveness, how to use
them effectivelthheir availability and cost;
educating parents to provide effective and
accurate sex education to their children;
encouraging and assisting the public media
to educate the public, especially parents
and young people, about the realities and
possible problems of unwanted pregnancies,
and to present appropriate role models for
teenagers;

using the public media as appropriate for
advertisements explaining the use, cost and
beneﬁts of certain over-the-counter contra-
ceptives;

upgrading the knowledge of family plan-
ning clinicians regarding the relative risks
and effectiveness of all family planning
methods and of lifestyle characteristics
which may place certain individuals at in—
creased risk of complications associated
with one or more speciﬁc methods, such as
smoking by users of oral contraception;
upgrading the counseling skills of individ-
uals who work in health care settings which

serve adolescents—taking care to avoid co-
ercive implications;

improving knowledge within the general
public (both males and females) of the rela-
tive safety and effectiveness of available
family planning methods;

preparing and expecting family planning
counselors and clinicians to include concern
for protection of future fertility and preven-
tion of sexually transmitted diseases when
they counsel family planning clients regard-
ing selection of a family planning method;
improving knowledge and skills of family
planning educators, counselors and clini-
cians regarding “natural” family planning
methods which require periodic abstinence;
increasing awareness of family planning
problems among health care planners;
informing HSAs how to interpret local data
relevant to family planning.

0 Service measures include:
—— making all forms of contraception accessi-

ble and acceptable to people who ﬁnd the
currently available services either inaccessi-
ble or unacceptable;

encouraging wider and more varied distribu-
tion of effective nonprescription contracep-
tives (in medical and other settings);
providing opportunities for teenage boys
and girls to attend family planning educa-
tional and counseling sessions in environ—
ments not identiﬁed speciﬁcally for family
planning and in which they do not feel pres-
sure to make a decision regarding use of
contraception;

providing family planning education, coun-
seling and services to sexually active males
as well as females;

reducing the waiting time required for the
social, educational and medical assessment
of clients in family planning clinics;
ensuring that family planning is part of rou-
tine pcrinatal service (if a woman is breast-
feeding, preference should be given to con-
traceptive methods which do not interfere
with normal lactation).

0 Technologic measures include:
— development of more reliable, acceptable

contraceptive methods for men and women.

b. Relative strength of the measures
0 By 1976, 68 percent of married U.S. couples

were using contraception:

— almost 80 percent of married users were

employing methods which are at least 95
percent effective in preventing conception
(male or female surgical sterilization, oral
contraception or an intrauterine device);

— most of the 32 percent non—users were try-

ing to conceive, were pregnant, post partum,
subfecund or sterile because of surgery per-
formed for a non-contraceptive reason;

—— fewer than 8 percent of married couples
were not using contraception for some other
reason, including lack of access to services.

0 Some forms of infertility are related to sexually
transmitted diseases and to other known causes.
However, in a high proportion of cases, basic
knowledge for prevention and treatment is not
yet available.

3. Speciﬁc Objectives for 1990 or Earlier
0 Improved health status

-—-- Avoiding the personal or social burdens of un-
intended pregnancy (or infertility) is an impor-
tant health status objective, though not easily
quantiﬁable. However, family planning is a key
component of efforts to reduce infant and mater-
nal mortality.

— See Pregnancy and Infant Health.

Reduced risk factors*

a. By 1990, there should be virtually no unintended

births to girls 14 years old or younger. Fulﬁlling

this objective would probably reduce births in
this age group to near zero. (In 1978, there
were less than 10,800 births in this age group.)

By 1990, the fertility rate for 15-year-old girls

should be reduced to 10 per 1,000. (In 1978,

there were 14.2 births per 1,000 for this age

group.)

c. By 1990, the fertility rate for 16-year-old girls

should be reduced to 25 per 1,000. (In 1978,

there were 31.8 births per 1,000 for this age

groun)

By 1990, the fertility rate for 17-year-old girls

should be reduced to 45 per 1,000. (In 1978,

there were 52.1 births per 1,000 for this age

group.)

6. By 1990, reductions in unintended births among
single American women (15 to 44 years of age)
should reduce the fertility rate in this group to
18 per 1,000. (In 1978, there were 26.2 births
per 1,000 unmarried women 15 to 44 years of
age.)

f. By 1990, the proportion of abortions performed

in the second trimester of pregnancy should be

reduced to 6 percent (in 1976, about 11 per-
cent of abortions were performed in the second
trimester), thereby reducing the death-to-case
rate for legal abortions in the United States to

0.5 per 100,000. (In 1977, it was 1.4 per

100,000.)

By 1990, the availability of family planning in-

formation and methods (education, counseling

and medical services) to all women and men
should have sufficiently increased to reduce by

50 percent the disparity between Americans of

different economic levels in their ability to avoid

unplanned births. (In 1976, 52 percent of births

13

that occurred during the previous ﬁve years
reported by evermarried women with family in—
comes below the poverty level were unplanned,
compared to 29.2 percent for women with family
incomes of 150 percent of poverty level or
higher.)

*NOTE: Objectives a. to e. specify reductions in
the fertility rate to reduce unintended births
for speciﬁc age and marital status groups of
women. Some births to women in these groups
are planned. However, unintended births ac-
count for a very large proportion of births to
women in these groups. Thus, reductions in un-
intended births would allow the target objec-
tives to be met without affecting the numbers
of planned births.

Increased public/professional awareness

h. By 1990, at least 75 percent of men and women
over the age of 14 should be able to describe
accurately the various contraceptive methods,
including the relative safety and effectiveness of
one method versus the others. (Baseline data un-
available.)

Improved services/protection

i. By 1985, sales of oral contraceptives contain-
ing more than 50 micrograms of estrogen should
have been reduced to 15 percent of total sales.
(In 1978, about 27.1 percent of preparations
sold were at this level.)

j. By 1985 , 100 percent of Federally funded fam-
ily planning programs should have an estab-
lished routine for providing an initial infertility
assessment, either directly or through referral.
(Baseline data unavailable.)

4. Principal Assumptions

There will continue to be no policy on population
growth in the United States. Therefore, the goals
and objectives of family planning are predicated
solely on individual choice, social responsibility and
concern for health.

Stable families promote the physical, emotional and
social health of the family members, community
and society. The ability of couples to plan the num-
ber and timing of the births of their children sup—
ports the stability of families.

Religious convictions will be respected in the devel-
opment of fertility control policies and programs.
Federal support of family planning services will in-
crease as evidence grows on the ability of family
planning dollars to effect savings in dollars ex-
pended to address problems in other publicly-
ﬁnanced health, social and welfare programs.

The mechanisms for funding clinical family plan—
ning services will remain the same.

Legal, socioeconomic and institutional barriers to
contraception will be removed.

Federal support of population and family planning
research will continue.

Although the overall US. abortion rate may decline

somewhat by 1990, the incidence of abortion among
certain high risk groups will not decrease signiﬁ-
cantly.

0 There will be no major breakthroughs in contracep-
tive technology available to the public during the
1980s.

0 Education can result in behavioral change.

0 Few adolescents younger than age 18 are adequately
prepared for the responsibilities of parenthood.

0 The current trend of an increasing proportion of
adolescents who are sexually active will continue.
However, many teenagers are not ready for sexual
relationships which include intercourse, and the
majority of adolescents under 18 will continue to
defer sexual activity.

0 In the 1980s, industry will not invest heavily in
research and development of new contraceptive
methods.

5. Data Sources

2!. To National level only

0 National Survey of Family Growth (NSFG).
Proportion of women sexually active by age,
race and marital status, and a wide range of
socioeconomic characteristics; fertility experi-
ence (pregnancy histories) of the sexually ac-
tive poulation, including sterility and subfecun-
dity; planning status of each pregnancy accord-
ing to whether contraception had been used and
whether the birth had been wanted, mistimed
(wanted but as a later date), or unwanted at
the time of conception; pregnancy outcome and
survival of the newborn; family planning serv-
ices received; sources of contraceptive supplies,
including over—the-counter methods; contracep-
tive methods being used, use-effectiveness of
methods; switching of methods and reasons for
switching, side effects of contraception. DHHS—
NCHS. NCHS Vital and Health Statistics, Series
23, selected reports. Interview survey of 10,000
women in National probability sample repre-
senting American women 15—44 years of age.
Surveys in 1973 and 1976 limited to women
who were or had been married, or single with

14

offspring in the household. In later surveys, all
women 15—44 years of age will be represented.

0 The National Prescription Audit (NPA). Dis-
tribution of contraceptive prescriptions written
by physicians, by hormonal potency. IMS
America Ltd., Ambler, Pennsylvania. Selected
reports. Continuing survey; pharmacies on MS
panel.

0 National Reporting System for Family Plan-
ning Services (NRSFPS). Visits to family plan-
ning clinics. DHHS—NCHS. Annual reports.
Continuous sample survey since June 1977; con-
tinuous full count reporting from 1972 to June
1977.

b. To State and / or local level

0 Abortion Surveillance. Number and characteris-
tics of women who have legally induced abor-
tions in the United States, abortion related mor-
bidity and mortality. DHHS—Center for Disease
Control (CDC). Annual reports since 1972.
Continuous reporting of abortions from central
health agencies in 40 States and from hospitals
and/or other facilities in the remaining juris-
dictions. Abortion related deaths reported from
the vital statistics section of State health depart-
ments, abortion related morbidity reported from
the Joint Program for the Study of Abortion.

0 National Vital Registration System

— Natality. Births and birth rates by place of
occurrence and by the mother’s place of
residence, age, race and parity. DHHS—
NCHS. NCHS Vital and Health Statistics,
Series 21, selected reports, and Monthly
Vital Statistics Report. Continuous report-
ing by States; full count of birth certiﬁcates
38 States; 50 percent sample remaining
States. State health agencies, derived from
certiﬁcates of live births to US. residents.
Birth rates calculated on the basis of the
number of women 14—49 years of age re-
siding in the respective areas, enumerated
in census years, and estimated for inter-
census years.

PREGNANCY AND INFANT HEALTH

1. Nature and Extent of the Problem

Assuring all infants a healthy start in life and enhanc—
ing the health of their mothers are among the highest
priorities in preventing disease and promoting health.
The principal threats to infant health are problems
associated with low birth weight and birth defects
which can lead to lifelong handicapping conditions. Of
particular concern are the disparities in the health of
mothers and infants that exist between different popu-
lation groups in this country. These differences are
associated with a variety of factors, including those
related to the health of the mother before and during
pregnancy as well as parental socioeconomic status and
lifestyle characteristics. Although the precise relation-
ship between speciﬁc health services and the health
status of pregnant women and their infants is not
certain, the provision of high quality prenatal, ob-
stetrical, and neonatal care, and preventive services
during the ﬁrst year of life, can reduce a newborn’s
risk of illness and death. Of particular concern are
adolescents, whose infants experience a high degree
of low birth weight and whose health problems should
be addressed in a broad context taking into considera-
tion social and psychological implications.

a. Health implications

0 Maternal and infant mortality and morbidity
records show striking demographic variations:

— an overall rate of maternal mortality of 9.6
per 100,000 live births in 1978, but with a
rate for blacks almost four times that for
whites;

— an infant mortality rate of 13.8 per 1,000
live births in 1978, but with the infant
mortality rate for black babies 92 percent
higher than for whites;

— infant mortality rates for individual States
ranged from 10.4 to 18.7 in 1978;

— infant mortality rates in 1977 for 26 major
cities (with populations greater than
500,000) ranged from 10.0 to 27.4; 22 of
the 26 major cities had higher rates than the
National average of 14.1 in 1977.

0 The greatest single problem associated with
infant mortality is low birth weight; nearly two-
thirds of the infants who die are low birth
weight.

0 Maternal factors associated with a high risk

15

of low birth weight babies are: age (17 and
under, and 35 and over), minority status, high
parity, previous unfavorable pregnancy out-
come, low education level, low socioeconomic
status, inter-pregnancy interval less than 6
months, inadequate weight gain during preg-
nancy, poor nutrition, smoking, misuse of
alcohol and drugs and lack of prenatal care.

0 High quality early and continuous prenatal,
birth and postnatal care can decrease a new-
born’s risk of death or handicap from pregnancy
complications, low birth weight, maternal infec-
tion from sexually transmitted disease and
developmental problems, both physical and
psychological.

0 After the neonatal period the causes of infant
mortality and morbidity, many of which may be
preventable, are: disorders related to a high

risk birth, infectious diseases, congenital
anomalies, accidents, lack of health care and
abuse.

b. Status and trends

0 Although the overall rate has been gradually
improving since 1965, an excessive number of
infants born in the United States are of less than
optimal birth weight for survival and good
health. This includes:

— approximately 7 percent of all babies are of
low birth weight, that is, 2,500 grams or
less; the rate is almost twice as high for
blacks; other industrialized nations experi-
enced substantially lower rates during the
period 1970-1976; for example in Japan
5.3 percent of births were low birth weight
and in Sweden 4.1;

— approximately another 17 percent of all
newborns in the United States in 1978 had
birth weights falling between 2,501 and
3,000 grams.

0 Many children in the United States are born
to women who have an increased risk of having
a low birth weight infant or other health prob-
lems, particularly:

— the 25 percent of women giving birth in
1978 who made no prenatal visit during the
ﬁrst trimester and the 5 percent who had no
prenatal care during either of the ﬁrst two
trimesters;

-— the pregnant teenagers (at higher risk for

low birth weight babies) who accounted for
17 percent of the infants born in 1978;

—— the two-thirds of pregnant teenagers in 1976

whose pregnancies were not intended when
they occurred;

— the births to single women (26.2 births per

1,000 single women in 1978) for whom the
data indicate special risk of poor health
outcomes for mother and infant.

portation, to regional centers for high risk
expectant mothers and newborns;

outreach perinatal and infant care services
for currently underserved populations, such
as teenage expectant mothers;

evaluating the quality of perinatal and in-
fant care being received and relating pro-
gram activities to pregnancy and infant
health outcomes;

identifying and tracking infants and families
with medical, congenital, psychological,

2. Prevention/ Promotion Measures social, and/or environmental problems;

— reducing the number of low birth weight
infants by reducing teenage and other high
risk pregnancies, reducing damaging effects
from alcohol, cigarettes and other toxic
substances, improving nutrition, and assur-

a. Potential measures
0 Education and information measures include:

—— developing, implementing and evaluating the

quality and quantity of health education
curricula in schools and communities, with
emphasis on lifestyle risk factors (poor nu-
trition and use of alcohol, cigarettes and
drugs), as well as family life and parenting;
developing, implementing and evaluating
preventive educational strategies and ma-
terials for use in private and public prenatal
care;

increasing the use of mass media to encour-
age more healthful lifestyles; developing
television and radio programs that support
healthful lifestyles;

making prospective parents at high risk of
impaired fetuses aware of genetic diagnosis
and counseling services so that those af-
fected can make informed decisions con-
sistent with their personal ethical and re-
ligious values;

--— promoting, educating and supporting breast-

feeding where possible.

0 Service measures include:

— family planning services which optimize the

timing of pregnancies;

prenatal care which routinely includes edu-
cation on avoidable risks to maternal and
fetal health during pregnancy;

assuring that all populations are served by
organized medical care systems that include
providers (physicians, nurse practitioners,
nurse midwives, nutritionists and others)
who are trained to deliver prenatal, post-
natal and infant care on site (requires per-
sonnel strategies and economic and pro-
fessional incentives);

developing local, easily accessible prenatal
services for all, including access to amniocen-
tesis for high risk pregnant women;
regionalizing prenatal and perinatal services
so that all women and newborns receive
diagnostic and therapeutic care appropriate
to their assessed needs;

—— assuring adequate linkages, including trans-

16

ing participation in comprehensive pre-
conceptional, inter-conceptional and early
and continuing prenatal care;

eliminating unnecessary radiation exposure
to pregnant women and babies;

assuring that all programs of primary care
support and contribute to the fulﬁllment of
objectives related to maternal and infant
health; ,
encouraging parent support groups, hotlines,
and counseling for parents of high risk in-
fants and supports for lowering stress levels
in troubled parents who may have potential
for child abuse.

— See Family Planning, Immunization, and

Sexually Transmitted Diseases.

0 Legislative and regulatory measures include:
— requiring that all Federally funded programs

for delivering perinatal care assure adequate
health and prenatal education, screening for
pregnancy risks and patient plans for care
during labor and delivery appropriate to
discovered risks, and for infant follow-up
and care through the ﬁrst year of life;

' requiring ﬁscal and pregnancy outcome ac-

countability in publicly funded prenatal and
perinatal programs;

reducing exposures to toxic agents that may
contribute to physical handicaps or cogni-
tive impairment of babies.

0 Economic measures include:
— reviewing all programs that ﬁnance or pro-

vide health services for mothers and children

in order to:

— assure inclusion of health promotion and
preventive services;

— optimize their effect by reducing overlaps,
pockets of neglect and contradictory
objectives;

adequate public ﬁnancing for outreach, early

and continuous prenatal care, deliveries,

support services, intensive care when needed
and continuing care of infants;

— consideration of direct Federal ﬁnancing
tied to uniform standards of performance
where public health departments show po-

' tential for expanding maternal and child
health services to populations in need.

b, Relative strength of the measures

0 The relative effectiveness of various interven-
tions to improve pregnancy Outcome and infant
health is not without controversy. The records
of many demonstration projects, both domestic
' and foreign, amply conﬁrm that dramatic im-
provements can be made in the indicators of
maternal, and infant health. For example, the
infant mortality rate for American Indians was
reduced by 74 percent between 1955-1977 and
maternal mortality decreased from 2.2 times the
total US. rate in 1958, to below the total US.
rate by 1975-76. Unfortunately, studies have
not generally been designed to yield ﬁrmly de-
fensible data on the relative contribution of
programs. However, the evidence indicates that
emphasis be placed on family planing which
optimizes the timing of pregnancies, early identi—
ﬁcation of pregnancy and routine involvement
of all pregnant women in prenatal care. There-
fore, the following priorities are strongly sug-
gested: _

—— systems of care that reach everyone with
basic services, emphasizing advantageous
personal health behavior and including out-
reach, education, and easy access to com-
munity-based services without social, eco-
nomic, ethnic or time or distance barriers;
measures which prevent unwanted preg-
nancies and which optimize the most favor-
able maternal age for childbearing, including
sex education, contraception, easy access to
pregnancy testing, genetic counseling, pre-
natal diagnosis and associated counseling;
early and continuing prenatal care, particu-
larly for those at greatest risk—poor, poorly
educated women, those near the beginning
or the end of their reproductive age, those
with previous pregnancy loss and those with
recent pregnancy;

nutrition education and food supplementa-
tion as needed, as well as parent education
on importance of good infant nutrition, pre-
ventive measures essential to avoid child-
hood disease and accidents and parenting
conducive to sound emotional development;
cessation of smoking during pregnancy
(which may contribute much more to the
improvement of birth weight and to favor-
able pregnancy outcome than is now fully
documented) ;

regionalized programs of care with referral
system which assure access to levels of care
appropriate to special risks.

17

3. Speciﬁc Objectives for 1990
0 Improved health status

a.

*h.

By 1990, the National infant mortality rate
(deaths for all babies up to one year of age)
should be reduced to no more than 9 deaths
per 1,000 live births. (In 1978, the infant mor-
tality rate was 13.8 per 1,000 live births.)

By 1990, no county and no racial or ethnic
group of the population (e.g., black, Hispanic,
Indian) should have an infant mortality rate in
excess of 12 deaths per 1,000 live births. (In
1978, the infant mortality rate for whites was
12.0 per 1,000 live births; for blacks 23.1 per
1,000 live births; for American Indians 13.7
per 1,000 live births; rate for Hispanics is not
yet available separately.)

By 1990, the neonatal death rate (deaths for all
infants up to 28 days old) should be reduced to
no more than 6.5 deaths per 1,000 live births.
(In 1978, the neonatal death rate was 9.5 per
1,000 live births.)

By 1990, the perinatal death rate should be re-
duced to no more than 5.5 per 1,000.“l (In
1977, the perinatal death rate was 15.4 per
1,000.)

*NOTE: The perinatal death rate is total deaths
(late fetal deaths over 28 weeks gestation plus
infant deaths up to 7 days old) expressed as
a rate per 1,000 live births and late fetal
deaths.

By 1990, the maternal mortality rate should
not exceed 5 per 100,000 live births for any
county or for any ethnic group (e.g., black,
Hispanic, American Indian). In 1978, the over-
all rate was 9.6—-—the rate for blacks was 25.0,
the rate for whites was 6.4, the rate for Ameri-
can Indians was 12.1; the rate for Hispanics
is not yet available separately.)

By 1990, the incidence of neural tube defects
should be reduced to 1.0 per 1,000 live births.
(In 1979, the rate was 1.7 per 1,000.)

By 1990, Rhesus hemolytic disease of the new-
born should be reduced to below a rate of 1.3
per 1,000 live births. (In 1977, the rate was
1.8 per 1,000.)

By 1990, the incidence of infants born with
Fetal Alcohol Syndrome should be reduced by
25 percent. (In 1977, the rate was 1 per 2,000
births or aproximately 1,650 cases.)

*NOTE: Same objective as for Misuse of Alco-
hol and Drugs.

—— See Nutrition.
0 Reduced risk factors

i.

j.

By 1990, low birth weight babies (2,500 grams
and under) should constitute no more than 5
percent of all live births. (In 1978, the pro-
portion was 7.0 percent of all births.)

By 1990, no county and no racial or ethnic

group of the population (e.g., black, Hispanic,
American Indian) should have a rate of low
birth weight infants (prematurely born and
small-for-age infants weighing less than 2,500
grams) that exceeds 9 percent of all live births.
(In 1978, the rate for whites was about 5.9
percent, for Indians about 6.7 percent, and for
blacks about 12.9 percent; rates for Hispanics
are not yet separately available; rates for some
other nations are 5 percent and less.)

By 1990, the majority of infants should leave
hospitals in car safety carriers. (Baseline data
unavailable.)

See Nutrition, Family Planning, Smoking and
Health, Misuse of Alcohol and Drugs, Sexually
Transmitted Diseases, Immunization, Occupa-
tional Safety and Health, Toxic Agent Control,
and Accident Prevention and Injury Control.

0 Increased public/professional awareness

1. By 1990, 85 percent of women of childbearing
age should be able to choose foods wisely (state
special nutritional needs of pregnancy) and
understand the hazards of smoking, alcohol,
pharmaceutical products and other drugs during
pregnancy and lactation. (Baseline data unavail-
able.)

See Nutrition, Smoking and Health, Misuse of
Alcohol and Drugs, Sexually Transmitted Dis-
eases, Immunization, Occupational Safety and
Health, and Toxic Agent Control.

0 Improved services/protection

m. By 1990, virtually all women and infants should
be served at levels appropriate to their need by
a regionalized system of primary, secondary and
tertiary care for prenatal, maternal and perinatal
health services. (In 1979, approximately 12
percent of births occurred in geographic areas
served by such a system.)

By 1990, the proportion of women in any
county or racial or ethnic groups (e.g., black,
Hispanic, American Indian) who obtain no
prenatal care during the ﬁrst trimester of preg-
nancy should not exceed 10 percent. (In 1978,
40 percent of black mothers and 45 percent of
American Indian mothers received no prenatal
care during the ﬁrst trimester; percent of His-
panics is unknown.)

By 1990, virtually all pregnant women at high
risk Of having a fetus with a condition diagnos-
able in utero, should have access to counseling
and information on amniocentesis and prenatal
diagnosis, as well as therapy as indicated. (In
1978, about 10 percent of women 35 and over
received amniocentesis. Baseline data are un-
available for other high risk groups.)

By 1990, virtually all women who give birth
should have appropriately-attended, safe de-
livery, provided in ways acceptable to them and

p.

18

their families. (In 1977, less than .3 percent
of births were unattended by a physician or
midwife. Furthermore, of births which are at-
tended by a physician or midwife, an unknown
share are not considered satisfactory by the
women or their families.)

By 1990, virtually all newborns should be pro-

vided neonatal screening for metabolic disorders

for which effective and efﬁcient tests and treat-
ments are available (e.g., PKU and congenital
hypothyroidism). (In 1978, about 75 percent

of newborns were screened for PKU; about 3

percent were screened for hypothyroidism in the

early 1970’s, with the rate now rapidly increas-
ing.)

r. By 1990, virtually all infants should be able to
participate in primary health care that includes
well child care; growth development assessment;
immunization; screening, diagnosis and treat-
ment for conditions requiring special services;
appropriate counseling regarding nutrition,
automobile safety, and prevention of other ac-
cidents such as poisonings. (Baseline data
unavailable. )

— See Nutrition, Immunization, Accident Pre-
vention and Injury Control.

Improved surveillance/evaluation systems

s. By 1990, a system should be in place for com-
prehensive and longitudinal assessment of the
impact of a range of prenatal factors (e.g.,
maternal exposure to radiation, ultrasound,
dramatic temperature change, toxic agents,
smoking, use of alcohol or drugs, exercise, or
stress) on infant and child physical and psycho-
logical development.

4. Principal Assumptions

Assurances of participation in essential services will
be enhanced by various programs of outreach and
by communication with client groups to achieve
styles of service that are appropriate and acceptable
to different populations, and by initiating or expand-
ing publicly sponsored programs of care as may be
necessary for people who are not reached by private
and traditional provider systems.

Current efforts to ensure an adequate supply of food
will be continued and extended (WIC and food
stamps).

Information will be routinely provided to pregnant

women on serum alphafetoprotein screening; screen-

ing will be provided for medical, obstetric, psycho-
social and genetic risks, and participation assured
in appropriate levels of diagnosis, support and
treatment.

Prenatal care will routinely include education on
avoidable risks to maternal and fetal health during
pregnancy, and to infant health following birth.
Perinatal and infant care will include but not be
limited to:

— nutritional education and supplementation as

needed, including preparation and support for
breastfeeding (See Nutrition);

— psychosocial supports which promote parenting
behavior conducive to parent—child attachment;

— promotion of lifestyles that encourage good
parental, infant and child health practices;

— linkages that assure antenatal identiﬁcation of
risks, risk reduction activities and completed
plans for participation in appropriate intrapar-
tum and continuing infant care;

—— provision of Rhesus immune globulin to all Rh
negative women, not previously sensitized, who
have a known or presumed Rh positive
pregnancy.

Achieving objectives that deal with mortality and
low birth weight presumes participation in compre-
hensive services that will also work to reduce
maternal and infant morbidity associated with life-
style and environmental risks, including:

— alcohol and drug use;

— smoking;

— management of parental stress;

— toxic substances during pregnancy and lactation;

— occupational safety and health;

— prevention of infant and child accidents;

— See Misuse of Alcohol and Drugs, Smoking
and Health, Control of Stress and Violent Be-
havior, Toxic Agent Control, Occupational
Safety and Health, Accident Prevention and
Injury Control.

Reduction of unwanted and unintended pregnancies
will achieve reduction of pregnancies in teenage and
late childbearing years, and will concentrate child-
bearing during optimum maternal ages. Efforts to
reduce unwanted pregnancies are presumed to pro-
vide for:

—— education on sex, family life and reproductive
health;

— ready access to all forms of family planning
servrces;

— ready access to pregnancy testing, with asso-
ciated counseling and referral;

— See Family Planning.

All needful infants and families will participate in
support services (e.g., food supplementation, in-
come supports, day care, minimum housing) that
are deﬁned by National standards which assure
equity.

All pregnant women will have access to regionalized
systems of maternity care which assure services
appropriate to need.

Agencies receiving public funds related to health
care—including Federal, State and local units of
government, private agencies, and quasi-public
agencies such as HSAs—will adopt these or more
stringent objectives, and will document their
progress toward meeting them.

19

5. Data Sources
a. To National level only

0 Health Interview Survey (HIS). Smoking and
drinking prevalence among women of childbear-
ing age. DHHS-NCHS. NCHS Vital and Health
Statistics, Series 10, selected reports, and NCHS
Advance Data from Vital and Health Statistics,
selected reports. Continuing household inter-
view survey; National probability samples.

0 Hospital Discharge Survey (HDS). Deliveries
in hospital. DHHS-NCHS. NCHS Vital and
Health Statistics, Series 13, selected reports.
Continuing survey, National probability sample
of short-stay hospitals.

0 National Ambulatory Care Survey (NAMCS).
Visits to private physicians for prenatal care.
DHHS-NCHS. NCHS Vital and Health Statis—
tics, Series 13, selected reports. Continuing
survey; National probability sample ofﬁce-based
physicians.

0 National Reporting System for Family Planning
Services (NRSFPS). Visits to family planning
clinics. DHHS-NCHS. Annual Reports. Con-
tinuous sample survey since June 1977; con-
tinuous full count reporting from 1972 to June
1977.

0 National Natality Follow Back Survey. Selected
data from 1964-66 Follow Back. NCHS Vital
and Health Statistics, Series 22. Survey of
mothers with legitimate live births; sample of
birth records.

0 1980 National Natality Survey/1980 National
Fetal Mortality Survey. Birth and fetal deaths
by numerous characteristics not available from
the Vital Registration System. DDHS-NCHS.
Currently in the ﬁeld. Public use data tapes will
be available from the survey. National sample
survey.

0 National Survey of Family Growth (NSFG).
Characteristics of women of childbearing age.
DHHS-NCHS . . . NCHS Vital and Health Sta-
tistics, Series 23, selected reports, and Advance
Data from Vital and Health Statistics, selected
reports. Periodic surveys at intervals of several
years; National probability sample.

b. To State and/ or local level

0 National Vital Registration System

—- Natality: Births by age, race, parity, marital
status. Most States also have number of
prenatal visits, timing of ﬁrst prenatal visit,
educational level of mother, sometimes of
father. DHHS-NCHS. NCHS Vital Statistics
of the United States. Vol. 2, and Monthly
Vital Statistics Reports, Series 21. Continu-
ous reporting by States; full count of birth
certiﬁcates 38 States, 50 percent sample
sample remaining States. (Many States issue
their own earlier reports).

— Mortality. Deaths (including infant and fetal

deaths) by age at death, sex, race. Some
States 'link mortality and natality thus mak-
ing full natality data available. DHHS-
NCHS. Vital Statistics of the United States,
Vol. 1, parts A and B; and NCHS Monthly
Vital Statistics Report by States, Series 21,
selected reports. Continuous reporting by
States, all events. (Many States issue their
own earlier reports.)

0 Hospitalized illness discharge abstract systems.

— Professional Activities Study (PAS). Pa-
tients in short stay hospitals; patient charac-
teristics, deliveries, diagnoses of congenital
anomolies, procedures performed, length of
stays. Commission on Professional and Hos-
pital Activities, Ann Arbor, Michigan. An-

20

nual reports and tapes. Continuous report-
ing from 1900 CPHA member hospitals; not
a probability sample, extent of hospital
participation varies by State.

— Other hospital discharge systems as locally
available.

— Selected health data. DHHS-NCHS. NCHS
Statistical Notes for Health Planners. Com-
pilations and analysis of data to State level.

Area Resource File (ARF). Demographic,
health facility and manpower data at Statearid
county level from various Sources. DHHS-
Health Resources Administration. Area Re-
source File—a Manpower Planning and Re-
search T 001, DHHS HRA-80—4, Oct 79. One
time compilation.

IMMUNIZATION

1. Nature and Extent of the Problem

Vaccines are among the safest and most effective meas-
ures for the prevention of infectious and communica-
ble diseases. Introduction and widespread use of vac-
cines have resulted in global eradication of smallpox
and in dramatic declines in the incidence of diphtheria,
measles, mumps, pertussis (whooping cough), polio,
rubella and tetanus. Although eﬂorts to vaccinate in-
creasingly higher proportions of target populations
have been successful in recent years, continued activi-
ties are required to complete the task. Moreover, con-
tinued vigilance is required to maintain past successes
in avoiding illnesses and deaths from these diseases,
since, with the exception of smallpox, the causal agents
have not been eliminated and the risk continues. Full
implementation of inﬂuenza immunization, and new
vaccines as they are developed, imposes a continuing
challenge since the target populations (such as for a
sexually transmitted diseases vaccine) may be different
from those presently receiving vaccines.

a. Health implications

0 Cessation of vaccination would inevitably lead
to the recurrence of annual epidemics, for exam-
ple, of measles, rubella, diphtheria, and mumps,
as well as periodic epidemics of polio and greater
incidence of tetanus.

0 During periodic pandemics, thousands of people
may die prematurely as a result of inﬂuenza. Be-
tween these pandemics, excess mortality due to
inﬂuenza may also be in the thousands. Those
primarily aﬁected are the chronically ill and the
elderly.

0 Pneumonia causes over 50,000 deaths annually
and over half these deaths occur among people
over 65. The risk of death from pneumonia is
2.5 times higher for those aged 65 to 74 and 10
times higher for those 75 to 84 than for the pop-
ulation as a whole.

b. Status and trends

0 From the years of their initial development to
the present, the various immunizations have
brought global eradication of smallpox and sharp
declines in morbidity and mortality from other
diseases:

—- diphtheria—approximately 160,000 cases
and 10,000 deaths or more annually in the
early 19205; 59 cases in 1979 and 4 deaths

21

in 1978 (most recent year for which data are
available);

— whooping cough—approximately 200,000
cases and approximately 5,000 deaths annu—
ally in the early 1930s; 1,617 cases in '1979
and 6 deaths in 1978;

— polio—21,000 cases of paralytic polio in
1952 (epidemic year); 26 cases in 1979;

—— mumps—152,000 cases in 1968; 14,225 in
1979;

— rubella—60,000 cases in 1969, 11,795 in
1979;

—- measles—480,000 cases in 1962; 13,597
cases in 1979.

0 Morbidity from inﬂuenza and pneumonia is not
reportable, so trends cannot be determined.

0 With the dramatic reduction of vaccine prevent-
able diseases, the rare adverse eﬁects of immuni-
zation have become increasingly visible.

0 An effective system for assuring that routine im-
munizations are delivered to susceptible popula-
tions has not yet been established nationwide.

0 Immunization is required by law for ﬁrst entry
into school in all 50 States and the District 0
Columbia. ‘

0 Liability associated with vaccines, and compen-
sation of those injured as a result of immuniza-
tion, have emerged as issues in the effective de-
livery of services.

2. Prevention/Promotion Measures

a. Potential measures
0 Education and information measures include:

-— providing useful immunization information
to all mothers and new parents by hospitals,
physicians and others;

—- aiming educational programs at members of
the health care professions;

-— including discussion of immunization and
preventive measures in school health curric-
ula;

—- enlisting day care centers, senior citizen cen-
ters and churches to provide immunization
information to parents and to older people;

—- using the mass media for immunization ac-
tivities;

—— continuing use of volunteers.

0 Service measures include:

adopting standardized ofﬁcial immunization
records;

developing and using “tickler” and recall
systems to ensure that children return for
immunizations on schedule;

reviewing records to identify children need-
ing immunizations;

making immunizations available without ﬁ-
nancial barriers in all health care settings as
a part of comprehensive health services;
providing information and immunization

severe complications associated with some vac-
cines are essential to maintain and extend pre-
vention of these diseases. Experience developed
from the recent Childhood Immunization Initia-
tive has demonstrated the importance of mass
media and volunteer promotion of routine immu-
nization to parents and children.

3. Speciﬁc Objectives for 1990 or Earlier

0 Improved health status

services to special populations such as immi- 3. 13331990’ reportﬁd measles 1nc1dence should.be
grants and non-English speaking groups; re need to 1.655. t an 50 cases per year—allim-

_ continuing use of volunteers. ported or Wlthln two generations of importation.

(In 1979, there were 13, 597 measles cases re-

Legislative and regulatory measures include: ported.)

— enforcing existing school immunization re- b. By 1990, reported mumps incidence should be
quirements and extending them to include reduced to less than 1,000 cases per year. (In
children at all grade levels in both public 1979, there were 14,225 mumps cases re-
and private schools, as well as in organized ported.)
preschool settings; c. By 1990, reported rubella incidence should be

— including consideration of coverage of im- reduced to less than 1,000 cases per year. (In
munization as a Medicare beneﬁt; 1979, there were 11,795 rubella cases reported.)

—— requiring carriers under any National health (1. By 1990, reported congenital rubella syndrome
insurance plan to reimburse for immuniza— incidence should be reduced to less than 10 cases
tion services; per year. (In 1979, there were 62 new cases of

— requiring immunization as a condition of em- congenital rubella syndrome.)
ployment (e.g., in health care institutions e. By 1990, reported diphtheria incidence should
and for school age employees); be reduced to less than 50 cases per year. (In

— requiring rubella immunization as a service 1979, there were 59 diphtheria cases reported.)
routinely offered in family planning clinics, f. By 1990, reported pertussis incidence should be
primary care clinics, hospitals (particularly reduced to less than 1,000 cases per year. (In
post-partum settings) and HMOs. 1979, there were 1,617 pertussis cases reported.)

Economic measures include: g. By 1990, reported tetanus incidence should be

_ . b r 'n f . rn nization nder ublic reduced to less than 50 cases per year. (In 1979,
reign u 51 ghorl 1:1“. u i u . p there were 81 tetanus cases reported.)
an private ea t insurance p ans, h. By 1990, reported polio incidence should be less

— providing vaccine free to all health care pro-
viders as long as they do not charge for it;
— providing economic incentives to health care

than 10 cases per year. (In 1979, there were 26
polio cases reported.)

0 Increased public/ professional awareness

i. By 1990, all mothers of newborns should receive
instruction prior to leaving the hospital or after
home births on immunization schedules for their

providers and vaccine recipients.

b. Relative strength of the measures
0 The uniform and forceful implementation of

school immunization requirements is one of the
most effective means of improving immunization
levels currently available. Enforcement of such
requirements to the point of exclusion from
school has resulted in the highest achievable im-
munization levels of school children and the
lowest reported levels of diseases such as mea-
sles. One problem with this measure is that it
does not assure that all preschool children are
adequately immunized before the time of entry
to school. Other potential regulatory measures,
such as immunization requirements for employ-
ment in hospitals, address speciﬁc problems in
selected population groups and are less effective.
Continuing education and motivation of the gen-
eral public and health providers about the need
to continue routine immunization and the ac-
companying need to accept the minimal risk of

22

babies. (Baseline data unavailable.)

0 Improved services/ protection

J.

By 1990, at least 90 percent of all children
should have completed their basic immunization
series by age 2—measles, mumps, rubella, polio,
diphtheria, pertussis and tetanus. (In 1978, com-
pletion varied from 50 to 90 percent.)

By 1990, at least 95 percent of children attend-
ing licensed day care facilties, and kindergarten
through 12th grade should be fully immunized.
(Based on data collected during the 1978—1979
school year, the immunization level for measles,
rubella, polio and DTP was about 90 percent for
ﬁrst school entrants, lower overall.)

By 1990, at least 60 percent of high risk popula-
tions as deﬁned by the Immunization Practices
Advisory Committee of the Public Health Serv-

ice (ACIP) should be receiving annual immuni-
zation against inﬂuenza. (In 1979, about 20 per-
cent of high risk populations were immunized.)

m. By 1990, at least 60 percent of high risk popula-
tions, as deﬁned by the ACIP, should have re-
ceived vaccination against pneumococcal pneu-
monia. (Baseline data unavailable.)

*n. By 1990, at least 50 percent of people in popula-
tions designated as targets by the ACIP should
be immunized within 5 years of licensure of new
vaccines for routine clinical use.

*NOTE: Same objective as for Surveillance and
Control of Infectious Diseases. Potential candi-
dates include: hepatitis A and B; otitis media
(S. pneumoniae and H. inﬂuenza); selected
respiratory and enteric viruses; meningitis
(group B N. meningitides, S. pneumoniae, H.
inﬂuenza).

0. By 1985, the Nation should have a plan in place
to mount mass immunization programs in the
face of possible epidemics of inﬂuenza or other
epidemic diseases for which vaccines may exist.

p. By 1990, no comprehensive health insurance
policies should exclude immunizations. (Base-
line data unavailable.)

Improved surveillance/ evaluation systems

q. By 1990, at least 95 percent of all children
through age 18 should have up-to—date ofﬁcial
immunization records in a uniform format using
common guidelines for completion of immuniza—
tion. (Baseline data unavailable.)

r. By 1990, surveillance systems should be suﬂi-
ciently improved that (1) at least 90 percent of
those hospitalized, and 50 percent of those not
hospitalized, with vaccine preventable diseases
of childhood are reported, and that (2) uniform
case deﬁnitions are used nationwide. (Baseline
data unavailable.)

4. Principal Assumptions

Support for immunization activities in the private
sector will remain at least as high as in 1978—79.

In the public sector, local, State and Federal support
will maintain immunization activities at least at cur-
rent levels.

Issues of vaccine liability and compensation of indi-
viduals damaged by vaccine—which have occasion—
ally hampered immunization activities—will be re-
solved, or at least will not worsen. Procedures for
informing recipients of the risks and beneﬁts of vac-
cines will not become more complex and may be
simpliﬁed. Any worsening in these areas would jeop-
ardize attainment of the objectives.

Vaccines will continue to be available in the quanti-
ties needed, in a timely fashion, and with no extraor-
dinary increase in cost.

No hitherto-unknown serious adverse reactions will
appear which will affect vaccine acceptability.
Immunity induced by recently introduced vaccines

23

(e.g., measles, mumps and rubella) will prove to be
permanent. Immunity will be induced in well over
90 percent of recipients.

Schools will continue active involvement and strict
enforcement of immunization requirements; no legal
challenges to this approach will be successful.

. Use of multiple antigen vaccines (e.g., combined

measles—mumps-rubella) will be standard procedure.
Support for the development and testing of new and
improved vaccines will continue at least at present
levels. Current diﬂiculties in recruiting volunteers for
vaccine trials will be resolved.

5. Data Sources
3. To National level only

0 National Ambulatory Medical Care Survey
(NAMCS). Patient visits to physicians by pa-
tient and physician characteristics, diagnosis, pa-
tient’s reasons for the visit and services provided,
including immunization. DHHS-National Center
for Health Statistics (NCHS). NCHS Vital and
Health Statistics, Series 13, selected reports, and
NCHS Advance Data from Vital and Health Sta-
tistics. Continuing; National probability sample
physician’s ofﬁce based practices since 1973.

0 Health Interview Survey (HIS). Interview re-
spondents reports of illness (including childhood
communicable diseases, inﬂuenza, pneumonia),
disability, use of hospital, medical, dental, and
other services, and other health-related topics.
DHHS-NCHS. NCHS Vital and Health Statis-
tics, Series 10. Continuing survey; household in-
terviews, National probability sample.

0 Health and Nutrition Examination Survey
(HANES). Immunization status; serologic data.
DHHS—NCHS. HANES I, 1971—1974; HANES
II, 1979. NCHS Vital and Health Statistics, Se-
ries 10. Periodic surveys, data obtained from
physical examinations, National probabiilty sam-
ples.

0 US. Immunization Survey (USIS). Percentages
of individuals immunized with DTP, TOPV,
measles, rubella and mumps vaccines by age and
socioeconomic status. DHHS—Center for Disease
Control (CDC). Survey; National subsample of
households interviewed for the Current Popula-
tion Survey of the US. Census. United States
Immunization Survey: 1979. Continuing, annual.

0 Vaccine distribuiton system. Distribution of vac-
cines by antigen. DHHS-CDC. CDC Biologics
Surveillance Report. Quarterly. Continuing; re-
ports frorn vaccine manufacturers.

0 Vaccines administered. Doses of vaccines admin-
istered in the public sector. DHHS—CDC. CDC
Memoranda to State and local health depart-
ments. Continuing; quarterly reporting from
State and local immunization programs.

0 'Adverse Reaction Monitoring System (ARMS).
Adverse reactions to vaccination. DHHS-CDC.
Surveillance report. Continuous reporting from
State and local immunization programs.

0 School Entry Immunization Survey. Immuniza-

tion status of children on entry to kindergarten
or ﬁrst grade. DHHS-CDC. Memoranda to State
and local health departments. Annual reporting
from State and local immunization programs.
Preschool immunization surveys. Immunization
status of preschool children. DHHS-CDC. Mem-
oranda to State and local health departments.
Annual or as needed. Survey of day care centers
and other surveys of 2 year old children by State
and local immunization programs.

b. To State and / or local level

National Vital Registration System

— Mortality. Deaths by cause (including dis-
eases preventable by immunization), age,
sex and race. DHHS—NCHS. NCHS Vital
Statistics of the United States, Vol. II, and
NCHS Monthly Vital Statistics Reports.
Continuing reporting from States; National
full count. (Many States issue earlier reports.)

Hospitalized illness discharge abstract systems

— Medicare hospital patient reporting system
(MEDPAR). Characteristics of Medicare pa-
tients, diagnoses, procedures. DHHS-Health
Care Financing Administration-Ofﬁce of
Research, Demonstrations and Statistics
(ORDS). Periodic reports. Continuing re-
porting from hospital claim data; 20 percent
sample.

24

—— Other hospital discharge systems as locally
available.

Selected health data. DHHS-NCHS. NCHS Sta-
tistical Notes for Health Planners. Compilations
and analysis of data to State level.

National Morbidity and Mortality Reporting
System. Numbers of 46 reportable diseases;
deaths in 121 US. cities. DHHS—CDC. CDC
Morbidity and Mortality Weekly Report, and an-
nual reports. Morbidity: continuous reporting
from State health departments on basis of physi-
cian reports. (Completeness of reporting varies
greatly, since not all cases receive medical care
and not all treated conditions are reported.)
Mortality: continuous reporting from volunteer
panel of health departments in 121 US. cities,
full count.

Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) reporting system. Immuni-
zation status and referral of children screened.
DHHS—Health Care Financing Administration
(HCFA), Ofﬁce of Research, Demonstration
and Statistics. Medicaid Statistics, selected re-
ports. Continuing reporting from State Medicaid
ﬁles.

Area Resource File (ARF). Demographic,
health facility and manpower data at State and
county level from various sources. DHHS-
Health Resources Administration (HRA). HRA
Area Resource File: A Manpower Planning and
Research Tool. DHHS-HRA-80-4, Oct 79. One
time compilation.

SEXUALLY TRANSMITTED DISEASES

1. Nature and Extent of the Problem

Sexually transmitted diseases (STDs) are infections
grouped together because they spread by transfer of in-
fectious organisms from person to person during sexual
contact. Sexually transmitted diseases are major public
health problems because they cause enormous human
suffering, cost hundreds of millions of dollars and im-
pose tremendous demands on medical care facilities.
The sexually transmitted disease problem is rooted in
apathy and ignorance. Neglect is widespread, dehuman-
izing and institutionalized in the public and private
sectors, including educational settings ranging from
public schools to those for the health professions.
Women and children bear an inordinate share of the
sexually transmitted disease burden: sterility, ectopic
pregnancy, fetal and infant deaths, birth defects and
mental retardation. Cancer of the cervix may be linked
to sexually transmitted Herpes II virus.

a. Health implications

0 The most serious complications caused by sex-
ually transmitted agents are pelvic inﬂammatory
disease, infant pneumonia, infant death, birth de-
fects and mental retardation.

0 Pelvic inﬂammatory disease is the most serious
complication from gonorrhea and chlamydia] in-
fections. More than 850,000 cases are diagnosed
and treated each year; the major proportion of
these are associated with past or present sexually
transmitted diseases. In 1978, it was estimated
that 150,000 new cases of pelvic inﬂammatory
disease were caused by gonorrhea. In addition:

— half of all women hospitalized for pelvic in-
ﬂammatory disease are less than 25 years of
age; sterility due to pelvic inﬂammatory dis-
ease currently aﬂects over 50,000 women
annually and is increasing;

— over 35,000 ectopic pregnancies occur each
year resulting in danger to the woman’s life;
many of these result from the long-term
effects of pelvic inﬂammatory disease;

— pelvic inﬂammatory disease yearly accounts
for over 250,000 hospitalizations and over
50,000 major surgical procedures, many in-
volving total removal of the reproductive
organs.

0 Chlamydia causes an estimated 50,000 eye in-
fections and 25,000 cases of pneumonia per year
in infants.

0 Genital herpes infections are very common, with
an incidence of one-half to one million new cases
annually, with several million recurrences each
year, and:

— no effective treatment is currently available
for this painful condition; periodic recur-
rences are the rule;

——- herpes-complicated pregnancies often result
in abortion, stillbirth or severe neonatal in-
fection; neonatal herpes results in death or
permanent disability in two-thirds of the
cases.

0 Hepatitis B is caused by a virus with many dif-
ferent modes of transmission, including sexual
transmission. Homosexual men are at very high
risk; nearly 60 percent attending sexually trans-
mitted disease clinics show evidence of past or
present Hepatitis B infection. This same popula-
tion is also at high risk of several other sexually
transmitted diseases, including amebiasis and
giardiasis. -

0 These and other sexually transmitted diseases
have placed great strain upon the resources of
local health departments during the 19705.

b. Status and trends

0 Total costs for sexually transmitted diseases
vastly exceed one billion dollars annually.

0 Costs for the most common reported sexually
transmitted disease, gonorrhea, were estimated
to total over $770 million in 1978.

2. Prevention/Promotion Measures

a. Potential measures
0 Education and information measures include:

— education and training, including clinical ex-
perience in schools for health professionals;

— education and information about sexually
transmitted diseases for school children be-
fore, and during, the time they are at highest
risk;

— pre—service and continuing professional edu-
cation for both health providers and health
educators to deal with sexually transmitted
diseases in a conﬁdential, non-judgmental
fashion;

— improved public understanding of sexually
transmitted disease risks and conﬁdentiality

of treatment through effective and continu-
ous campaigns using mass media; the meas—
ures may be directed to wide populations or
targeted to special groups such as adoles-
cents, homosexuals, women with pelvic in-
ﬂammatory disease and other risk groups;
cOunseling of patients being treated for sex-
ually transmitted diseases regarding compli-
cations and measures to avoid future infec-
tion;

use of peers, who are often adjuncts to edu-
cate and counsel adolescents about sexually
transmitted diseases.

0 Service measures include:

——- provision of diagnostic and treatment ser-
vices for the sexually transmitted diseases
and their complications;

counseling infected patients and tracing and
treating their contacts;

screening for selected sexually transmitted
diseases;

encouraging joint availability of services
among related programs such as sexually
transmitted diseases, family planning and
maternal and child health.

0 Technologic measures include:

—- properly used condoms as the best known
measure for persons engaging in sexual ac-
tivity to avoid acquiring or transmitting many
of the sexually transmitted diseases;

— a vaccine for Hepatitis B (being tested for
efﬁcacy); vaccines for gonorrhea and genital
herpes (at an earlier stage of development).

0 Legislative and regulatory measures include:

— Health Systems Agencies (HSAs) determin-
ing the magnitude of the sexually transmitted
disease problem and establishing objectives
for inclusion in their Annual Implementation
Plans (AIPs);

State Health Planning and Development
Agencies (SHPDAs) making certain that the
State health plan addresses gaps in education
and service delivery regarding sexually trans—
mitted diseases;

examination of health professionals’ knowl-
edge of sexually transmitted diseases and
competency in dealing with sexually trans-
mitted diseases by specialty boards, certify-
ing agencies and other regulatory boards;
establishment of a comprehensive review rat-
ing and accreditation to evaluate and main—
tain the quality of STD care and services;
State and local governments repealing stat-
utes and ordinances which inhibit the adver-
tising, display, sale or distribution of con-
doms;

regulations mandating information about
sexually transmitted diseases as part of
school health education programs.

26

Economic measures include:

— sexually transmitted disease services, as with
other prevention-related activities, being ex-
empted from coinsurance or deductible pro-
visions of health insurance;

prepaid health plans receiving ﬁnancial in-
centives for sexually transmitted disease pre-
vention activities including management of
contacts who are not members of the plan.

b. Relative strength of the measures

Readily available quality clinical services without
stigma form a necessary foundation for other
clinic-related prevention activities.

Early diagnosis and treatment of sexually trans-
mitted diseases among patients attending clinics,
contacts and those identiﬁed in screening pro-
grams are highly effective in preventing trans-
mission of the diseases and in limiting their dis-
abling complications.

Persons who properly and consistently use con-
doms experience lower rates of sexually trans-
mitted diseases.

As vaccines are developed and introduced, they
can be effectively administered in the health care
system.

Mass and targeted education and information
measures appear to be the only way to modify
hardened public opinion and reduce sexually
transmitted disease ignorance and apathy.
Education and training of health professionals
and health educators is a necessary ﬁrst step
toward effective sexually transmitted disease
service measures.

3. Speciﬁc Objectives for'l990 or Earlier

0 Improved health status

a.

By 1990, reported gonorrhea incidence should
be reduced to a rate of 280 cases per 100,000
population. (In 1979, the reported case rate was
457 per 100,000 population.)

By 1990, reported incidence of gonococcal pel-
vic inﬂammatory disease should be reduced to a
rate of 60 cases per 100,000 females. (In 1978,
the estimated rate was 130 cases per 100,000
females.)

By 1990, reported incidence of primary and sec-
ondary syphilis should be reduced to a rate of 7
cases per 100,000 population per year, with a
reduction in congenital syphilis to 1.5 cases per
100,000 children under 1 year of age. (In 1979,
the reported incidence of primary and secondary
syphilis was 11 cases per 100,000 population
while reported congenital syphilis was 3.7 cases
per 100,000 children under 1 year of age.)

By 1990, the incidence of serious neonatal in-
fection due to sexually transmitted agents, espe-
cially herpes and chlamydia, should be reduced
to a rate of 8.5 cases of neonatal disseminated
herpes per 100,000 children under 1 year of age,

and a rate of 360 cases of chlamydial pneumonia
per 100,000 children under 1 year of age. (In
1979, about 16.8 cases of neonatal disseminated
herpes per 100,000 children under 1 year of age
and about 720 cases of chlamydial pneumonia
per 100,000 children under 1 year of age were
estimated to have occurred.)

e. By 1990, the incidence of nongonococcal ureth-
ritis and chlamydial infections should be reduced
to a rate of 770 cases per 100,000 population.
(In 1979, the case rate was estimated to be
1,140 per 100,000 population.)

0 Reduced risk factors

f. By 1990, the proportion of sexually active men
and women protected by properly used condoms
should increase to 25 precent of those at high
risk of acquiring sexually transmitted diseases.
(In 1979, the estimated proportion was less than
10 percent.)

0 Increased public/professional awareness

g. By 1990, every junior and senior high school
student in the United States should receive accu-
rate, timely education about sexually transmitted
diseases. (Currently, 70 percent of school sys-
tems provide some information about sexually
transmitted diseases, but the quality and timing
of the communication varies greatly.)

h. By 1985, at least 95 percent of health care pro-
viders seeing suspected cases of sexually trans-
mitted diseases should be capable of diagnosing
and treating all currently recognized sexually
transmitted diseases, including: genital herpes
diagnosis by culture, therapy (if available) and
patient education; hepatitis B diagnosis among
homosexual men, prevention through a vaccine
(when proved effective), and patient education;
and nongonococcal urethritis diagnosis, therapy
and patient education. (Baseline data unavail-
able.)

0 Improved services/ protection

i. By 1990, at least 50 percent of major industries
and Governmental agencies offering screening
and health promotion programs at the worksite
should be providing sexually transmitted disease
services (education and appropriate testing)
within those programs. (Baseline data unavail-
able.)

0 Improved surveillance/ evaluation systems

j. By 1985, data should be available in adequate
detail (but in statistical aggregates to preserve
conﬁdentiality) to determine the occurrence of
nongonococcal urethritis, genital herpes and
other sexually transmitted diseases in each local
area, and to recommend approaches for prevent-
ing sexually transmitted diseases and their com-
plications.

k. By 1990, surveillance systems should be sufﬁ-
ciently improved that at least 25 percent of sex-

27

4.

5.

ually transmitted diseases diagnosed in medical
facilities are reported, and that uniform deﬁni-
tions are used nationwide. (Baseline data un-
available.)

Principal Assumptions

0 Biologic changes in the sexually transmitted disease
organisms are likely but unpredictable as to their
occurrence or effect, therefore they have not been
considered.

0 The size of the at—risk sexually-active population is
not expected to change substantially during the
19805. (Declines in younger age groups are expected
to be balanced by increases in nonmonogamous sex-
ual activity in all groups.)

0 During the next decade, the health planning process
will provide the opportunity to inﬂuence providers
to raise norms and meet guidelines for prevention
and management of sexually transmitted diseases.
HSAs will include sexually transmitted diseases
among other health status indicators, and will in-
clude sexually transmitted disease objectives and
control measures in their plans.

0 All health professional training programs will give
greater emphasis to the prevention, early diagnosis
and treatment of sexually transmitted diseases.

0 Medical schools will establish clinical afﬁliations
with public and private sexually transmitted disease
facilities so that all medical students and physicians
in training will receive supervised clinical experience
in the diagnosis and treatment of sexually trans-
mitted diseases.

0 Support for studies of mechanisms of antibiotic re-
sistance and for the development of antiviral drugs
and new vaccines will continue at 1979 levels.

Data Sources

a. To National level only

0 Annual Census of State and County Mental Hos-
pitals. Resident patients and new admissions to
mental institutions; costs, diagnoses of syphilitic
psychoses. DHHS—Alcohol Drug and Mental
Health Administration, National Institute of
Mental Health (NIMH). Mental Health Statisti-
cal Notes, selected issues; special reports and
tabulations furnished to the Center for Disease
Control (CDC), Venereal Disease Control Divi-
sion. Continuing; National sample surveys of pa-
tients in State and county mental hospitals.

0 National Ambulatory Medical Care Survey
(NAMCS). Patient characteristics, diagnoses of
STD. DHHS-National Center for Health Statis-
tics (NCHS). NCHS Vital and Health Statistics,
Series 13, selected reports, and CDC, Division
of Venereal Disease Control, special tabulation
from tapes provided by NCHS. Continuing; Na-
tional probability sample, ofﬁce-based physi-
c1ans.

0 Health and Nutrition Examination Survey
(HANES). Adults, patient characteristics, serio-

logic tests for syphilis, urine cultures for gono-
rrhea. DHHS-NCHS. NCHS Vital and Health
Statistics, Series 11, selected reports. Periodic
surveys; National probability sample.

Hospital Discharge Survey (HDS). Patient stays
in short-stay hospitals, patient characteristics,
diagnoses, including salpingitis and PID; surgery
and other procedures; length of stay. DHHS-
NCHS. NCHS Vital and Health Statistics, Series
13, selected reports, and special tabulations by
CDC, Venereal Disease Control Division from
tapes provided by NCHS. Continuing survey;
National probability sample of short stay hospi-
tals.

STD Surveillance. Nonreported as well as re-
ported STDs. Patient visits to VD clinics; age,
race, sex, reason for attendance, sexual prefer-
ence, laboratory tests and results, diagnoses of
14 of the sexually transmissible diseases. DHHS-
CDC, Venereal Disease Control Division. In-
house summaries provide part of basis for Na-
tional incidence/prevalence estimates of STD in
STD Fact Sheet, HEW Publication No. (CDC)
8195, and other program documentations. Con-
tinuing reporting; full count from 7 STD clinics.
Gonorrhea Therapy Monitoring Network. Gono-
rrhea patients treated with a variety of anti-
biotics in varying dosages; post treatment results,
minimum inhibitory concentration of antibiotics.
DHHS—CDC, Veneral disease Control Divi-
sion. Supplement to Sexually Transmitted Dis-
eases (Journal of the American Venereal Dis-
ease Association) Vol. 6, No. 2, April-June
1979. Continuing 1971—1979; discontinued
1979. '

The Hepatitis B Collaborative Study. Hepatitis
incidence and prevalence among male homosex-
uals; sexual behavior modalities. DHHS-CDC,
Venereal Disease Control Division and Hepatitis
Laboratories Division. Results in preparation.
One time study from ﬁve clinics.

b. To State and/ or local level
0 National Case Reporting System (NCRS). Re-

ported cases of gonorrhea, syphilis by stage,
chancroid, granuloma inguinale and lympho-
granuloma; age, race, sex and reporting source
(private vs. public). DHHS-CDC, Bureau of
Epidemiology and Venereal Disease Control Di-
vision. STD Fact Sheet, Publication No. (CDC)
8195; Sexually Transmitted Disease (STD) Sta-
tistical Letter. Continuing full National count of
reported cases, State and major city breakdown,
additional characteristics, e.g., marital status,
may be locally available in some States.
Hospitalized illness from discharge abstract sys-
tems

—-—- Professional Activities Study (PAS). Patient
stays in short-stay hospitals; patient char-
acteristics, diagnoses of salpingitis and PID.

28

Commision on Professional and Hospital
Activities (CPHA), Ann Arbor, Michigan.
Special tabulations and/or tapes provided
to DHHS—CDC, Venereal Disease Control
Division. Continuing reporting from dis—
charge records. Full count of patients dis-
charged from CPHA 1900 member hospitals.
Not a probability sample. Extent of hospital
participation varies by State.

— Other hospital discharge systems as locally
available.

— National Morbidity and Mortality Report-
ing System. Numbers of 46 reportable dis-
eases; deaths in 121 US. cities. DHHS—
CDC. CDC Morbidity and Mortality Weekly
Report, and anual reports. Morbidity: con-
tinuous reporting from State health depart-
ments on basis of physician reports. (Com-
pleteness of reporting varies greatly, since
not all cases receive medical care and not
all treated conditions are reported.) Mor-
tality: continuous reporting; volunteer panel
of health departments in 121 US. cities,
full count.

Quarterly Epidemiologic Activity Report (CDC
9.2127). Number of interviews by disease, con-
tacts elicited and examined, medical disposi-
tion. DHHS—CDC, Venereal Disease Control
Division. STD Fact Sheet, HEW Publication No.
(CDC) 8195; Sexually Transmitted Disease
(STD) Statistical Letter. Continuing reporting
from State health departments; full National
count with project area breakdown.

Gonorrhea Culture Results of Females. Number
women screened and positive, by type of pro-
vider. DHHS—CDC, Venereal Disease Control
Division. STD Fact Sheet, HEW Publication No.
(CDC) 8195, Sexually Transmitted Disease
(STD) Statistical Letter. Continuing reporting
from State health departments; National full
count of federally sponsored gonorrhea screen-
ing activity.

Infectious Syphilis Epidemiologic Control Rec-
ord. Early syphilis interviews; age, race, sex of
cases, contacts, time intervals between case re-
port and ﬁnal disposition of contacts. DHHS—
CDC, Venereal Disease Control Division. STD
Fact Sheet, HEW Publication No. (CDC) 8195;
Sexually Transmitted Diseases (STD) Statistical
Letter. Continuing reporting from State health
departments; National full count.

Results of Followup of Serologic Reactors.
Reactive serologic tests reported to health de-
partments and results of followup. DHHS—CDC,
Venereal Disease Control Division. STD Fact
Sheet, HEW Publication No. (CDC) 8195 ;
Sexually Transmitted Disease (STD) Statistical
Letter. Continuing reporting from State health
departments; National full count.

VD Laboratory Surveillance Report. Number

of tests for syphilis performed, number positive, — Mortality. Deaths by cause (including infant

type of laboratory. DHHS—CDC, Venereal Dis— deaths attributable to sexually transmissible
ease Control Division. STD Fact Sheet, HEW diseases and to syphilis) by age, sex and
Publication No. (CDC) 8195; Sexually Trans- race. DHHS—NCHS. NCHS Vital Statistics
mitted Disease (STD) Statistical Letter. Con- of the United States, Vol. II, and NCHS
tinuing reporting from State health departments; Monthly Vital Statistics Reports. Continu-
National full count. ing reporting from States; full count. (Many
0 National Vital Registration System States issue earlier reports.)
29

 

 

TOXIC AGENT CONTROL

1. Nature and Extent of the Problem

Toxic agents include, but are not limited to, natural
and synthetic chemicals, dusts, minerals, and mate-
rials which produce acute or chronic illness. Such
agents may be carcinogenic, mutagenic or teratogenic,
and they may adversely affect the reproductive system,
nervous system, or speciﬁc organs such as the liver or
kidney. Included as a toxic agent for the purposes of
this document are radiation exposures of various

types.

a. Health implications

0 Health effects attributed to toxic agents and/or
radiation of various types include:

— acute effects, including systemic poisoning;

— chronic effects including teratogenic abnor-
malities and growth impairment;

— infertility and other reproductive abnormali-
ties;

— skin disorders;

—— cancer;

— neurologic disorders;

— behavioral abnormalities;

—- immunologic damage;

— chronic degenerative diseases involving the
lungs, joints, vascular system, kidneys, liver
and endocrine organs.

0 Though the extent to which toxic agents are
associated with disease is not completely known,
recent empirical evidence conﬁrms that serious
environmental health hazards exist. New evi-
dence unfolds regularly, revealing previously
unsuspected associations between speciﬁc envi-
ronmental agents and diseases. The detection
of speciﬁc etiology is greatly complicated be-
cause (a) many agents may contribute to the
same diseases, (b) there may be long latency
periods between exposure and disease onset,
and (c) data are sometimes unavailable or in-
appropriately aggregated for discovery purposes.

0 Diseases associated with toxic agents may dif-
ferentially affect different age groups, present
and future generations and groups with different
histories of past exposure and predisposing
conditions.

0 Varying latency associated with many chronic
diseases, complex history of previous exposure
and other factors mentioned above make assess-

31

ment of the magnitude of the problem difficult.
Although current disease incidence and mor-
tality data are inaccurate measures, they serve
as indicators of the effectiveness of existing
control and prevention efforts.

Objective laboratory measurements of toxicity,
levels of concentrations, and human biological
effects are necessary to characterize effective-
ness of control mechanisms and to deﬁne bio-
chemical sequelae of toxic insults to biological
systems.

b. Status and trends

Sources of environmental health hazards pres-
ently subject to Federal regulation include:

—— air/water emissions/eﬂfuents;

——- hazardous waste disposal;

— transportation of hazardous materials;

—— occupational exposure;

— products (food additives, pharmaceuticals,
pesticides, consumer and industrial chemi-
cals);

—- radiation exposure from medical devices,
consumer products, food and the environ-
ment.

The rapid advancement of post-World War II
industrial production has created substantial in-
creases in the quantity and kinds of substances
and materials which may pose signiﬁcant health
hazards.

It is estimated that of the four million chemical
compounds which have been synthesized or
isolated from natural materials, more than
55,000 are produced commercially. Approxi—
mately 1,000 new compounds are introduced
annually; pesticide formulations alone contain
about 1,500 active chemical ingredients.
There may be as many as 30,000 toxic solid
waste disposal sites in the United States.
Over 13,000 substances currently in commercial
use have been identiﬁed as potentially toxic to
workers, with an additional number introduced
every year.

Over 2,000 chemicals are suspected carcinogens
in laboratory animals. Current epidemiologic
evidence builds a convincing case for the car-
cinogenicity in humans of 26 chemicals and/or
industrial processes.

More than 20 agents are known to be associated

with birth defects in humans; many times this
number are associated with birth defects in
animals.

Of 700 atmospheric contaminants, 47 have been
identiﬁed in animal studies as recognized car-
cinogens, 42 as suspected carcinogens, 22 chem-
icals as promoters and 128 as mutagens.

From over 2,200 contaminants of all kinds iden-
tiﬁed in water, 765 were identiﬁed in drinking
water. Of these, 12 chemical pollutants were
recognized carcinogens, 31 were suspected car-
cinogens, 18 were carcinogenic promoters and
59 were mutagens. It is not known what the
additive effects of these chemicals will be on the
total cancer burden.

As water resources become in shorter supply,
more and more surface water, used for drinking
water, will be recycled or reprocessed, con-
tinuing the recycling of pollutants unless ade-
quate water treatment measures are taken.
Even if carcinogenic pesticides are no longer
available for sale by 1990, some will persist in
the environment, in food supplies and in human
bodies for many years.

Problems with toxic agents are not only attrib-
utable to industry, but also medical and dental
care (x-rays and drugs), agriculture (pesticides
and herbicides), Government (biological and
chemical agents), consumers (incorrect use of
consumer products which contain toxic sub-
stances) and natural sources (fungal products).
Low levels of ionizing radiation can produce
delayed effects, such as cancer, after a latent
period of many years. Fifty percent of the
current United States population dose comes
from naturally occurring background radiation,
radioactive materials in the water, soil and air,
and cosmic radiation; 45 percent results from
diagnostic and therapeutic medical applications.
Fallout, industrial use, production of nuclear
power and consumer products account for the
remaining 5 percent. Thus roughly half the
exposure of the population at large comes from
manmade sources.

The synergistic effects of exposures to ionizing
radiation and toxic agents may greatly increase
carcinogenic risks.

2. Prevention / Promotion Measures
Potential measures

0 Many of the measures outlined below need to

be carried out by environmental and health
regulatory and research agencies. Mechanisms
such as the Interagency Regulatory Liaison
Group (IRLG) are essential to coordinate their
activities in areas of :

— assessing agent toxicity;
— asses-sing the number of persons at risk from
a particular agent and estimating intensity

32

of exposures and conditions of exposure as
they affect risk;

— technology assessment and development;

— economic impact analyses;

-— developing generic or group standards for
classes of toxic substances;

—— pooling limited technological resources re-
quired to control environmental health
hazards;

— establishing eﬁective mode(s) of control
for each agent.

0 Education and information measures include:

— informing the public that exposure to haz-
ardous agents is serious, but manageable,
and that government control measures are
essential;

— through television announcements;

- through establishing a system to warn
consumers and workers of possible car-
cinogens, teratogens, or other toxic sub-
stances so that precautionary actions to
prevent health effects may be exercised;

— through providing information on the
control of environmental and occupa-
tional health hazards to teachers and
students in elementary and secondary
schools within the context of comprehen-
sive mandatory classroom health educa-
tion;

— educating health professionals and directors
in industry about toxicology, epidemiology,
industrial hygiene, medical surveillance, con-
trol technology design and hazardous sub-
stance control;

— expanding sensitivity of practicing physi-
cians, nurses and other health professionals
in the diagnosis of environmental and occu-
pational diseases and associated reporting
responsibilities;

— educating managers of industrial ﬁrms
through both their training curricula and
through continuing education (especially
those trained in chemical and mechanical
engineering, law and business administra-
tion);

— stafﬁng the regulatory agencies with well-
trained professionals, not only in the sci-
ences, medicine and engineering, but also
in policy analysis.

0 Service measures include:

_— relating diseases to toxic agent exposures
and providing appropriate medical care;

— screening and diagnostic services for indi-
viduals with suspected exposure to toxic
substances, and treatment as necessary.

0 Technologic measures include:

——timely efforts to encourage and/or upgrade:
— instrumentation and laboratory operations
for hazard detection and monitoring;

— laboratory standardization programs to
insure validity and interlaboratory com-
parability of data;

— emission and efﬂuent control technology;

— hazardous and radioactive waste disposal
technology;

— manufacturing process design;

— new product development and testing for
deleterious health effects.

— Government assistance in developing con-
trol technology and process redesign where
the industrial incentives or requirements for
such development are lacking;

— technology to control nuclear wastes and
certain classes of hazardous waste and tech—
nology to minimize transportation risks;

— technology improvements including modiﬁ-
cation of current technology and develop-
ment of new diagnostic tools to reduce the
amount of radiation required for medical
and dental diagnosis and treatment;

— sharing of control technology information
among the regulatory agencies and joint
technology development among agencies to
address related problems;

— technology-forcing regulatory initiatives to
encourage process redesign and new product
development.

Legislative and regulatory measures include:

— enforcement of major environmental laws
controlling hazardous substances:

— Clean Air Act;

- Clean Water Act and the Safe Drinking
Water Act;

— Resource Conservation and Recovery Act
(regulating hazardous substances dis-
Posal);

-— Toxic Substances Control Act;

— Federal Hazardous Substances Control
Act;

— Consumer Product Safety Act;

— Federal Environmental Pesticide Control
Act;

— The Food, Drug, and Cosmetic Act;

- Hazardous Substances Transportation
Act;

— Atomic Energy Act;

— National Environmental Protection Act;

- Occupational Safety and Health Act;

- Federal Insecticide, Fungicide, and
Rodenticide Act;

- Radiation and Safety Act.

— ensuring the comprehensive application of
these laws; certain groups of chemicals and
classes of substances are now exempted from
existing testing and regulatory authorities;

-- grouping of toxic agents into classes for
both testing and regulatory action under all
toxic substances control law; continuing to

33

place the burden of obtaining an exemption
from a class rule on the manufacturer since
similar compounds can have diﬂering
toxicities;

labeling hazardous ingredients in trade name
products, to address both the content of the
product with respect to potentially hazard-
ous substances and directions for proper
use and disposal of the chemical (a pre-
requisite for both effective hazard recogni-
tion and the implementation of appropriate
control measures);

full disclosure of health—related data to
potentially affected parties, including toxi-
cological and epidemiological data, in vitro
tests, elemental analysis, molecular struc-
ture and process or synthesis information;
establishing priorities and developing more
standards for hazardous substances in both
air and water (e.g., careful attention to
ambient air standards as energy programs
are implemented);

establishing State systems for monitoring
pollution from both diesel and convention-
ally powered vehicles;

expediting promulgation of regulations de-
ﬁning categories of hazardous materials dis-
posal under the Resource Conservation and
Recovery Act (RCRA) and coordination of
their control;

identifying and detoxifying past hazardous
substance disposal sites, and prioritizing the
action taken on sites to reﬂect the magni-
tude of the public health risk;

requiring suﬂicient screening examination
by the manufacturer (before marketing) for
the full range of health effects for all new
chemicals for which there may be potentially
serious risk to health/environment;
withholding from introduction into com-
merce new chemicals that pose a signiﬁcant
public health threat unless the manufacturer
can demonstrate that there are safe and
practical methods for their manufacture, in-
tended uses and disposal;

implementing expedited procedures to re-
move from the market consumer products
containing known carcinogens, teratogens
and mutagens;

controlling intensive use of pesticides to
achieve marginal or questionable production
increases; ‘
implementing integrated pest management;
establishing it as a condition for permits to
use the more hazardous pesticides;
developing and implementing improved
standards for transportation containers and
inspection standards for vehicles and routes
of transportation for hazardous substances,
with particular emphasis on railroad safety;

—- developing an adequate system of records of
toxic substances being transported;
establishing centralized National occupa-
tional records of radiation exposure of
workers to include exposure to all types and
levels of radiation, including records for
part-time workers;

establishing siting criteria for industries
using radioactive materials (to preclude
such events as the recent contamination of
food in a grammar school cafeteria);
establishing approved routes for transpor-
tation of nuclear fuels and nuclear wastes
designed to avoid metropolitan areas and
potential watershed contamination.

Economic measures include:
— taxation and legal redress:

— efﬂuent/emission taxes (using eﬂluent/
emission taxes as supplements to, and
not replacements for, regulation to create
additional incentives for hazard abate-
ment);

- favorable tax treatment of investment in
pollution control;

— legal redress for harm resulting from
exposure to toxic agents.

tax policies encouraging capital investment
in redesigning process technology to em-
phasize process improvement over add-on
technology;

amending the limited liability principles
applied to reactor safety by the Price
Anderson Act in measures that deal with
the effects of toxic substances.

b. Relative strength of the measures

Exerting effective control in these areas by
means appropriate to each is complex. Steps
are required to ensure that Federal regulatory
eﬂorts are adequately coordinated, that they are
anticipatory rather than reactive in dealing with
the problems of a rapidly changing industrial
production system and that they are appropri-
ately attentive to protecting the public health.
There are inherent and complicated inter-
relationships between regulatory and economic
and technologic measures applied to protecting
the public from the hazards of exposure to toxic
agents.

The most effective measures may well be tech-
nologic, but their development and application
depends upon adequate regulatory support and
economic incentives.

Industry, which is the principal target of most
efforts to reduce exposure to toxic agents, is
most likely to be responsive to economic incen-
tives.

Education of the public is of particular impor-
tance, given the substantial counterpressures

34

offered by conﬂicting social values (e.g. energy
production) and by existing advertising efforts.
The pressures which drive the demand for in-
creased consumption must be reconciled with
an increased demand for protection of health
or the environment. Resolving these conﬂicting
social goals has been attempted (a) by pro-
viding legislative guidelines and directives in
individual environmental laws, (b) by giving
extensive discretion to agency administrators,
(c) by requiring economic impact statements
through Presidential directives, and (d) by in-
troduction of Federal legislation requiring regu-
latory impact analysis. To the present, the bal-
ancing of social goals and the fulﬁllment of
regulatory mandates have been reviewed by the
courts with unpredictable results.

3. Speciﬁc Objectives for 1990
0 Improved health status

— Improvements in the control of toxic agents

can be expected over the longer term to yield
reduced rates (or slowing in the rates of in-
crease) for cancer, birth defects, respiratory
disease, kidney disease, nervous system disease
and other acute and chronic conditions. Be-
cause of uncertainties in the quantiﬁcation of
the exposure-to-disease relationship (short and
long term), the statement of measurable health
status objectives at this time has been limited
to the two noted below.

By 1990, 80 percent of communities should
experience a prevalence rate of lead toxicity“
of less than 500/ 100,000 among children ages
0 to 5, especially age 0 to 1. (In 1980, the
estimated prevalence of lead toxicity Nationally
exceeds 1,000/ 100,000.)

*NOTE: Lead toxicity is deﬁned as an erythro-
cyte protoporphyrin level exceeding 50 ug/dl
whole blood and a blood lead level exceeding
30 ug/dl.

By 1990, virtually no individual should suffer
birth defects or miscarriage as a result of expo-
sure to a toxic chemical disposed after imple-
mentation of the Resource Conservation and
Recovery Act. (Baseline data unavailable.)

. Reduced risk factors

C.

By 1990, virtually all communities should ex-
perience no more than one day per year when
air quality exceeds an individual ambient air
quality standard with respect to sulfur dioxide,
nitrous dioxide, carbon monoxide, lead, hydro-
carbon and particulate matter. (In 1979, the
level was estimated to be about 50 percent.)

By 1990, at least 95 percent of the population
should be served by community water systems
that meet Federal and State standards for safe
drinking water. (In 1979, the level was 85 to

90 percent for the National Interim Primary
Drinking Water Standards.)

By 1990, there should be virtually no prevent-
able contamination of ground water, surface
water or the soil from industrial toxins asso-
ciated with wastewater management systems es-
tablished after 1980. (Baseline data unavailable,
but EPA is starting a series of programs to
prevent ground water contamination in 1980
that should show results by 1990.)

By 1990, there should be no pesticides, herbi-
cides, fungicides, or rodenticides available for
sale which are known to be carcinogenic, terato-
genie or mutagenic in man, unless determined
to be vital to the National interest under certain
conditions. (Baseline data unavailable.)

By 1990, inhalation of fumes from toxic mate-
rials during transport of such materials should
be eliminated. (Baseline data unavailable.)

By 1990, the number of medically unnecessary
diagnostic x-ray examinations should be re-
duced by some 50 million examinations annu-
ally. (In 1979, the number of diagnostic x-ray
examinations performed in the United States
annually was 278 million, of which 83 million
were estimated to be medically unnecessary.)

0 Increased public/professional awareness

i.

By 1990, at least 75 percent of all city council
members in urban communities should be able
to report accurately whether or not the quality
of their air and water has improved or worsened
over the decade and to identify the principal
substances of concern. (Baseline data unavail-
able.)

By 1990, at least half of all adults should be
able to accurately report an accessible source of
information on toxic substances to which they
may be exposed—including information on the
interactions with other factors such as smoking
and medications. (Baseline data unavailable.)
By 1990, at least half of all people ages 15 years
and older should be able to identify the major
categories of environmental threats to health
and note some of the health consequences of
those threats. (Baseline data unavailable.)

By 1990, at least 70 percent of all primary care

' physicians should be able to identify the princi-

pal health consequences of exposure to each of
the major categories of environmental threats
to health. (Baseline data unavailable.)

0 Improved services/ protection
In. By 1990, at least 90 percent of all children

identiﬁed with lead toxicity in the 0 to 5 age
group (especially those age 0 to 1) should have
been brought under medical and environmental
management. (Baseline data unavailable. Ap-
proximately 34,000 children ages 1 to 5 with
lead toxicity are reported annually from Fed-
erally supported programs, and an estimated one

percent of the US. population ages 1 to 5 have
lead toxicity.)

By 1990, the Toxic Substances Control Act and
the Resource Conservation and Recovery Act
should be fully implemented to protect the US.
population against hazards resulting from pro-
duction, use, and disposal of toxic chemicals.
(Baseline data unavailable.)

By 1990, individuals purchasing a potentially
toxic product sold commercially or used indus-
trially should be protected by clear labeling as
to content, as to direction for proper use and
disposal, and as to factors that may make that
individual especially susceptible (health status,
age, sex, medications, genetic traits). (Baseline
data unavailable.)

By 1990, every individual should have access to
an acute care facility with the capability to pro-
vide, or make appropriate referrals for screen-
ing, diagnosis and treatment of suspected ex-
posure to toxic agents. (Baseline data unavail-
able.)

By 1990, every individual residing in an area of
a population density greater than 20 per square
mile, or an area of particularly high risk, should
be protected by an early warning system de—
signed to detect the most serious environmental
hazards posing imminent threats to health.
(Baseline data unavailable.)

By 1990, every populated area of the country
should be able to be reached within 6 hours by
an emergency response team in the event of
exposure to an environmental hazard posing
acute threats to health from a toxic agent,
chemical and/or radiation. (Baseline data un-
available.)

0 Improved surveillance/ evaluation systems

S.

By 1990, a broad scale surveillance and moni-

' toring system should have been planned to dis-

cern and measure known environmental hazards
of a continuing nature as well as those resulting
from isolated incidents. Such activities should be
continuously carried out at both Federal and
State levels.

By 1990, a central clearinghouse for observa-
tions of agent/disease relationships and host
susceptibility factors should be fully operational,
as well as a National environmental data registry
to collect and catalogue information on concen-
trations of hazardous agents in air, food and
water.

4. Principal Assumptions

0 Control and prevention measures will continue to be
developed within a framework reﬂecting Federal
regulatory efforts developed during the 1970s.

0 Consumers and workers will have ready access to

central information sources (like Poison Control
Centers) describing major substances or products
known to be toxic, their known interactions with

life style behaviors such as smoking and medica-
tions, insofar as these are known, and recommended
actions to be taken.

The capability to trace the generation, transport,
disposal and ultimate fate of various agents through
the various environments relevant to public health
will continue to be enhanced.

Permissible exposure levels and individual harmful
levels will reﬂect real-world multiple exposures, the
history of previous exposure, individual susceptibil-
ities and the effects of aging, and will accommodate
qualitative and quantitative differences in the health
consequences of toxic substances exposures in the
prenatal and perinatal periods.

A substance-by-substance regulatory approach alone
will not be able to solve a large proportion of public
health problems traceable to toxic agents.

In designing a regulatory strategy, potential health
problems arising from technology will be antici-
pated.

Schools for the health professions and continuing
education programs will have evaluated their cur-
ricula so that by 1990 health professionals will be
receiving training in toxicology and in the health
consequences of environmental exposure to toxic
agents.

An integrated health education curriculum in most
public school systems will include information on
toxic substances, their relationship to the environ-
ment and the students’ role in protecting their
health.

Control technology will have been developed for
dealing with the major known toxic agents.
Programs will be operating to replace pesticides that
show high acute toxicity and/or carcinogenic or
teratogenic effects by safer substances or approaches
(such as integrated pest management). They will be
targeted in each year to the 10 percent most hazard-
ous materials in use.

Transportation of toxic and radioactive materials
will be fully regulated.

State systems of mobile source monitoring for both
diesel and conventionally power vehicles will be
fully operational.

The National water quality goals for 1984 of ﬁsh-
able and swimable water will have been met and
maintained.

Performance standards in hospital and ambulatory/
patient care situations involving exposure to toxic
agents will be operational.

Sufﬁcient penalties will be attached to toxic agent
pollution to provide strong economic incentives to
abate.

Industrial investment for reducing exposure to toxic
agents will receive favorable tax treatment.

A strict liability system for industrial waste disposal
will be operational.

By 1985, a plan will have been developed to pro-
tect humans from the consequences of toxic agents
in existing sites of toxic solid waste disposal. (Ap-

36

proximately 30,000 solid waste disposal sites may be
involved. Proposed “Superfund” will be used to
clean up the worst sites.)

5. Data Sources
a. To National level only

0 Nationwide Evaluation of X-ray Trends
(NEXT). X—ray examination dosimetry, distri-
bution of exposure levels by type of examina~
tion, type of facility and type of equipment.
DHHS—Food and Drug Administration (FDA).
Periodic reports. Continuing reporting from par-
ticipating State radiation control programs.

0 Breast Exposure: Nationwide Trends (BENT).
Mammography dosimetry, distribution of radi-
ation exposure levels of x—ray equipment used in
mammography. DHHS-FDA. Periodic reports.
Continuous reporting from participating State
radiation control programs.

0 Dental Exposure Normalization Technique
(DENT). Data on dental x-ray exposure, dis—
tribution of radiation exposure levels of dental
x-ray equipment used in dental facilities. DHHS-
FDA. Periodic and annual reports. Continuous
reporting from participating State radiation con—
trol programs.

0 Birth Defects Monitoring Program. Birth defects
diagnosed at birth, by major types. DHHS-CDC.
CDC quarterly report, Congenital Malforma-
tions Surveillance Report. Continuing analysis
of data reported on hospital discharge abstracts
from hospital members of the Professional Ac-
tivities Study (PAS), Commission on Profes-
sional Hospital Activities. (Not a random sam-
ple of hospitals.)

0 National Occupational Hazard Survey. Inven-
tory of work hazards. DHHS—CDC, National
Institute for Occupational Safety and Health
(NIOSH). National Occupational Hazard Sur-
vey Records, Vol. 1—4, 1974—1979. Survey will
be updated 1980—82. Data obtained from on-
site inspections of 800 industrial facilities,
1972—79.

0 Health and Nutrition Examination Survey
(HANES). Levels of various toxic agents in
blood obtained from laboratory tests. DHHS,
NCHS. HANES II, 1979. Reports will appear
in NCHS Vital and Health Statistics, Series 10.

0 Toxic Effects. Listing of chemical substances for
which toxic effects have been reported. DHHS-
CDC, NIOSH. NIOSH Reports of Toxic Effects
of Chemical Substances. Annual reports derived
from ﬁndings reported in journal literature.

b. To State and/ or local level

0 Early and Periodic Screening, Diagnosis and
Treatment (EPSDT) reporting system. Lead
poisoning detected among children screened, and
referral. DHHS-Health Care Financing Admin-
istration (HCFA), Ofﬁce of Research, Demon-

strations and Statistics (ORDS). Medicaid Sta-
tistics, selected reports. Continuous reporting
from State Medicaid ofﬁces.

Lead based paint poisoning prevention. Number
children screened for lead toxicity, number posi-
tive, number brought under environmental and
medical management in participating areas.
CDC Laboratory Quarterly Report, Surveillance
of Childhood Lead Poisoning, United States.
DHHS-CDC. Quarterly report. Continuous re-
porting from States.

Surveillance, Epidemiology and End Result
Program (SEER). Cancer incidence, morbidity

37

and survival. DHHS-National Institutes of
Health, National Cancer Institute. Periodic re-
ports from cancer registries, selected geographic
areas.

0 National Aerometric Bank (NADB). Measure-

ments on the ﬁve pollutants for which National
Ambient Air Quality standards have been set.
Environmental Protection Agency (EPA). Na-
tional Air Quality Monitoring and Emissions
Trends Report, 1977, and continuing reports.
Research Triangle Park, NC. Continuing re-
porting, quarterly, from 3,400 pollution control
agencies.

 

OCCUPATIONAL SAFETY AND HEALTH

1. Nature and Extent of the Problem

Occupational illnesses and injuries are of human origin,
and thus preventable. With approximately 100 million
workers in this country, occupational hazards can pose
a serious threat to health. Work conditions can yield
daily exposure to such risks as: toxic chemicals, asbes-
tos, coal dust, cotton ﬁber, ionizing radiation, physical
hazards, excessive noise, as well as stress and routinized
trivial tasks. A broad range of health problems may be
associated with such exposures, including cancers, lung
and heart diseases, birth defects, sensory deﬁcits, in-
juries and psychological problems. Steps important to
protecting the health of workers include not only edu-
cation of workers about potential hazards, but engi-
neering modiﬁcations to control hazards, regulatory
efforts to promote worker safety, and additional re-
search to identify the full range of occupational safety
and health problems.

It must be recognized that there are limitations to the
ability of regulatory agencies to contribute to the
achievement of these objectives. The Occupational
Safety and Health Administration and the Mine Safety
and Health Administration are responsible for setting
and enforcing standards to control work place hazards,
but the enabling legislation for both of these agencies
holds employers responsible for a healthful and safe
work environment. Meeting these objectives will re-
quire a concerted National effort involving a commit-
ment from not only regulatory agencies, but also em-
ployers and employee organizations.

a. Health implications

0 Occupational illness

— occupational exposure to toxic chemicals and
physical hazards such as dust from asbestos,
silica, grain and cotton; fumes from chemi-

partial disability brought on by job-related
diseases, the National Institute for Occupa-
tional Safety and Health (NIOSH) estimates
that each year 100,000 Americans die from
occupational illnesses; nearly 400,000 new
cases of occupational diseases are recognized
annually; although these estimates made by
NIOSH for the May 1972 President’s Report
on Occupational Safety and Health are con-
troversial, no better estimates are available
from the presently inadequate reporting of
occupational disease;

skin diseases are the largest group of occu-
pational illness (43 percent in 1976), fol-
lowed by repeated trauma (14 percent);
about 15 percent of coal miners exhibit some
chest x—ray evidence of coal workers’ pneu-
moconiosis, and black lung disease may be
responsible for 4,000 deaths each year;
recent studies suggest that occupations asso-
ciated with handling wood and wood prod-
ucts have increased risk of certain cancers;
an estimated 1.6 million present and former
asbestos workers have increased risk of death
from asbestos-related diseases such as lung
cancer, mesothelioma and asbestosis;

the lung cancer rate among coke oven work-
ers is about 10 times the National average;
an estimated 2 million workers have been ex-
posed to benzene and 2 to 3 million to vinyl
chloride, chemicals thought to cause cancer;
job-related stress, ergonomic issues, and poor
job design also contribute to illness and in-
jury (in both service and manufacturing sec-
tors) to an undetermined degree.

See Misuse of Alcohol and Drugs and Con-
trol of Stress and Violent Behavior.

cals; noise; ionizing radiation; sunlight and Occupational injury

vibration—can all produce various problems — in 1978, work accidents resulted in 4,590

such as lung disease, cancers, sensory loss, deaths;

skin disorders, degenerative diseases in a —— in 1977, more than 2.3 million workers ex-

number of vital organ systems, birth defects perienced disabling injuries (80,000 of

or genetic changes; these toxic effects may which were permanently disabling);

be acute or chronic; — the injuries span a wide spectrum including:
—— occupational exposures to some agents can electrical shocks, falls, crushes, motor vehi-

also increase the frequency of stillbirths, cle accidents, burns and eye injuries;

spontaneous abortions, reduced fertility and — workers in mining, agriculture (including

sterility; forestry and ﬁshing) and construction are
-— in addition to the burden of permanent and six, three and three times, respectively, more

39

likely to die from a work-related injury than
other private sector workers;

slips and falls are often due to lack of good
housekeeping at the job site;

poor architectural design such as incorrect
placing of stairs, wrong height of stair lifts,
improper lighting and ventilation, and im-
proper engineering of equipment can contrib-
ute to or cause illness and injuries.

b. Status and trends
0 Occupational illness

toxic effects have been reported for nearly
45,000 to 50,000 chemicals which are
thought to appear in the workplace—over
2,000 of which are suspected human carcino-
gens in laboratory animals;

one survey has indicated that 9 out of 10
American industrial workers may not be ade-
quately protected from exposure to at least
1 of the 163 most common hazardous indus—
trial chemicals;

approximately 21 million American workers
are exposed to substances regulated by the
Occupational Safety and Health Administra-
tion.

0 Occupational injury

direct and indirect costs of occupational acci-
dents are estimated at $20.7 billion per year;
each year about one worker in nine in private
industry experiences an occupational injury;
in 1978, there were, on average, 9.2 injuries
and illnesses and 62.1 lost workdays per 100
full-time workers;

Worker’s Compensation payments in 1976
($7.5 billion) were up 14 percent from 1975
and were three times the level of 1966;
between 1976 and 1977, the number of
work-related injuries increased from 5.0 mil-
lion to 5.3 million, the number of workdays
lost increased from 32.5 million to 35.2 mil-
lion, the average days lost per injury de-
creased from 17 days to 16 days, and the
number of fatalities increased for companies
with 11 or more employees from 3,940 to
4,760; these data show aggregate trends,
however, they do not reﬂect the relative
severity of different injuries.

2. Prevention/Promotion Measures
a. Potential measures

0 Education and information measures include:

— reviewing, recommending, initiating and pub-

licizing occupational health and safety stand-
ards, procedures, controls, and practices
necessary for assessing, monitoring, control-
ling, and eliminating on-the-job health and
safety hazards, including environmental
health requirements;

40

initiating, as a management responsibility in
concert with workers and their representa-
tives, experimental and innovative educa-
tional programs regarding exposures to and
control of occupational health and safety
hazards;

initiating and expanding methods designed
to motivate labor and management responsi-
bility for the development and maintenance
of a safe and healthful work and community
environment;

developing awareness of the potential inter-
actions between occupational health hazards
and lifestyle habits and behavior and their
effects on health;

developing worker awareness through label-
ing, electronic and print media, vocational
training programs, health care providers,
campaigns aimed at high-risk worker groups
(e.g., asbestos workers, newly employed and
elderly workers) and organized labor pro-
grams;

developing professional occupational health
and safety personnel including occupational
health physicians and nurses, industrial hy-
gienists, toxicologists and epidemiologists
and including occupational health education
in the curricula of medical and nursing
schools and continuing education;
developing awareness in other groups that
either interact with workers or the work-
place, including engineers, managers, teach-
ers, social workers and health care workers;
developing public awareness of occupational
disease and injuries and their high cost to the
Nation;

labeling in simple language to inform work-
ers, employers, health professionals and the
public of the hazards, the associated risks
and symptoms as appropriate;

including occupational health as part of the
comprehensive health education curricula in
high schools and vocational schools.

Service measures include:

well-designed corporate occupational health
programs that include preventive and treat-
ment services directed at nonoccupational as
well as occupational health;

consultation services of Governmental agen-
cies to assist businesses to identify problems
and to establish suitable programs to elimi-
nate or control them;

encouraging small businesses to form coop-
erative groups to seek occupational health
expertise; _.
developing a personal health service delivery
system in which the diagnosis and treatment
of occupational illnesses and injuries will be
coordinated and integrated with all other

health services provided the worker and his
family;

— upgrading capabilities of State and local
health departments to participate in occupa-
tional health and safety services, including
monitoring, surveillance and consultation to
small businesses.

0 Technologic measures include:

— improved architectural and engineering de-
sign of worksite to prevent injuries;

— control technology to protect workers, in-
cluding development of safe substitutes for
toxic substances, design of process units
that eliminate worker exposure, design of
safe maintenance procedures and design of
jobs to eliminate harmful physical and
mental stress;

— measurement technology to enable quick,
accurate and economical assessment of
hazard levels in the workplace by workers,
employers or health professionals.

0 Legislative and regulatory measures include:

— fully implementing the OSHA/MSHA and
other laws related to workers’ health as well
as the product control provisions of the
Toxic Substances Control Act and the Con-
sumer Product Safety Act;

—— recommending, initiating and evaluating
measures designed to improve and expand
occupational health and safety legislation,
paying particular attention to possibilities
of standardizing beneﬁts through a national
system of worker’s compensation;

— developing criteria documents recommend-
ing standards (NIOSH);

— promulgating new health standards on haz-
ardous substances (OSHA);

— annual inspections by industrial hygienist
compliance ofﬁcers;

— conducting mandated industrywide studies
and Health Hazard Evaluations for carcino—
genicity, reproductive effects, and other haz-
ards that could lead to Emergency Tempo-
rary Standards;

— changing Worker’s Compensation Laws to
provide stronger economic pressures on em-
ployers to reduce hazardous conditions at
the worksite.

0‘ Economic measures include:

-— fines and negative publicity for poorly con-
trolled health and safety conditions;

—— tax deductions and other economic incen-
tives for capital investment in control tech-
nology or occupational health programs.

b. Relative strength of the measures

0 Given the broad nature and scope of occupa-
tional safety and health problems, the relative
strength of the measures varies with the problem

41

at hand, with the nature and adequacy of en-
forcement effort and social and political support
and with research capacity. Most occupational
health problems require the simultaneous or
consecutive application of several types of mea-
sures as a total strategy to comprehensive haz-
ard eradication. For example, eradication of the
asbestos hazard might be achieved by:

—- banning all nonessential uses of asbestos;

—— substitution of other effective materials
found to be nonhazardous;

— research to determine physiologic effects of
human exposure to the asbestos ﬁber;

—— worker information to minimize exposure
that may still occur during demolition and
repair work;

— rigid enforcement of asbestos standards
while use remains necessary;

— professional education for physicians to as-
sure proper medical help for exposed indi-
viduals.

This type of eradication program focuses public
attention on the problem and goes beyond estab-
lishing a standard for permissible exposure
levels.

3. Speciﬁc Objectives for 1990 or Earlier
0 Improved health status
a. By 1990, workplace accident deaths for firms or

employers with 11 or more employees should be
reduced to less than 3,750 per year. (In 1978,
there were 4,170 work-related fatalities for ﬁrms
or employers with 11 or more employees.)

By 1990, the rate of work-related disabling in-
juries should be reduced to 8.3 cases per 100
full time workers. (In 1978, there were approxi—
mately 9.2 cases per 100 workers.)

By 1990, lost workdays due to injuries should
be reduced to 55 per 100 workers annually. (In
1978, approximately 62.1 days per 100 workers
were lost.)

By 1990, the incidence of compensable occupa-
tional dermatitis should be reduced to about
60,000 cases. (In 1976, there were approxi-
mately 70,000 cases involving compensation.)
By 1990, among workers newly exposed after
1985, there should be virtually no new cases of
four preventable occupational diseases—asbes-
tosis, byssinosis, silicosis and coal worker’s
pneumoconiosis. (In 1979, there were an esti—
mater 5,000 cases of asbestosis; in 1977, an
estimated 84,000 cases of byssinosis were ex-
pected in active workers; in 1979, an estimated
60,000 cases of silicosis were expected among
active workers in mining, foundries, stone, clay
and glass products and abrasive blasting; in
1974, there were an estimated 19,400 cases of
coal workers pneumoconiosis.)

By 1990, the prevalence of occupational noise-
induced hearing loss should be reduced to

415,000 cases. (In 1975, there were an esti-
mated 462,000 cases of work-related hearing
loss.)

By 1990, occupational heavy metal poisoning
(lead, arsenic, zinc) should be virtually elimi-
nated. (Baseline data unavailable.)

0 Reduced risk factors

h. By 1985, 50 percent of all ﬁrms with more than
500 employees should have an approved plan of
hazard control for all new processes, new equip-
ment and new installations. (Baseline data un-
available.)

i. By 1990, all ﬁrms with more than 500 employ-
ees should have an approved plan of hazard
control for all new processes, new equipment
and new installations. (Baseline data unavail-
able.)

0 Improved public/ professional awareness

]. By 1990, at least 25 percent of workers should
be able, prior to employment, to state the na-
ture of their occupational health and safety risks
and their potential consequences, as well as be
informed of changes in these risks while em-
ployed. (In 1979, an estimated 5 percent of
workers were fully informed.)

By 1985, workers should be routinely informed
of lifestyle behaviors and health factors that
interact with factors in the work environment to
increase risks of occupational illness and in-
juries. (Baseline data unavailable.)

1. By 1985, all workers should receive routine
notiﬁcation in a timely manner of all health
examinations or personal exposure measure-
ments taken on work environments directly re-
lated to them. (Baseline data unavailable.)

By 1990, all managers of industrial ﬁrms should
be fully informed about the importance of and
methods for controlling human exposure to the
important toxic agents in their work environ-
ments. (Baseline data unavailable.)

By 1990, at least 70 percent of primary health
care providers should routinely elicit occupa-
tional health exposures as part of patient his-
tory, and should know how to interpret the in-
formation to patients in an understandable
manner. (Baseline data unavailable.)

By 1990, at least 70 percent of all graduate
engineers should be skilled in the design of
plants and processes that incorporate occupa-
tional safety and health control technologies.
(Baseline data unavailable.)

0 Improved services/ protection

p. By 1990, generic standards and other forms of
technology transfer should be established, where
possible, for standardized employer attention to
such major common problems as :3 chronic lung
hazards, neurological hazards, carcinogenic haz-
ards, mutagenic hazards, teratogenic hazards
and medical monitoring requirements.

42

q. By 1990, the number of health hazard evalua-
tions being performed annually should increase
tenfold; the number of industrywide studies
being performed annually should increase three-
fold. (In 1979, NIOSH performed approxi-
mately 150 health hazard evaluations; 50 indus-
trywide studies were performed.)

Improved surveillance / evaluation

r. By 1985, an ongoing occupational health haz-
ard/illness/injury coding system, survey and
surveillance capability should be developed, in-
cluding identiﬁcation of workplace hazards and
related health effects, including cancer, coronary
heart disease and reproductive effects. This sys-
tem should include adequate measurements of
the severity of work-related disabling injuries.

s. By 1985, at least one question about lifetime
work history and known exposures to hazardous
substances should be added to all appropriate
existing health data reporting systems, e.g.,
cancer registries, hospital discharge abstracts
and death certiﬁcates.

t. By 1985, a program should be developed to:
1) follow up individual ﬁndings from health
hazard and health evaluations, reports from
unions and management and other existing sur-
veillance sources of clinical and epidemiological
data; and 2) use the ﬁndings to determine the
etiology, natural history and mechanisms of sus-
pected occupational disease and injury.

4. Principal Assumptions

Control technology will have been developed in the
public and private sectors to reduce many major
workplace hazards.

A regulation program will have been developed for
pre-evaluation and approval of hazard control plans
for all new processes, new equipment and new
installations.

Greater use will be made of relevant State and local
Government agencies, as well as those academic
units which can address occupational safety and
health problems.

Comprehensive school health education curricula
will incorporate concepts of occupational illness and
injury including the role- of lifestyle and personal
habits (such as smoking and alcohol consumption)
and the level of hazard for the individual with occu-
pational exposures (e.g., asbestos and smoking,
vinyl chloride and excessive drinking).

Growing awareness of the importance of preventing
occupational disease and injuries will facilitate legis-
lative incentive to support the recommendations.
Coordinated State and local implementation systems
for recognition and prevention of occupational
health and safety hazards will have been developed.
Quality control in the delivery of occupational
health and safety services will be improved.

Workers in the public sector will be extended the
same protection as those in the private sector.

juries and Illnesses (summary tables). Continu-
ous reporting; National sample.

Surveillance, Epidemiology and End Result
Program (SEER). Cancer incidence, morbidity

5. Data Sources

a. To National level only .
0 National Occupational Hazard Survey. Inven-

tory of work hazards. DHHS—Center for Disease
Control (CDC), National Institute for Occupa-
tional Safety and Health (NIOSH). CDC Na-
tional Occupational Hazard Survey Reports,
Vol. 1-4, 1974—1979. Survey to be updated
1980—1982. Data obtained from on-site inspec-
tions of 800 industrial facilities 1972—79.

Health hazard evaluation and industrywide
studies. Morbidity, mortality and environmental
studies. DHHS—CDC, NIOSH. Selected NIOSH
Technical Reports. Continuous reporting.

Occupational injury and illness. Job related in-
jury and illness rates. Bureau of Labor Statistics.
Annual reports, Chartbook of Occupational In-

43

and survival. DHHS-National Institutes of
Health, National Cancer Institute. Periodic re-
ports. Continuous reporting from State and
regional cancer registries.

Mine injuries. Injuries per hours worked. De-
partment of Labor-Mine Safety and Health Ad-
ministration. Quarterly reports. Mine Injuries
and Work Time. Continuous reporting from
workplace. '

b. To State and/ or local level
0 State Worker’s Compensation Systems. Occupa-

tional illness and injuries. Data collected by ofﬁ-
cial State agencies. Sometimes analyzed in form
to permit incidence estimates.

i.

«Mi; .

 

ACCIDENT PREVENTION AND INJURY CONTROL

1. Nature and Extent of the Problem

The principal causes of disability and death from in-
jury are those associated with motor vehicles, falls,
drownings, burns, poisoning and gunshot Wounds.
Most such deaths and injuries occur while driving, in
the home or at work; many are also associated with
recreation and sports. See Pregnancy and Infant
Health, Toxic Agent Control, Occupational Safety
and Health, Smoking and Health, Misuse of Alcohol
and Drugs.

a. Health implications

Unintentional injuries are the leading cause of
death for people between 1 and 38 years of
age, and a leading cause of disability.
Minorities have higher accidental death rates
than the overall population. For example, in
1973—75 the American Indian accidental death
rate was 3.1 times the US. death rate for all
races.

According to the National Health Survey, 30
percent of the population is injured each year.
10,700 children under 15 years of age died from
accidental injuries in 1978:

— for children between 5 and 15, motor ve-
hicle fatalities accounted for 52 percent of
all accidental deaths;

— the overall death rates from accidents for
children under 15 fell from 26.6 per
100,000 in 1968 to 21.1 per 100,000 in
1978, a decrease of 20.7 percent.

— the most common fatal accidents to children
at home were from ﬁres (36 percent) and
suffocation (25 percent).

b. Status and Trends

Motor vehicle accidents account for the largest
number of trauma deaths and injuries:

—- there were approximately 52,400 deaths
from motor vehicle accidents in 1978, a rate
of 24.0 per 100,000 population, which rep-
resents an increase from the low of 21.5
deaths per 100,000 in 1975;

— of these motor vehicle accident deaths, over
9,000 were pedestrians, a 2 percent increase
from 1977;

— there were approximately 2 million disabling
injuries from motor vehicle accidents in
1978;

—— the motor vehicle fatality rate for children
under 15 decreased from 10.4 per 100,000
children in 1968 to 9.1 per 100,000 in
1978, a decrease of 12.5 percent;

—- for 15 to 24 years olds, the motor vehicle
fatality rate has climbed from 39.2 per
100,000 in 1975 to 46.1 in 1978;

— at least 45 percent of all fatal motor vehicle
accidents are alcohol related; in single ve-
hicle accidents, 65 percent of drivers are
legally drunk (i.e., with blood alcohol con-
centration of over .10 percent).

0 Falls

—- there were 13,690 deaths from falls in 1978
and over 11 million injuries;

— the mortality rate from falls was 6.3 per
100,000 in 1978, and has been declining in
recent years;

— over ﬁfty percent of fatal falls occur in the
home;

— ﬁfty-seven percent of fatal falls involve per-
sons 75 or older;

— older people who survive falls are more apt
to experience fractures than are younger
people; '

— impairment by alcohol is a major contributor
to falls.

0 Drownings

—— in 1978, there were 6,900 deaths from
drownings, a number which has remained
fairly constant over the past 15 years despite
increasing participation in water-related
activities;

— approximately 1 in 6 drownings (over 1,000)
involve boating mishaps;

— a substantial proportion of drownings occur
in unattended bodies of water.

0 Burns

—— there were 6,300 deaths from ﬁres and burn
injuries in 1978, a rate of 2.9 per 100,000
persons; _

—— there are. an estimated 60,000 hospital ad-
missions for burn injuries per year, with the
average length of hospital stay being 15
days;

— age speciﬁc rates for bum deaths are high
in children and the elderly;

— most ﬁre deaths are caused by residential
ﬁres; about one-third of fatal house ﬁres,

and a substantial number of burn injuries,
are related to cigarette smoking;

the largest number of burn injuries requir-
ing hospitalization are caused by scalds;
both alcohol and smoking are signiﬁcant
factors in ﬁre-related deaths.

0 Gunshot wounds

are second only to motor vehicle crashes in
causing death from traumatic injury;

in 1977, there were 31,000 deaths from gun—
shot wounds;

approximately 2,000 of these were acci-
dental; 12,900 were homicides; 16,000 were
suicides;

in 1978, the death rate for non-whites from
gunshot wounds (including accidents, sui-
cides and homicides) was 21.3 per 100,000
population; compared to a rate of 3.6 per
100,000 for whites; for black males 15 to
24, gunshot wounds were the leading cause
of death;

ﬁrearm deaths are strongly associated with
alcohol misuse.

0 Poisonings

an estimated 400,000 children under age 5
are accidentally poisoned each year, one-
fourth of Whom will be retreated for poison-
ing.

:. Prevention/Promotion Measures

a. Potential measures

0 Education and information measures include:

integrating safety education into the kinder-
garten through 12th grade school curricu-
lum, with special attention to highway safety
(and misuse of alcohol), poisoning, water
safety and burns;

educating parents and health professionals
about the importance of crash-tested child
restraints and seat belts and their proper
use in motor vehicles;

educating parents and child caretakers about
general safety for children, including pre-
school trafﬁc safety;

water safety and swimming education pro-
grams;

educating the elderly in measures to reduce
risks of falls;

educating architects, building contractors
and related professionals, including health
professionals, on ﬁre safety;

safety education and ﬁrst-aid training for
health professionals and the public;
educating the public on safe handling of ﬁre-
arms as part of general accident prevention
programs;

educating the general public, legislators and

46

other decisionmakers on the extent of the
ﬁrearm injury problem;

self-protection training programs for shop-
keepers, taxi drivers and others working in
jobs at high risk of armed robbery.

See Misuse of Alcohol and Drugs.

Technologic measures include:

improved automobile crashworthiness;
improved highway design facilitating pre-
vention of automobile crashes;

increased use of impact attenuators on high-
ways;

bikepath development;

improved design criteria for homes to pre-
vent injury from falls;

improved design of swimming pools and
environs;

increased use of ﬂame retardant materials
for clothes and furnishings;

introduction of self-extinguishing matches
and cigarettes into general use;

improvement of trigger safety lock designs;
uSe of non-lethal (wax) bullets for target
guns;

improved safety design of toys, gymnasium
equipment, other play equipment for schools
and playgrounds; ’

continued safety packaging of medications
to prevent poisoning;

efﬁcient emergency medical services.

Legislative and regulatory measures include:

mandatory automatic restraint systems in
cars;

mandatory infant and child carrier use in
cars;

standards for crashworthiness and crash
avoidance;

motorcycle helmet laws;

improved enforcement of laws related to
speeding, driving‘while under the inﬂuence,
and seat belt use;

strengthened building and housing codes;
ﬂoor-covering standards to protect against
falls;

standards for personal ﬂotation devices;
safety standards for public swimming pools;
mandatory use of smoke detectors;
mandatory non-scald settings for hot water
heaters;

uniform laws regarding the purchase and
possession of handguns.

Economic measures include:

reduced insurance premium rates for drivers
who do not drink or are otherwise at very
low risk;

reduced rates on home insurance for special
protective measuers against falls or ﬁres;
reduced insurance rates for recreational fa-

cilities, such as children’s camps and parks,
which have implemented effective safety
measures.

b. Relative strength of the measures

0 Safety education is a time-honored and widely
used prevention measure in injury control. The
National Safety Council, the American Red
Cross, and a large number of accident preven-
tion projects at all levels of Government depend
on education as the mainstay of their programs.
Although there is widespread support for all
kinds of educational efforts in this ﬁeld, evalua-
tion of educational programs that use rates of
morbidity and mortality as outcome measures
have not demonstrated signiﬁcant effects in re-
ducing injury rates. However, a majority of
safety professionals express strong conﬁdence
in training and education as a powerful tool for
building skills, increasing awareness and creat—
ing a climate for change.

Technologic strategies have accounted for sig-
niﬁcant reductions in morbidity and mortality
from injury and poisoning. Motor vehicle de-
sign changes to improve occupant protection
have been demonstrated to reduce the proba-
bility of death or serious injury in the event of
a collision. Industry has achieved remarkable
reductions in injury rates through improvements
in machinery design. Childproof containers for
medications have dramatically reduced acci-
dental poisoning. The effectiveness of techno-
logic depends on both the relationship of the
design to injury causation and the rate of adop-
tion of the change.

Regulatory measures such as building codes, ﬁre
codes and safety standards for materials and
machinery are widely accepted as effective coun-
termeasures. Regulatory measures have variable
effectiveness depending on compliance rates,
enforcement and the relationship of the measure
itself to injury causation.

The effectiveness of economic incentives for the
prevention of injury is only beginning to be ex-
plored outside the industrial setting. It has been
suggested that low insurance rates for drivers
who have not been involved in crashes or who
have no violations on their record may provide
incentives for more careful driving, but the stra-
tegy has not been evaluated. Product liability
suits have created incentives for manufacturers
to design and market safer products and to
recall defective ones. Adjustment of insurance
premiums for summer camps has been used to
provide incentives for hazard removal and has
been associated with reductions in injury rates.

3. Speciﬁc Objectives for 1990

0 Improved health status
a. By 1990, the motor vehicle fatality rate should

be reduced to no greater than 18 per 100,000

population. (In 1978, it was 24.0 per 100,000
population.)

b. By 1990, the motor vehicle fatality rate for chil-
dren under 15 should be reduced to no greater
than 5.5 per 100,000 children. (In 1978, it was
9.2 per 100,000 children under 15.)

c. By 1990, the home accident fatality rate for
children under 15 should be no greater than
5.0 per 100,000 children. (In 1978, it was 6.1
per 100,000 children under 15).

d. By 1990, the mortality rate from falls should be
reduced to no more than 2 per 100,000 persons.
(In 1978, it was 6.3 per 100,000.)

e. By 1990, the mortality rate for drowning should
be reduced to no more than 3.0 per 100,000
persons. (In 1978, it was 3.2 per 100,000.)

f. By 1990, the number of tap water scald in-
juries requiring hospital care should be re-
duced to no more than 2,000 per year. (In
1978, it was 4,000 per year.)

g. By 1990, residential fire deaths should be re-
duced to no more than 4,500 per year. (In
1978, it was 5,400 per year.)

h. By 1990, the number of accidental fatalities
from ﬁrearms should be held to no more than
1,700. (In 1978, there were 1,800.)

—— See Misuse of Alcohol and Drugs.

0 Reduced risk factors

i. By 1990, the proportion of automobiles con-
taining automatic restraint protection should be
greater than 75 percent. (In 1979, the propor—
tion was 1 percent.)

j. By 1990, all birthing centers, physicians and
hospitals should ensure that at least 50 percent
of newborns return home in a certiﬁed child pas—
senger carrier. (Baseline data unavailable).

k. By 1990, at least 110 million functional smoke
alarm systems should be installed in residential
units. (In 1979, there were approximately 30
million systems.)

0 Increased public/professional awareness

1. By 1990, the proportion of parents of children
under age 10 who can identify appropriate
measures to address the three major risks for
serious injury to their children (i.e., motor ve—
hicle accidents, burns, poisonings) should be
greater than 80 percent. (Baseline data unavail-
able.)

m. By 1990, virtually all primary health care pro-
viders should advise patients about the import-
ance of safety belts and should include instruc-
tion about use of child restraints to prevent
injuries from motor vehicle accidents as part
of their routine interaction with parents. (In
1979, the proportion of pediatricians who re—
ported that they advised parents on car safety
measures was approximately 20 percent.)

0 Improved services/ protection
11. By 1990, at least 75 percent of communities

47

with a population of over 10,000 should have
the capability for ambulance response and
transport within 20 minutes of a call. (In 1979,
approximately 20 percent had this capability.)

o. By 1990, virtually all injured persons in need
should have access to regionalized systems of
trauma centers, burn centers and spinal cord
injury centers. (In 1979, about 25 percent of
the population lived in areas served by region-
alized trauma centers.)

p. By 1990, at least 90 percent of the population
should be living in areas with access to regional-
ized or metropolitan area poison control centers
that provide information on the clinical manage-
ment of toxic substance exposures in the home
or work environment. (In 1979, about 30 per-
cent of the population lived in such areas.)

Improved surveillance/ evaluation systems

q. By 1990, at least 75 percent of the states will
have developed a detailed plan for the uniform
reporting of injuries.

4. Principal Assumptions

Children:

— improvements will occur in design and use of
child restraint systems;

-—— increases will occur in use of automatic re—
straints;

— trends in product safety regulation for the pro-
tection of children will continue.

Motor Vehicles:

— highway safety and vehicle safety will continue
to be improved;

—— use of safety belts and child restraints will in-
increase to thirty-ﬁve percent;

—— the 55 MPH speed limit will be vigorously en-
forced;

—— more State laws will be passed to reduce
alcohol-related crashes, and more stringent en-
forcement of existing laws will occur;

— See Misuse of Alcohol and Drugs.

Falls:

— improved design will be effected in new and
existing dwelling units (handrails, lighting);

— alcohol abuse prevention and treatment pro-
grams will be increasingly available.

Drownings:

—— swimming pool design will improve, including
modiﬁcations to access;

— licensing/certiﬁcation of boat operators will
grow.

Burns:

— there will be a continued decline in per capita
cigarette consumption;

—— improvements in building codes and their en-
forcement will occur;

— self-extinguishing matches and cigarettes will
become available.

48

0 Gunshot wounds:

— there will be an increase in State law concern-
ing purchase and possession of handguns;

— fewer people will purchase handguns;

— there will be improvements in design and in-
crease in use of gun safety devices.

5. Data Sources

a. To National level only

0 National Electronic Injury Surveillance System
(NEISS). Traumatic consumer product related
injuries. Consumer Product Safety Commission
(CPSC). NEISS Data Highlights and News
from CPSC, selected reports. Continuous daily
injury reporting and detailed accident investi-
gations of selected high priority cases, National
sample of 74 hospital emergency rooms. Re-
porting initiated in 1972, revised in 1978.

0 Occupational injury and illness. Job related in-
jury and illness rates. Department of Labor,
Bureau of Labor Statistics. Compiled from con-
tinuous monthly and selected reports, from
Chartbook an Occupational Injuries and Ill—
nesses tables.

0 Fatal Accident Reporting System (FARS). De-
scribes detail of fatal highway accidents. De-
partment of Transportation (DOT), National
Highway Trafﬁc Safety Administration. Fatal
Accident Reporting System Annual Report.
Continuous reporting.

0 Health Interview Survey (HIS). Sickness and
injuries among members of households experi-
enced during two weeks prior to the interview.
DHHS—National Center for Health Statistics
(NCHS). NCHS Vital and Health Statistics,
Series 10. Continuous household interview sur-
vey; National sample.

0 Boating accidents. Compilation of boating
accident and registration statistics. DOT—U.S.
Coast Guard. Boating Statistics (COMDTINST
M16754.1, Old CG—357). Full count and se-
lected activities reported annually from recrea-
tional boat numbering and casualty reporting
systems.

0 Surveillance and studies of accidents. Causes
and prevention of vehicular accidents; other
studies. Accident Analysis and Prevention—An
International Journal. Pergamon Press, Ltd.
Continuous quarterly reports.

0 Surveillance and studies of accidents. Selected
study reports, various topics. Metropolitan Life
Insurance Company. Statistical Bulletin. Survey
and full count data. Continuous quarterly pub-
lication.

0 Hospital Discharge Survey (HDS). Trauma,
burn patients discharged from short stay hospi-
tals. DHHS-NCHS. NCHS Vital and Health
Statistics, Series 13, selected reports. Continu-
ous; National probability sample.

b. To State and / or local level

National Vital Registration System

— Mortality. Deaths by cause (including acci-
dents) by age, sex and race. DHHS-NCHS.
NCHS Vital Statistics of the United States,
Vol II, and NCHS Monthly Vital Statistics
Reports. Continuing reporting from States;
National, full count. (Many States issue
earlier reports.)

Accident reports. Numbers and rates of acci-
dents by type. National Safety Council. Accident
Facts, an annual report of surveys, full count
data, and extrapolations of data, including se-
lected summary reports; and Journal of Safety
Research, selected accident study reports, pub-
lished quarterly. Data from State, Federal, local
governments and private industry and organza-
tions.

Motor vehicle accidents

— Reports from State Motor Vehicle depart—
ments.

— Epidemiologic survey data on trafﬁc acci—
dents and conditions. When, where and how
traffic accidents occur. State trafﬁc authori-
ties and DOT-Federal Highway Administra-
tion. Selected reports and annual summaries.

State burn registries, where established.
Hospitalized illness discharge abstract systems.

49

— Professional Activities Study (PAS). Pa-
tients in short stay hospitals; patient charac-
teristics, diagnoses of trauma and burns,
procedures performed, length of stays. Com—
mission on Professional and Hospital Activi-
ties, Ann Arbor, Michigan. Annual reports
and tapes. Continuous reporting from 1900
CPHA member hospitals; not a probability
sample, extent of hospital participation var-
ies by State.

—— Medicare Hospital Patient Reporting System
(MEDPAR). Characteristics of Medicare
patients, diagnoses, procedures. DHHS-
Health Care Financing Administration,
Oﬂice of Research, Demonstration and Sta-
tistics (ORDS). Periodic reports. Continu-
ing reporting from hospital claim data; 20
percent sample.

— Other hospital discharge systems as locally
available.

Selected health data. DHHS-NCHS. NCHS Sta-
tistical Notes for Health Planners. Compilations
and analysis of data to State level.

Area Resource File (ARF). Demographic,
health facility and manpower data at State and
county level from various sources. DHHS-
Health Resources Administration. Area Re-
source File: A Manpower Planning and Re-
search Tool. DHHS—HRA-80-4, Oct 79. One
time compilation.

 

FLUORIDATION AND DENTAL HEALTH

1. Nature and Extent of the Problem

Dental diseases probably constitute, in the aggregate,
the most prevalent health problem in the Nation. The
two most prevalent oral diseases are dental caries
(tooth decay) and periodontal disease (diseases of
the gums and other tissues supporting the teeth). If
not controlled, each of these diseases progresses to an
advanced stage that is diﬂicult and, therefore, expen-
sive to treat. If left untreated, or if treatment is delayed
too long, dental caries and periodontal disease result
in tooth loss. However, based on current knowledge,
both of these diseases can be prevented in most per-
sons. Fluoridation—particularly of community water
supplies—is the most effective measure to reduce the
incidence of the largest problem, dental caries, with
the capability of preventing 65 percent of dental caries
and 50 percent of children’s dental bills. Fluoridation
is, therefore, the major focus of this section, but other
measures important to dental health are also discussed.

a. Health implications

0 Dental caries is localized, progressive destruc-
tion of the tooth initiated by acid demineraliza-
tion of the outer tooth surface. Caries results
from a complex interaction among three factors:
tooth susceptibility, bacteria in plaque and die-
tary environment.

O Periodontal disease is an insidious inﬂammatory
disease which affects the gums and the alveolar
bone supporting the teeth. There are several
type of periodontal disease. The initial and most
common type is gingivitis or inﬂammation of
the gums. If untreated, this condition usually
develops into periodontitis, the chronic destruc-
tive stage of the disease. In the advanced stages,
the bone supporting the teeth is destroyed, the
teeth loosen and eventually are lost.

0 Research ﬁndings indicate that certain oral bac-
teria—associated with plaque and calculus ac-
cumulations on teeth—are the prime cause of
periodontal disease. Several other factors that
may be associated with the development of the
disease include: poor nutrition, malocclusion,
grinding of the teeth, the loss of teeth which
causes those remaining to drift out of position
and hormonal imbalances.

b. Status and trends
0 Dental caries affects 98 percent of the US.

51

population, creating a dental disease problem of
massive proportions.

0 By 17 years of age, 94 percent of children have
experienced caries in their permanent teeth. On
average, 17 year-olds have had about nine
permanent teeth affected.

0 Low income children have about four times
more untreated decayed teeth than high income
children.

0 Forty-seven percent of children under age 12
have never been to a dentist.

0 About 31 million adults aged 18 to 74 years
have lost all of their upper or lower natural
teeth. This includes about 19 million adults who
have lost all their teeth.

0 Periodontal disease is the second most prevalent
oral disease. More than 65 million persons have
periodontal disease, including nearly 12 million
children and more than 53 million adults.

0 The proportion of persons with periodontal dis-
ease increases signiﬁcantly with age:

— almost one-third of children aged 12 to 17
years have gingivitis;

—— among those persons 65 to 74 years of age
with some natural teeth still present, two-
thirds have periodontal disease, half of
whom have the disease in its destructive
stage.

0 Data from the initial and 1971—74 National
Center for Health Statistics (NCHS) health ex-
amination survey suggest periodontal disease is
decreasing in prevalence. '

0 Injuries to the teeth and mouth also constitute a
sizeable dental problem.

2. Prevention / Promotion Measures

Dental disease prevention covers a spectrum of many
activities—the ﬂuoridation of community and school
water supplies, dental health education, ﬂuoride sup-
plements and rinses, individual improvement of oral
hygiene and dietary practices and routine professional
check-ups. Included in this spectrum are procedures to
modify the behavior patterns of individuals regarding
measures such as diet change, tooth brushing and
ﬂossing.

a. Potential measures

Measures to prevent dental caries may be directed
at one of the three principal contributing factors:

tooth susceptibility, bacteria in plaque and dietary
environment. Reduction of bacterial agents is ac—
complished through a proper personal oral hygiene
regimen and regular prophylaxes given by a dental
professional. For a proper dietary environment,
highly cariogenic foods and snacks, particularly
those containing reﬁned sugars, should be avoided;
however, if such foods are consumed, the teeth
ought to be thoroughly brushed immediately after-
wards. The caries susceptibility of teeth is signiﬁ-
cantly reduced through the proper use of ﬂuorides.
For persons not ingesting suﬂicient ﬂuoride as it
occurs naturally in their drinking water, ﬂuoride
measures are needed. The ingestion of ﬂuorides
from birth is most effective and may be accom-
plished' through either ﬂuoridation of drinking
water supplies or the use of dietary ﬂuoride supple-
mentary. Fluoridation of water supplies is the most
practical measure. As a less effective alternative,
topical ﬂuorides may be applied either by the indi-
vidual or a dental professional. The beneﬁts and
safety of ﬂuorides in preventing dental caries are
well documented as the result of almost ﬁve decades
of research and over 30 years of experience. Al-
though the technology of ﬂuoridation as an effec-
tive prevention measure for dental caries is well
established, a considerable gap persists between
knowledge and application. To implement near
universal ﬂuoridation in the United States requires
an array of interacting strategies.

The prevention of periodontal disease requires
proper oral hygiene to minimize plaque deposits
on the teeth. Calculus, a hard crust-like material
formed at and below the gum margin by deposition
of calcium and phosphate from saliva in neglected
plaque, must also be removed. As periodontal
pockets are formed, bacteria and food particles
may lodge in the pockets resulting in more inﬂam-
mation and setting up a cycle in the disease
process. Plaque can be removed by the individual
by thorough brushing and ﬂossing of the teeth on
a daily basis. Calculus, however, cannot be re-
moved by simple brushing, but requires scaling of
the teeth regularly by a dentist or dental hygienist.
0 Education and information measures include:

— public educational efforts to promote ﬂuori—
dation of community and school water sys-
tems as well as other caries and periodontal
disease preventive measures at National,
State and local levels—using electronic and
print media, school health curricula, health
organizations and lay groups;

— informing and involving key groups and in-
dividuals, including health professionals,
community decisionmakers, health organi-
zati0ns, waterworks associations, and lay
groups and organizations in the prevention
of dental disease;

— using schools to promote both ﬂuoridation
and improved preventive periodontal meas-
ures;

52

~—— developing local advocacy groups to en-
courage the adoption and retention of
ﬂuoridation through the appropriate politi-
cal process.

0 Service measures include:
— ﬂuoridation of water systems“:

— community water ﬂuoridation: most com-
munity water supplies contain less than
optimum concentrations of naturally-
occurring ﬂuoride and need to be ﬂuori-
dated; among communities of 1,000 or
more population, about 8,670 water sys-
tems serving about 5,860 communities
have not yet been ﬂuoridated; approxi—
mately 32 percent of the US population
(67 million persons) were served by
these ﬂuoride-deﬁcient water systems in
1975; another 17 percent were not served
by community water systems at all; thus,
approximately 51 percent of the popula-
tion was served by public water systems
providing an adjusted optimal ﬂuoride
level and an additional 8 percent of the
population used naturally ﬂuoridated
drinking water at optimum or higher ﬂuo-
ride level.

— school water ﬂuoridation: elementary and
secondary schools on independent water
systems (i.e., schools not served by com-
munity water systems) that are located in
ﬂuoride-deﬁcient areas need to be ﬂuori-
dated; school water ﬂuoridation can re-
duce the incidence of dental decay by up
to 40 percent, and could serve an addi-
tional 2.2 million school children.

*NOTE: Optimum ﬂuoride concentration:
For community water ﬂuoridation, the
recommended optimum ﬂuoride concen-
tration is determined by the mean maxi-
mum daily temperature over a ﬁve-year
period—in the United States, the opti-
mum ﬂuoride concentration for com-
munity water ﬂuoridation ranges between
0.7 and 1.2 parts of ﬂuoride per one
million parts of water (ppm); for sepa-
rate school water ﬂuoridation, the rec-
ommended ﬂuoride concentration is 4.5
times the optimum ﬂuoride concentra-
tion recommended for community water
ﬂuoridation in the same geographic area.

— school-based caries and periodontal disease
preventive services; a full range of appropri—
ate preventive services can be made readily
available to children enrolled in elementary
and secondary schools and to younger chil—
dren in day-care centers, Head Start pro-
grams and preprimary programs, including
as appropriate:

— self-applied ﬂuoride measures through

dietary ﬂuoride supplements, usually
taken in tablet form, or ﬂuoride mouth-
rinses;

— educational and informational measures
as a component of general health educa-
tion;

— school and community activities to limit
the accessibility of highly cariogenic foods
and snacks to children;

— school-based educational and hygienic
periodontal disease preventive services.

0 Technology measures include:

— efforts to ensure that the ﬂuoride concentra-
tions of water distributed from ﬂuoridated
water systems are maintained at optimum
levels at all times (unless the ﬂuoride con-
centration is maintained at the optimum
level, the reduction of dental caries is
markedly decreased) :

- continuous operation of ﬂuoridation
equipment;

— proper and timely monitoring and surveil-
lance of ﬂuoridated water systems;

— training and continuing education for
waterworks personnel and engineers and
for school personnel responsible for op-
eration of school ﬂuoridation equipment;

— use of modern technology in ﬂuoridation
system surveillance;

— improved technology for ﬂuoridation
equipment, and testing and engineering
procedures;

— ensuring an adequate supply of needed
types of ﬂuoride compounds.

0 Legislative and regulatory measures include:

— developing model State laws and regulations
for ﬂuoridation and ﬂuoridation monitoring
and surveillance systems;

— clarifying speciﬁc provisions of Federal and
State safe drinking water laws and regula-
tions which potentially delay the implemen-
tation of ﬂuoridation.

0 Economic measures include:

-— ﬁnancial and technical assistance to support
expansion of community and school water
ﬂuoridation;

— inclusion of ﬂuoridation equipment, where
appropriate, in the funding of new or im-
provide water systems by the US. Depart-
ment of Housing and Urban Development,
the Economic Development Administration
and the Farmers Home Administration;

-— reducing premiums for dental insurance for
families with children who live in ﬂuoridated
communities;

— reducing HMO capitation charges for dental
coverage for families with children who live
in ﬂuoridated communities.

53

b. Relative strength of the measures
0 Measures which in combination ensure that chil-

dren receive the full beneﬁts of ﬂuoride, infre—
quently consume highly cariogenic foods and
follow a proper personal oral hygiene regimen
have a synergistic effect on preventing dental
caries and reducing the need for and cost of
children’s dental care. These measures do not
alter the need for regular visits to the dentist
and the prompt treatment of caries that does
develop.

Fluoridation of community water supplies is
estimated to yield $50 in savings from reduced
treatment for each dollar invested.

The ﬂuoridation of community water systems is
the most eﬂective, least costly public health
measure for preventing dental caries. Beneﬁts
that accrue in children include:

—-— teeth that are more resistant to caries;

— as much as two-thirds less caries in children
who drink ﬂuoridated water from birth;

—- as many as six times more caries-free teen-
agers in ﬂuoridated communities as in non-
ﬂuoridated communities;

— fewer extractions of primary and permanent
teeth;

-—— fewer and less complex and, therefore, less
costly restorative services (children’s dental
treatment costs in ﬂuoridated communities
can be one-half the costs in nonﬂuoridated
communities) .

Adults consuming ﬂuoridated water throughout
life can expect fewer caries-related treatment
needs and less loss of teeth due to caries.

Substantial, though in most instances less
beneﬁcial, results can be realized from other
ﬂuoride measures (the percentage reductions of
these measures are not arithmetically additive):

—— dietary ﬂuoride supplements in recommend-
ed dosages:

-— if provided in school programs, result in
caries reductions in permanent teeth rang-
ing from 25 to 35 percent after two or
more years of ﬂuoride ingestion.

— a weekly ﬂuoride rinse regimen, utilizing a
0.2 percent neutral sodium ﬂuoride solution,
can reduce caries incidence by about 25
percent;

— a ﬂuoride dentrifrice (toothpaste) can re-
duce caries incidence by 20 percent;

— professionally-applied ﬂuorides can reduce
caries incidence by about 35 percent.

Regular oral examinations serve to identify

caries at an early stage so that treatment can.be

prompt, andunnecessary further destruction and
potential loss of the teeth prevented.

Both ﬂuoridation and school—based programs

ensure that children of all socioeconomic levels

receive caries preventive services.

0 Since the United States began using community
ﬂuoridation in 1945, there have always been
barriers to attaining goals of near universal ﬂuo-
ridation, including community inaction, ﬁnancial
limitations on communities, improper systems
surveillance, and the powerful antiﬂuoridationist
lobby. Also, some ﬂuoridated systems are main-
tained below the recommended optimum level.

0 Vigorous promotional efforts to prevent perio—
dontal disease can also be eﬂective. Particularly
important in this regard are efforts to encourage
the public—especially school children—to prac-
tice good oral hygiene on a daily basis and to
make regular visits to the dentist.

3. Speciﬁc Objectives for 1990 or Earlier

0 Improved health status

a. By 1990, the proportion of nine-year-old chil-

dren who have experienced dental caries in their

permanent teeth should be decreased to 60 per—
cent. (In 1971—74, it was 71 percent.)

By 1990, the prevalence of gingivitis in children

6 to 17 years should be decreased to 18 percent.

(In 1971—74, the prevalence was about 23 per-

cent.)

c. By 1990, in adults the prevalence of gingivitis
and destructive periodontal disease should be
decreased to 20 percent and 21 percent, respec-
tively. (In 1971-74, for adults aged 18 to 74
years, 25 percent had gingivitis and 23 percent
had destructive periodontal disease.)

0 Reduced risk factors

(1. By 1990, no public elementary or secondary
school (and no medical facility), should offer
highly cariogenic foods or snacks in vending ma-
chines or in school breakfast or lunch programs.

6. By 1990, virtually all students in secondary
schools and colleges who participate in orga-
nized contact sports should routinely wear
proper mouth guards. (Baseline data unavail—
able.)

0 Increased public/ professional awareness

f. By 1990, at least 95 percent of school children
and their parents should be able to identify the
principal risk factors related to dental diseases
and be aware of the importance of ﬂuoridation
and other measures in controlling these diseases.
(Baseline data unavailable.)

By 1990, at least 75 percent of adults should be
aware of the necessity for both thorough per-
sonal oral hygiene and regular professional care
in the prevention and control of periodontal dis-
ease. (In 1972, only 52 percent knew of the
need for personal oral hygiene and only 28 per-
cent were aware of the need for dental check-

ups.)
0 Improved services/ protection

h. By 1990, at least 95 percent of the population
on community water systems should be receiv-

54

ing the beneﬁts of optimally ﬂuoridated water.
(In 1975, it was 60 percent.)

i. By 1990, at least 50 percent of school children
living in ﬂuoride-deﬁcient areas that do not have
community water systems should be served by
an optimally ﬂuoridated school water supply.
(In 1977, it was about 6 perent.)

j. By 1990, at least 65 percent of school children
should be proﬁcient in personal oral hygiene
practices and should be receiving other needed
preventive dental services in addition to ﬂuorida-
tion. (Baseline data unavailable.)

Improved surveillance/ evaluation systems

k. By 1990, a comprehensive and integrated sys-
tem should be in place for periodic determina-
tion of the oral health status, dental treatment
needs and utilization of dental services (includ-
ing reason for and costs of dental visits) of the
US. population.

1. By 1985, systems should be in place for deter-
mining coverage of all major dental public health
preventive measures and activities to reduce
consumption of highly cariogenic foods.

4. Principal Assumptions

Even though community water ﬂuoridation is the
most effective public health measure for preventing
dental caries, this measure alone cannot do the job.
Signiﬁcant progress will not be made in reducing
the national dental caries rate in children and in-
creasing the proportion of children who are caries
free until such time as all three major approaches
to caries prevention—proper personal oral hygiene,
diet low in highly cariogenic foods and ﬂuoride pro-
tection—are followed in combination, as needed,
by the majority of children in this country.

Support for ﬂuoridation assistance programs will
grow to a level to meet the program’s major objec-
tive—near universal ﬂuoridation.

Organized dentistry’s support for dental caries and
periodontal disease prevention measures will in-
crease at the National, State and local levels.

State and local health and education agencies, the
Health Systems Agencies, the State Health Planning
and Development Agencies and the Statewide
Health Coordinating Councils will increase their
concern for and expand their activities to support
ﬂuoridation, school-based prevention oriented dental
programs and periodontal health promotion.
Fluoridation will continue to have the strong en-
dorsement of virtually every major National health
organization.

The cost/beneﬁt ratio of community water ﬂuorida-
tion will continue to be more favorable than for any
other known public health measure implemented for
the prevention of dental caries.

The percent of the total US. population on com—
munity water supplies will not change appreciably
between 1980 and 1990 (approximately 82 percent
in 1979).

1975. To be conducted annually beginning in
1980. Data to be aggregated at National and

. _ _ State levels.
' The Health and Nutritlon Examination Survey 0 National Dental Caries Prevalence Survey. Den-

5. Data Sources
a. To National level only

(HANES). Prevalence of dental caries, perio-
dontal disease, edentulousness and related infor-
mation in US. population. DHHS-National
Center for Health Statistics (NCHS). NCHS
Vital and Health Statistics, Series 11, selected
reports. Periodic survey, national sample. Note:
dental data collected in HANES I (1971—74),
not in HANES 11 (1976—80).

State legislation on ﬂuoridation. New or pro—
posed State legislation affecting ﬂuoridation of
water supplies. DHHS-Center for Disease Con-
trol (CDC). CDC analysis compiled from Com—
merce Clearing House, Inc. information. Con-
tinuing.

Effects of ﬂuoridation on dental practice and
dental human resource requirements. American
Dental Association Bureau of Economic and
Behavioral Research. Periodic reports. Continu-
ing: national surveys of practicing dentists.

b. To State and/ or local level

0 Fluoridation census. Fluoridation status of com-

munity water supplies, adjusted and natural;
population served, dates ﬂuoridation initiated,
other related information. DHHS—CDC. CDC

55

tal caries and periodontal disease among school
children, grades K—12, related to ﬂuoride con—
tent of drinking water for the school and place
of residence of the children in the study. DHHS-
National Institute of Dental Research. Report
forthcoming. Survey, 1980. Additional surveys
planned at 3 year intervals.

Early and Periodic Screening, Diagnosis and
Treatment (EPSDT) reporting system. Oral
health status and referral of children screened.
DHHS-Health Care Financing Administration
(HDFA), Ofﬁce of Research, Demonstration
and Statistics. Medicaid Statistics, selected re-
ports. Continuous reporting from State Medicaid
oﬂices.

Selected health data. DHHS-NCHS. NCHS Sta-
tistical Notes for Health Planners. Compilations
and analysis of NCHS data to State level.

Area Resource File (ARF). Demographic,
health facility and manpower data at State and
county level from various sources. DHHS—
Health Resources Administration. Area Re-
source File: A Manpower Planning and Research
Tool, DHHS—HRA—80—4, Oct 79. One time
compilation

 

SURVEILLANCE AND CONTROL OF INFECTIOUS DISEASES

1. Nature and Extent of the Problem

Current surveillance and classiﬁcation systems do not
accurately reﬂect the importance of infectious diseases
on the health and well—being of the nation. Only one
category of infectious diseases (inﬂuenza and pneu-
monia) is ranked among the top 10 causes of death
according to the National Center for Health Statistics
(NCHS). However, were infectious diseases to be
grouped in a manner similar to the cardiovascular
diseases and cancer, 123,000 deaths would have been
attributable to infectious diseases in 1976, surpassed
only by cardiovascular diseases (719,000) cancers
(387,000), and stroke (182,000). However, even this
ﬁgure is an underestimate of the total impact. When
it is adjusted for the probable sensitivity of the sur-
veillance systems used, over 300,000 deaths may be
attributable to infectious diseases each year. Particu-
larly underestimated are the incidences of the common
infectious diseases of the respiratory, gastro-intestinal
and genitourinary tracts.

a. Health implications

0 Over 2 million nosocomial infections (acquired
in patient-care institutions) occur each year, and
60,000 to 80,000 persons die as a direct or
indirect result of such infections. An estimated
20 percent of these infections are preventable
with current control technologies.

0 Each year, an estimated 2,400,000 cases of

pneumonia occur, with pneumococcal pneu-

mo‘ ' alone affecting 400,000 persons at a cost
osz$32 illion.

Ah anual average of 57,000 deaths attributable

to pneumonia and inﬂuenza has been reported

over the last 10 years.

0 In 1977, there were 30,145 reported cases of
tuberculosis and 2,968 associated deaths.

0 Each year, an estimated 1,200,000 cases of sal-
monellosis occur, with an estimated direct cost
of $774 million.

0 Annually, an estimated 200,000 cases of shigel-
losis occur, with an estimated direct cost of $130
million.

0 Almost three quarters of food-borne diseases
originate in food service establishments. (65 per—
cent) or food processing plants (4 percent).

0 Each year an estimated 200,000 infections of
hepatitis B virus occur, a third of which result
in jaundice. Approximately 200 people die due

57

to acute infection, 280 from liver cancer and
3,500 from cirrhosis caused by hepatitis B virus.
The cost of acute disease is estimated to be $70
million.

An estimated 60,000 acute cases of hepatitis A
and 60,000 cases of non A/ non B hepatitis occur
each year costng approximately $120 million.
Each year, an estimated 18,000 cases of bac-
terial meningitis are reported, with 2,500 asso-
ciated deaths and an estimated direct cost of
$58 million.

In 1975, an epidemic year, an estimated 544,000
infections of St. Louis Encephalitis occurred in
the United States.

A 1977 epidemic of dengue in Puerto Rico re-
sulted in an estimated 1,740,000 cases. Dengue
outbreaks continue in the Caribbean area and
in Mexico increasing the potential for the intro-
duction of dengue into the continental United
States.

Infectious diseases including malaria, hepatitis
and diarrheal diseases of viral, bacterial or
parasitic origin, remain serious health hazards
of international travel.

Status and trends

There are between 190 and 250 million acute
respiratory illnesses per year in the United
States, resulting in a minimum of 400 million
days in bed, 125 million days lost from work
and 125 million days lost from school.

Acute gastroenteritis is the second most com-
mon illness, accounting in one survey for 9.5
percent of all visits to pediatricians’ ofﬁces.
Infectious diseases result in approximately 27
million patient days of acute hospital care each
year (10 percent of the patient days in acute
care hospitals) at an estimated direct cost of
nearly $6 billion.

Infectious diseases, such as tuberculosis, con-
tinue to be more prevalent in poverty areas and
areas with high immigration rates.

Antibiotics and antimicrobials, the most com—
monly prescribed category of medication, ac-
count for a major portion of prescription drug
costs. _, .

R pl mine/mediated multiple-resistant orga-
nisms, lCh appear to be increasing among
pathogens of man, threaten to blunt the effec-
tiveness of previous therapeutic regimens.

/L

2. Prevention/Promotion Measures

Potential measures
0 Education and information measures include:

—- better understanding and practice of basic
hygienic measures, such as handwashing and
proper handling of food;

— creation of an atmosphere conducive to
greater public participation in health prac-
tice (e.g., more local demand for hygienic
practices in food service establishments and
for immunization availability);
school health, and public and professional
education to improve individual awareness
of, and responsibility for, disease prevention
practices such as handwashing, and obtain-
ing immunization for one’s self and one’s
children;

educational approaches that take into ac-

count socioeconomic and ethnic differences

that may inﬂuence both spread of disease
and receptivity to change.

0 Service measures include:

— operation of surveillance networks including
deﬁnitive and dependable laboratory infor—
mation to ensure early detection of infec-
tious diseases and their causes;

assistance in analysis of surveillance data to
assess the extent and impact of infectious
diseases, to evaluate the costs and beneﬁts
of public health efforts and to deﬁne im—
portant areas for research;

operation of communications technology to
facilitate national dissemination of data
within disease reporting systems;
dissemination of information to States and
localities concerning threatening infectious
disease agents and new prevention and con-
trol methods;

provision of epidemiologic investigation and
control services to facilitate response to
infectious disease problems within medical
care facilities as well as in the community.

0 Technologic measures include:

— better design of medical devices and im-
plants for safety and ease of sterilization or
disinfection;

— improved water treatment systems; ‘

— improved regulatory measures relating to
food processing, food service and waste dis-
posal;

— development and testing of new vaccines;

— development of new diagnostic tests for dis-
ease diagnosis and control;

— improved vector control and vector surveil-
lance technology;

— improved design of health-care facilities to
facilitate infection control practices (e.g.,
readily accessible sinks for handwashing
between visits to patients).

58

b. Relative strength of the measures

0 Surveillance, including epidemiologic investiga-

tions, is the basic and essential element of dis-
ease control. Historically, surveillance has pro-
vided the basis for understanding the major
infectious diseases of man. It will remain essen-
tial to the future of infectious disease control.
Improved surveillance systems will allow detec-
tion of new reservoirs of infection, deﬁnition of
populations at risk, understanding of patterns
of disease spread, and the evaluation of control
measures. Surveillance systems will serve an
increasingly important role in program evalua-
tion (e.g., cost-beneﬁt analyses) and the identi-
ﬁcation of new areas for intervention.

Although health education measures lack rigor-
ous evaluation, they have contributed substan-
tially to curbing disease transmission. Further
progress in preventing infectious diseases can
be expected from public education measures in
areas such as vaccine acceptance, proper use of
antibiotics and the understanding of personal
hygiene.

The history of successful intervention in the con—
trol of food and waterborne diseases anticipates
the development of new technologies for the
control of infectious diseases and the application
of new environmental control measures to large
populations. In the hospital setting, the Study
on the Eﬂicacy of Nosocomial Infection Con-
trol (SENIC) is a model for evaluating environ-
mental measures related to infectious disease
problems of public health importance.

3. Speciﬁc Objectives for 1990

0- Improved health status

a.

By 1990, the annual estimated incidence of
hepatitis B should be reduced to 20 per 100,000
population. (In 1978, it was estimated to be 45
per 100,000 population.)

By 1990, the annual reported incidence of
tuberculosis should be reduced to 8 per 100,000
population. (In 1978, it was 13.1 per 100,000
population.)

By 1990, the annual estimated incidence of
pneumococcal pneumonia should be reduced to
115 per 100,000 population. (In 1978, it was
estimated to be 182 per 100,000 population.)
By 1990, the annual reported incidence of bac-
terial meningitis should be reduced to 6 per
100,000 population. (In 1978, it was estimated
to be 8.2 per 100,000 population.)

By 1990, the (risk factor-speciﬁc) incidence of
nosocomial infection in acute care hospitals
should be reduced by 20 percent of what other-
wise would pertain in the absence of hospital
control programs. (In 1979, it was estimated
that 5 percent of all hospital patients suffered
nosocomial infections and the overall rate of
hospital acquired infections appears to be in—

creasing, although less so in hospitals with good
infection control programs.) A similar percent-
age of reduction should be seen in long-term
care and residential care facilities. (Baseline
data unavailable.)

0 Improved services/protection

f. By 1990, 95 percent of licensed patient care
facilities should be applying the recommended
practices for controlling nosocomial infectious.
(Baseline data unavailable.)

3. By 1990, surveillance and control systems
should be capable of responding to and contain-
ing: (1) newly recognized diseases and unex-
pected epidemics of public health signiﬁcance;
and (2) infections introduced from foreign
countries.

*h. By 1990, at least 50 percent of people in popu-
lations designated as targets by the Immuniza-
tion Practices Advisory Committee of the Public
Health Service should be immunized within 5
years of licensure of new vaccines for routine
clinical use.

*NOTE: Same objective as for Immunization.
Potential candidates include: hepatitis A and
B; otitis media (S. pneumoniae and H. inﬂu-
enza); selected respiratory and enteric viruses;
meningitis (group B N. m'eningitides, S. pneu-
moniae, H. inﬂuenza) .

0 Improved surveillance/evaluation systems

i. By 1990, data reporting systems in all States
should be able to monitor trends of common
infectious agents not now subject to traditional
public health surveillance (respiratory illnesses,
gastrointestinal illnesses, otitis media) and to
measure the impact of these agents on health
care cost and productivity at the local and State
levels, and by extension at the National level.

j. By 1990, the extent of epidemics of respiratory
and enteric viral illnesses should be predicted
within 2 weeks after they appear, through com—
munity-wide sentinel surveillance systems.

k. By 1990, all State health departments should be
linked by a computer system to Federal health
agencies for routine collection, analysis and
dissemination of surveillance data, rapid com-
munication of messages, and epidemic aid in-
vestigations.

1. By 1990, laboratories throughout the country
should be linked for monitoring infectious
agents and antibiotic resistance patterns and for
disseminating information.

4. Principal Assumptions

0 Despite anticipated changes in antibiotic resistance
patterns, there will be no dramatic changes in the
projected evolution of infectious disease patterns
before 1990—although disease agents will be newly
recognized and epidemiologic patterns deﬁned.

0 Continuing change in the age structure of the US.

59

population with increasing numbers of persons over
65 and a concomitant increase in the number and
size of residential facilities for the elderly will be
accompanied by a rise in the incidence of infectious
disease.

0 Current research efforts to understand the natural
history of infectious diseases will be maintained, and
improved tools for prevention, diagnosis and
therapy will be developed.

0 With the increased use of computer technology,
there will be improvements in surveillance, commu-
nications and data analysis.

0 There will be better dissemination of current tech-
nologies known to control disease, and new tech-
nologies will be developed (e.g., hepatitis B vac-
cine).

0 There will be an increasing proportion of institu-
tionalized patients with more serious illness who are
subjected to a greater number of interventions and
who are more prone to nosocomial infections.

0 There will be an increased emphasis on the preven-
tion and control of nosocomial infections, particu-
larly in residential health-care facilities.

0 Current Federal technical assistance and advisory
services in epidemiology and program management
will be maintained at the State and local level.

0 There will be an improved use of diagnostic and
therapeutic measures such as drugs for the treat-
ment of viral diseases.

0 There will be a continued overuse of antibiotic
therapy as well as an increase in the development
of antibiotic-resistant strains of bacteria such as the
penicillin-resistant gonococcus.

0 Because of increased international travel, there will
be more opportunities for international spread of
diseases.

5. Data Sources
a. To National level only

0 National Hospital Discharge Survey (HDS) and
National Ambulatory Medical Care Survey
(NAMCS). Utilization of health manpower and
facilities providing care for infectious diseases,
ambulatory care, hospital care. DHHS—National
Center for Health Statistics (NCHS). Vital and
Health Statistics, Series 13. Continuing surveys;
National probability samples.

0 Health Interview Survey (HIS). Interview re-
ports on infectious disease disability, use of
hospital, medical, and other services, and other
health-related topics. DHHS-NCHS. NCHS
Vital and Health Statistics, Series 10. Continu-
ing survey; National probability sample.

0 Health Examination Survey and the Health and
Nutrition Examination Survey (HANES). Nu-
trition risk factors for infectious disease, and
medical sequelae from infectious disease (e.g.,
rheumatic fever). DHHS-NCHS. NCHS Vital
and Health Statistics, Series 11. Periodic sur-
veys; National probability samples.

0 Investigation of epidemics. DHHS-Centers for

Disease Control (CDC). Continuous activity by
CDC in response to epidemics of infectious
disease activity throughout the US. Data peri-
odically made available in reports and publi-
cations.

Study on the Eﬁicacy of Nosocomial Infection
Control (SENIC). Hospital infection control
activities and occurrence of hospital acquired
infection. DHHS-CDC, Bureau of Epidemiol-
ogy, Bacterial Diseases Division (BE-BDD).
The Journal of Epidemiology, 111: 468—653
May 1980. Special issue on SENIC. One time
study, stratiﬁed sample of US. hospitals.
National Nosocomial Infections Study. Noso-
comial infections. DHHS—CDC, BEFBDD. Na-
tional Nosocomial Infections Study Report 80—-
8257. Continuous reporting from hospitals vol—
untarily cooperating with volunteer panel of 80
short stay hospitals.

b. To State and/ or local level
0 National Vital Registration System

— Mortality. Deaths by cause (including in-
fectious diseases), by age, sex and race.
DHHS—NCHS. NCHS Vital Statistics of the
United States, Vol II, and NCHS Monthly
Vital Statistics Reports. Continuing report-
ing from States; National full count. (Many
States issue earlier reports.)

0 Hospitalized illness discharge abstract systems.

— Professional Activities Study (PAS). Pa-
tients in short stay hospitals; patient charac-
teristics, diagnoses of infectious diseases,
procedures performed, length of stays. Com-
mission on Professional and Hospital Activi-
ties, Ann Arbor, Michigan. Annual reports
and tapes. Continuous reporting from 1900
CPHA member hospitals; not a probability
sample, extent of hospital participation var-
ies by State.

— Medicare hospital patient reporting system
(MEDPAR). Characteristics of Medicare
patients, diagnosis, procedures. DHHS-
Health Care Financing Administration,
Ofﬁce of Research, Demonstration and Sta-

60

tistics (ORDS). Periodic reports. Continu-
ing reporting from hospital claim data; 20
percent sample.

— Other hospital discharge systems as locally
available.

National Morbidity and Mortality Reporting
System. Numbers of 46 reportable diseases;
deaths in 121 US. cities. DHHS-CDC. CDC
Morbidity and Mortality Weekly Report, and
annual reports. Morbidity: continuous reporting
from State health departments on basis of physi-
cian reports. (Completeness of reporting varies
greatly, since not all cases receive medical care
and not all treated conditions are reported.)
Mortality: continuous reporting; volunteer
panel of health departments in 121 US. cities,
full count.

National surveillance data. Detailed data on
cases of 33 communicable diseases. Surveillance
Reports. DHHS-CDC, BE and Bureau of State
Services. Continuous reporting from States.
Third party payers and large group practices can
sometimes provide data on diagnosis, cost and
demographic features of deﬁned patients and
populations. Data are collected on a continuous
basis but are not consistently analyzed or dis-
tributed.

State disease surveillance systems. Report of
notiﬁable diseases required by State law (as
many as 100 in some States); analyzed and
periodically published by each of the States.
Special periodic Statewide studies to monitor
disease activity or to evaluate the effectiveness
of disease control programs available at State
health departments.

Statewide accounting procedures to document
public health activities available through the
National Public Health Reporting System of the
Association of State and Territorial Health
Ofﬁcers as well as individual State health de-
partments.

Investigation of epidemics. Continuous activity
by Federal, State and local health departments
in response to epidemic infectious disease ac-
tivity. Data periodically made available by
responsible health authorities.

SMOKING AND HEALTH

1. Nature and Extent of the Problem

Smoking, the single most important preventable cause
of death and disease, is associated with heart and
blood vessel diseases, chronic bronchitis and emphy-
sema, cancers of the lung, larynx, pharynx, oral cavity,
esophagus, pancreas, and bladder, and with other
problems such as respiratory infections and stomach
ulcers. Though the share of the population who smoke
has declined for the country as a whole, the declines
have not been as great among adolescents and there
have even been increases in the rates for 17 and 18
year-old women. To reduce the prevalence of smok—
ing in this country, a variety of approaches are needed
to discourage young people from starting to smoke, to
increase the number of smokers who quit, and to assist
those who continue to smoke to do so, to the extent
possible, in less hazardous ways. Particular attention
should be given to high risk groups such as pregnant
women, children and adolescents who initiate smoking
at a young age, and workers who are exposed to occu-
pational hazards that are exacerbated by cigarette
smoking.

a. Health implications

0 Cigarette smoking is responsible for approxi-
mately 320,000 deaths annually in the United
States.

0 Lung cancer is the leading cause of cancer death
among men; if present trends continue, by 1983
it will become the leading cause of cancer death
among women.

0 Cigarette smoking is a causal factor for: coro-
nary heart disease and arteriosclerotic peripheral
vascular disease; cancers of the lung, larynx,
oral cavity, esophagus, pancreas and bladder;
and chronic bronchitis and emphysema.

0 Cigarette smoking during pregnancy is associ-
ated with retarded fetal growth, an increased
risk for spontaneous abortion and prenatal
death, as well as slight impairment of growth
and development during early childhood.

0 Cigarette smoking acts synergistically with oral
contraceptives to enhance the probability of
coronary and cerebrovascular disease; with alco-
hol to increase the risk of cancer of the larynx,
oral cavity and esophagus; with asbestos and
other occupationally encountered substances to
increase the likelihood of cancer of the lung;

61

and with other risk factors to enhance cardio-
vascular risk.

0 Involuntary or passive inhalation of cigarette
smoke can precipitate or exacerbate symptoms
of existing disease- states such as asthma, cardio-
vascular and respiratory diseases. Pneumonia
and bronchitis are more common among infants
whose parents smoke.

0 Smoking is a major contributor to death and
injury from ﬁres, burns and other accidents.
Twenty-nine percent of fatal house ﬁres and a
substantial number of burn injuries are smoking
related.

0 Ten years after quitting cigarette smoking, the
death rates for lung cancer and other smoking-
related causes of death approach those of non-
smokers.

b. Status and trends

0 Adult per capita consumption of cigarettes de-
creased temporarily in 1953, 1954, 1964, and
1968—1970, coinciding with periods of increased
national publicity on health hazards of smoking.
The rate of decline has accelerated since 1977.

0 The percentage of adult men who regularly
smoke declined from 53 percent to 38 percent
between 1955 and 1978.

0 The percentage of adult women who regularly
smoke increased from 25 percent to 33 percent
between 1955 and 1965, decreasing to 30 per-
cent by 1978.

0 The percentage of all adults who smoke regu-
larly was about 33 percent in 1978, the lowest
point in over 30 years. Smoking cigarettes is
signiﬁcantly less prevalent in higher educated
groups. The decline since 1966 involves all so-
cioeconomic groups but cigarette smoking rates
among blacks still exceed those among whites.
Most of the decrease seen in smoking prevalence
among adults is explained by smoking cessation
rather than by a lower rate of initiation.

0 Teenage smoking has declined since 1974, ex-
cept for young women aged 17 to 18. Rates for
women aged 17 to 24 have risen and now ex-
ceed those of men in this age group.

2. Prevention/Promotion Measures

a. Potential measures
0 Education and information measures include:

— general educational campaigns using broad-

cast and other mass media, coordinated with
government, business and nonproﬁt volun-
tary efforts, focusing on such subjects as spe-
ciﬁc health consequences, self-initiated ces-
sation, less hazardous ways of smoking, the
immediate beneﬁts of cessation and the ef-
fects of passive smoking on infants and on
people with pre-existing heart and lung
conditions;

speciﬁc educational campaigns directed: to
women, focusing on the special health con-
sequenCes of cigarette smoking for pregnant
women (and fetus) or for women using oral
contraceptives; to youth and to people in
lower socioeconomic groups, focusing on
immediate consequences and how to deal
with social pressures to smoke; to workers
exposed to toxic agents and to others at
special risk to health, focusing on the syner-
gistic and additive eﬁects of smoking for
those exposed to occupational hazards; and
to those with other risk factors, such as high
blood pressure;

special smoking education programs reach-
ing high risk groups;

youth smoking prevention programs, espe-
cially in grades 7 through 10, focused on the
psychosocial factors which promote smok—
ing, which will impart knowledge and skills
necessary to help resist social inﬂuences
(e.g., using nonsmoking peer models);
media programs focused on self-initiated
cessation, referring people to materials ap-
pr0priate to their special risks and dealing
with common relapse situations;

advising consumers to consider carbon mon-
oxide as well as levels of “tar” and nicotine;
warning consumers that changing to ciga-
rettes with lower yields of tar and nicotine
may increase smoking hazards if accompa-
nied by smoking more cigarettes, inhaling
more deeply or starting smoking earlier in
life;

cautioning consumers that even the lowest-
yield cigarettes present health hazards much
greater than those encountered by non-
smokers, and that the most effective way to
reduce the hazards of smoking is not to start
or to quit.

0 Service measures include:
—- formal and self-help smoking cessation pro-

' grams made more available within the health

care system, occupational settings, union fa-
cilities and places convenient to the general
public;

-— coordination and exchange of programs and

materials between Government, business,
commercial and nonproﬁt agencies;

62

expanded direct counseling and patient edu-
cation by health care providers;

specialized service programs for women, for
pregnant women, for occupational and other
high risk groups and other smokers in par-
ticular need of assistance in stopping smok-
ing—to be carried on through community,
church, social and health organizations and
at the work place.

0 Technologic measures include:

continuing engineering and research on the
development of less hazardous ways of
smoking including the development of ciga-
rettes with lower yields of incriminated in-
gredients and the development of methods
to assess the relative risks of cigarettes with
lower yields.

0 Legislative and regulatory measures include:

continuing the ban on TV and radio adver-
tising and the requirement of a health wam—
ing on all cigarette packages;

continuing the FTC requirement of a health
warning in advertising;

improving enforcement of laws prohibiting
sales to minors;

strengthening State and local laws and regu—
lations which establish nonsmoking areas in
public places and work areas;

examining potential new areas of regulation,
such as: increased disease-speciﬁc informa-
tion in advertisements; deglamorizing the
visual and printed components of advertis-
ing; requiring greater visibility of warnings;
requiring that tar and nicotine yields be
placed on the package; banning distribution
of cigarette samples to minors.

0 Economic measures include:

tax policies vis—a-vis cigarettes;

income tax deduction policy for the cost of
smoking cessation programs;

encouraging employers to provide bonuses
and other incentives to workers who quit;
“no smoking” policies for workplaces where
smoking on the job presents particular haz-
ards;

encouraging insurance companies to exam-
ine feasibility of offering preferential life
and/or health insurance premiums to non-
smokers and of paying for smoking cessa-
tion programs offered to group insurance
subscribers.

b. Relative strength of the measures

0 Education, information, ﬁscal and regulatory
measures are key strategies in a National smok-
ing prevention program. Education is the pri-
ority in such programs, especially related to
children and pregnant women. Additional re-
search is needed to deﬁne the types of education
which best meet public needs.

The major gains may come through the identiﬁ-
cation of effective peer education strategies for
children and youth.

Counseling by physicians and health profession-
als on smoking would facilitate the decline in
smoking if incorpoarted into routine clinical
practice.

Legislative, regulatory and economic measures
(including taxation), consistently and vigorously
applied, should enhance the educational efforts,
but are less likely to be successfully enacted.

If cigarettes with lower tar and nicotine should
prove to be less hazardous for some smoking-
related diseases (as current evidence suggests),
the substitution of lower level cigarettes for
those with higher levels may prove a valuable
aid in reducing disease through less desirable
than not smoking at all.

tion should be aware that smoking is a major
cause of lung cancer, as well as multiple other
cancers including laryngeal, esophageal, bladder
and other types. (Baseline data unavailable.)
By 1990, at least 85 percent of the adult popula-
tion should be aware of the special risk of de-
veloping and worsening chronic obstructive lung
disease, including bronchitis and emphysema,
among smokers. (Baseline data unavailable.)

By 1990, at least 85 percent of women should
be aware of the special health risks for women
who smoke, including the eﬁect on outcomes of
pregnancy and the excess risk of cardiovascular
disease with oral contraceptive use. (Baseline
data unavailable.)

By 1990, at least 65 percent of 12 year olds
should be able to identify smoking cigarettes
with increased risk of serious disease of the

3. Speciﬁc Objectives for 1990 01' Earlier heart and lungs. (Baseline data unabailable.)

0 Improved health status
— Reductions in smoking can be expected to yield )-

0 Improved services/protection
' By 1990, at least 35 percent of all workers

reduced rates of coronary heart disease, chronic
lung disease, prematurity in newborns, smoking
related ﬁre deaths and fewer occupational ill-
nesses from exposure to substances with which
cigarette smoking acts synergistically. Over the
longer term, reductions in cancer rates (espe-
cially lung and bladder) can also be expected.
Because of uncertainties in short-term quantiﬁ-
cation of the exposure-to-disease relationship,
measurable health status objectives are not
stated.

0 Reduced risk factors
a. By 1990, the proportion of adults who smoke

should be reduced to below 25 percent. (In
1979, the proportion of the US. population
which smoked was 33 percent.)

. By 1990, the proportion of women who smoke
during pregnancy should be no greater than one
half the proportion of women overall who
smoke. (Baseline data unavailable.)

By 1990, the proportion of children and youth
aged 12 to 18 years old who smoke should be
reduced to below 6 percent. (In 1979, the pro-
portion of 12 to 18 year olds who smoked was
11.7 percent.)

. By 1990, the sales-weighted average tar yield of
cigarettes should be reduced to below 10 mg.
The other components of cigarette smoke known
to cause disease should also be reduced propor-
tionately. (In 1978, the sales-weighted average
yield was 16.1 mg.)

0 Increased public/ professional awareness
e. By 1990, the share of the adult population

aware that smoking is one of the major risk
factors for heart disease should be increased to
at least 85 percent. (In 1975, the share was 53
percent.)

f. By 1990, at least 90 percent of the adult popula-

63

should be offered employer/employee spon-
sored or supported smoking cessation programs
either at the worksite or in the community. (In
1979, 15 percent of US. business ﬁrms had
programs to encourage or assist their employees
in smoking cessation.)

By 1985, tar, nicotine and carbon monoxide
yields should be prominently displayed on each
cigarette package and promotional material.
(Carbon monoxide levels are not currently re-
quired.)

By 1985, the present cigarette warning should
be strengthened to increase its visibility and
impact, and to give the consumer additional
needed information on the speciﬁc multiple
health risks of smoking. Special consideration
should be given to rotational warnings and to
identiﬁcation of special vulnerable groups.

By 1990, laws should exist in all 50 States and
all jurisdictions prohibiting smoking in enclosed
public places, and establishing separate smoking
areas at work and in dining establishments. (In
1978, 31 States had some form of smoking
restriction laws.)

By 1990, major health and life insurers should
be offering diﬂerential insurance premiums to
smokers and nonsmokers. (In 1979, approxi—
mately 30 major companies were offering dif-
ferential premiums.)

Improved surveillance/evaluation

O.

p.

By 1985, insurance companies should have col-
lected, reviewed, and made public their actuarial
experience on the differential life experience and
hospital utilization by speciﬁc cause among
smokers and nonsmokers, by sex.

By 1990, continuing epidemiological research
should have delineated the unanswered research
questions regarding low yield cigarettes, and

preliminary partial answers to these should have
been generated by research eﬂorts.

q. By 1990, in addition to biomedical hazard sur-
veillance, continuing examination of the changing
tobacco product, and the sociologic phenomena
resulting from those changes should have been
accomplished.

4. Principal Assumptions

Policy, planning and programs to reduce smoking
will continue to be high priorities of government,
voluntary agencies and industry.

Educational programs to reduce smoking in youth,
women, pregnant women, high risk occupations and
populations and lower socio-economic groups will
become more intensive.

There will be a gradual increase in the availability
and use of smoking cessation service programs.
Smoking education will be increasingly integrated
into positive lifestyle promotion programs.

The social acceptability of smoking will continue to
decrease.

There will be a continued decline in smoking among
upper socioeconomic classes, spreading to lower
socioeconomic classes.

Regulations against smoking in public places will
increase, providing incentives and social supports to
reduce smoking.

The decline in sales-weighted average tar content of
cigarettes will continue.

Engineering measures will help reduce the yields by
cigarettes of hazardous particulants and the gaseous
ingredients of smoke.

There will be no dramatic change in tax policy on
cigarettes.

Data Sources
a. To National level only

0 Knowledge, attitudes and practices in cigarette
use. Demographic data, attitudes, information
and beliefs about cigarette use, and smoking
practices among people 21 years of age or
older, and changes between 1964 and 1970.
DHEW National Clearinghouse for Smoking and
Health (now/Ofﬁce on Smoking and Health)
Reports: Use of Tobacco: Practices, Attitudes,
Knowledge and Beliefs 1964—1966; and Adult
Use of T0bacco—I970/Adult Use of Tobacco,
1975. Longitudinal study of panel ﬁrst inter-
viewed 1964; follow up interviews in 1966 and
1970: one time survey (new sample), 1975.

0 Teenage smoking. Demographic data, attitudes,
beliefs and knowledge concerning smoking
among adolescents in the United States. Office
on Smoking and Health (formerly National
Clearinghouse for Smoking and Health) 1968—
1974; National Institute of Education 1979.
Teenage Smoking: National Patterns of Ciga-
rette Smoking, Age 12 through 18. Published
in 1968, 1970, 1972 and 1974. (In 1979 title

was changed to: Teenage Smoking: Immediate
and Long Term Patterns). Surveys of adoles-
cents ages 12—18 respondent sample of general
US. population.

0 Smoking behavior and attitudes of health pro-
fessionals. Ofﬁce on Smoking and Health (for-
merly National Clearinghouse for Smoking and
Health). Smoking Behavior and Attitudes: Phy-
sicians, Dentists, Nurses, and Pharmacists, 1975.
One time survey.

0 Health Interview Survey (HIS); Smoking Sup-
plement. Smoking prevalence among adults col-
lected as part of the Health Interview Survey.
DHHS-National Center for Health Statistics
(NCHS). NCHS Advance Data from Vital and
Health Statistics and Surgeon General reports
on smoking usually annual. 1980 Surgeon Gen-
eral’s report entitled Health Consequences for
Women: A Report of the Surgeon General. Con-
tinuing survey; National probability sample.
Smoking supplements periodic since 1978.

0 Health and Nutrition Examination Survey
(HANES). Clinical and biochemical data on
examinees collected, could be analyzed accord-
ing to their smoking characteristics. DHHS—
NCHS. NCHS Vital and Health Statistics, Series
11. Periodic survey; National probability sam-
ple.

0 Cigarette and cigar production and imports.
Number of cigarettes (large and small) and
cigars, by size and class, shipped from factory
or imported each month by manufacturer. De-
partment of Treasury-Bureau of Alcohol, To-
bacco and Firearms. Monthly statistical release,
Cigarettes and Cigars. Continuing; reports from
manufacturers, importers.

0 Tobacco crops. Average yield, stock, supply,
domestic use, price and crop value. Department
of Agriculture, Agricultural Marketing Service.
Annual Report on Tobacco Statistics. Continu-
mg.

0 “Tar” and nicotine content. Results of “tar” and
nicotine yield measurements of cigarettes by
brand. Federal Trade Commission, annual re-
port. “Tar” and Nicotine Content of the Smoke
of 176 Varieties of Cigarettes. Continuing analy-
sis and reports.

0 Cigarette marketing and regulatory issues. An-
nual review of current issues in labeling and
advertising, advertising themes and costs, regu-
latory activity, legislative recommendations,
types of cigarettes marketed. Some trend data.
Federal Trade Commission. Annual Report to
Congress Pursuant to the Public Health Ciga-
rette Smoking Act. Continuing.

b. To State and/ or local level

0 National Vital Registration System
— Mortality. Deaths by cause (including
smoking related diseases), by age, sex, and

race. DHHS—NCHS. NCHS Vital Statistics
of the United States, Vol II, and NCHS
Monthly Vital Statistics Reports. Continuing
reporting from States; National full count.
(Many States issue earlier reports.)

0 Hospitalized illness discharge abstract systems.

— Professional Activities Study (PAS). Pa-
tients in short stay hospitals; patient charac-
teristics, diagnoses of lung cancer and other
smoking related diseases, procedures per-
formed, length of stays. Commission on Pro-
fessional and Hospital Activities, Ann
Arbor, Michigan. Annual reports and tapes.
Continuous reporting from 1900 CPHA
member hospitals; not a probability sample,
extent of hospital participation varies by
state.

— Medicare Hospital Patient Reporting System
(MEDPAR). Characteristics of Medicare
patients, diagnoses, procedures. DHHS—
Health Care Financing Administration, Of-
ﬁce of Research, Demonstration and Statis-

65

tics (ORDS). Periodic reports. Continuing
reporting from hospital claim data; 20 per-
cent sample.

— Other hospital discharge systems as locally
available.

Cigarette sales. Number of cigarette packages
taxed for each month in each State, and com-
parison to one year previously. Tobacco Tax
Council, 5407 Patterson Avenue, Richmond,
Virginia: Monthly State Cigarette Tax Report.
Continuing.

Area Resource File (ARF). Demographic,
health facility and manpower data at State and
County level from various sources. DHHS—
Health Resources Administration. Area Re-
source File: A Manpower Planning an-d Re—
search Tool. DHHS—HRA—80—4, Oct 79. One
time compilation.

Selected health data. DHHS—NCHS. NCHS
Statistical Notes for Health Planners. Compila-
tions and analysis of data to State level.

 

 

MISUSE OF ALCOHOL AND DRUGS

1. Nature and Extent of the Problem

A major objective of the drug and alcohol prevention
policy is to reduce the adverse social and health con-
sequences associated with the misuse of these sub—
stances, especially among adolescents, young adults,
pregnant women and the elderly.

Alcohol and other drug problems have pervasive
effects: biological, psychological and social conse-
quences for the abuser; psychological and social effects
on family members and others; increased risk of injury
and death to self, family members and others (espe-
cially by accidents, ﬁres or violence); and derivative
social and economic consequences for society at large.
Destructive drug and alcohol use shares many similar-
ities with tobacco use and may respond to some of the
same prevention strategies (see Smoking and Health).

Per capita alcohol consumption and use of other
drugs for non-medical purposes decreases with older
age groups, but the use of drugs for medical purposes,
both over-the-counter and prescription drugs, in-
creases.* Since the aging process is accompanied by
physiologic changes that alter the body’s response to
both food and drugs, practices of self-medication,
over-prescribing and the concurrent use of two or more
drugs can create serious health problems for the
elderly. Concurrent misuse of alcohol and drugs con-
sumed for either non-medical or medical purposes in-
creases risks to health and complicates the delivery
and ﬁnancing of preventive and treatment measures
from both private and public sources.

*NOTE: For purposes of this report, the term “use of
other drugs” refers to self-reported use of licit or
illicit drugs for non-medical or self-deﬁned purposes.
It does not include inappropriate use of drugs con-
sumed for medical purposes, nor the use of alcohol
or tobacco. These are discussed separately.

a. Health implications

ALCOHOL

0 In 1975, an estimated 36,000 deaths from cir-
rhosis, alcoholism or alcoholic psychosis could
be directly attributed to alcohol use.

0 In 1975, an additional 51,000 fatalities could be
indirectly attributed to alcohol use.

0 Alcohol has been identiﬁed as a risk factor for
cancers of the oral cavity, esophagus and liver.

0 In 1977, about 45 percent of all motor vehicle
fatalities involved drivers with blood alcohol

67

O
0

levels of .10 percent or more, a rate of 11.5
per 100,000 population.

In 1975, the costs of alcohol problems were
estimated to be $43 billion in lost production,
health and medical services, accidents, crime
and other social consequences.

The Fetal Alcohol Syndrome is estimated to
cause some 1,400 to 2,000 birth defects an—
nually.

THER DRUGS

The vast majority of users of “other drugs” are
marijuana users, but the category is not limited
to this group.

The social cost of drug abuse, including law
enforcement, has been estimated to be at least
$10 billion per year, a ﬁgure which may be an
underestimate considering the difﬁculties of
measuring the aggregate health and social con-
sequences of those behaviors.

Between May 1976 and April 1977, there were
an estimated 7,000 to 8,000 deaths and an esti-
mated 275,000 to 300,000 medical emergencies
related to misuse of drugs.

An undetermined portion of deaths and medical
emergencies relate to drug use for suicide and
attempted suicide (see Control of Stress and
Violent Behavior) and may be very difﬁcult to
prevent.

Barbiturates were the class of drugs mentioned
most frequently by medical examiners in con-
nection with drug—related deaths reported to the
Drug Abuse Warning Network between May
1977 and April 1978 (2 percent of drugs men-
tioned).

Tranquilizers were the class of drugs mentioned
most frequently by emergency rooms during the
same period (24 percent of drugs mentioned).
The proportion of barbiturate and tranquilizer
misuse that is deliberate and the proportion that
is accidental is not known.

DRUGS USED FOR MEDICAL PURPOSES

Use of high estrogen content oral contraceptives
by women smokers increases risks of coronary
and cerebrovascular disease.

— See Family Planning

People over 65 years of age, 11 percent of the
population, use more drugs and for longer
periods of time than any other age group, ac-

counting for 30 percent of all medicines con— DRUGS USED FOR MEDICAL PURPOSES

sumed. 0 Barbiturate-related mortality accounted for less
0 The risk of adverse drug reactions in elderly than 1,300 deaths in 1976.
atients is almost twice that in patients between . .
£0 and 40 years of age_ 2. Prevention/Promotion Measures
0 Between 70 and 80 percent of reactions are pre- 3. Potential measures
dictable and preventable. 0 Education and information measures include:

0 Between 0.3 and 1.0 percent of the nation’s total
35.5 million hospital admissions each year are
due to adverse drug reactions.

0 Improper use of drugs forces curtailment of
normal activities, or contributes to such curtail-
ment, in an unknown proportion of the disabled
population.

Status and trends

ALCOHOL

0 An estimated 10 percent of the adult population
18 years and over are frequent heavy drinkers
(5 or more drinks per occasion at least once
per week).

0 Most problems indirectly attributable to alcohol
(homicides, car crashes) have the highest rates
among young adult males ages 18 to 24 years.

0 National surveys indicate no changes in peak
quantity consumed by teenagers 12 to 17 (ﬁve
or more beers at a time) or in regularity of
their drinking, between 1974 and 1978.

0 Alcoholism mortality rates (2 per 100,000) and
alcoholic psychosis rates (1 per 100,000) show
little overall increase between 1950 and 1975.

0 Based on survey reports and tax-paid with-
drawals, per capita consumption of absolute
alcohol did not change signiﬁcantly during the
years 1971 to 1976. More recent data indicate
that per capital consumption began to increase
again after 1976, from 2.7 gallons to 2.82 gal-
lons of absolute alcohol per capita in 1978.
Whether the increase will continue is not yet
known.

OTHER DRUGS

0 A dramatic decline in level of heroin-related
medical problem indicators was seen from 1976
to 1977, suggesting a decline in heroin use.

0 The proportion of adolescents (12 to 17 years
old) reporting current use of marijuana has
been rising continuously for the last decade and
has increased signiﬁcantly from 6 percent in
1971 to 16 percent in 1977.

0 The proportion of young adults (18 to 25 years
old) reporting that they had ever used marijuana
rose from 39 percent in 1971 to 60 percent in
1977.

0 It has been estimated that there are approxi-
mately 2,500,000 persons (roughly 2 percent of
the population age 18 and over) having serious
drug problems.

0 Epidemiological evidence suggests that the use
of alcohol, tobacco and marijuana by adoles-
cents is associated.

68

— general public information campaigns, and
programs targeted to children and youth and
to speciﬁc at-risk populations, with speciﬁc
messages to facilitate problem recognition or
reinforce desired behavior;

—- programs targeted at a wide array of service
professions concerning the recognition of,
and responses to, alcohol and other drug
problems;

-—- information on medicine labels on drug/
drug, drug/food and drug/alcohol interac-
tions, with practical guidance on avoiding
clinically signiﬁcant interactions;

—— school and community—based health educa-
tion programs, some using peer leaders and
models;

— special education programs emphasizing ef-

fective risk-management skills and altema—
tives to drug and alcohol use;

—— education of physicians, nursing home staff
and patients about hazards surrounding the
misuse of tranquilizers, hypnotics and other
classes of prescription and nonprescription
drugs;

—— easily understandable information available
to patients taking drugs for medical pur-
poses.

Service measures include:

— programs which offer general social support
(youth centers, recreation programs) and
thereby provide alternatives to drug and
alcohol use;

—— outreach and early intervention services at
the worksite and in community settings for
persons whose behavior indicates that they
are at-risk for the development of alcohol
or other drug problems;

-—— anticipatory guidance, identiﬁcation of chil-
dren at high risk of alcoholism;

— a broad range of treatment services in em-
ployee assistance programs, in general
health care delivery settings and in special-
ized alcohol and drug facilities;

— counseling by pharmacists to older people
taking drugs for medical purposes;

— maintenance of computerized drug proﬁles;

—— hotlines and drug information centers people
can use to learn about drug effects and
interactions.

Technologic measures include:

— product safety changes which reduce the risk
of injury and death in places associated with
use of alcohol and other drugs (e.g., airbags

in motor vehicles and improved ﬁreprooﬁng
in residences);

— modiﬁcation to alcoholic beverages them—
selves (e.g., reduction of alcohol content,
reduction or elimination of nitrosamines);

—— efforts by community institutions to modify
social settings and contexts to reduce the risk
associated with intoxication and to alter
social reaction to some types of drinking or
drug-using behavior.

0 Legislative and regulatory measures include:

—— regulating the conditions of availability of
alcoholic beverages (i.e., zoning regulations
regarding hours of sale, numbers of outlets
and numbers of licenses);

—— enforcing minimum drinking age laws and
employing legal disincentives to discourage
the dispensing of alcohol to obviously intoxi-
cated persons;

— enforcing laws prohibiting driving while in-
toxicated by alcohol or drugs and initiating
stronger legal disincentives;

— controlling advertising of alcoholic bever-
ages;

-— enforcing laWS related to production, distri-
bution and use of “other drugs” that are
proscribed except for medical and scientiﬁc
purposes; special law enforcement agencies
are responsible for enforcing such prohibi-
tions and violations are punishable by crim-
inal sanctions;

—— regulation of conditions under which these
substances are available for authorized uses,
such as measures relating to scheduling of
“controlled substances’ and limitations on
prescriptions;

— periodic re—examination of sanctions to en-
sure correspondence to the degree of severity
of the health and social problems associated
with the overuse of each particular sub-
stance or drug;

— patient labeling for certain prescription drugs
(estrogens, progestins);

— drug information for patients in nursing
homes and in other long-term care facilities.

0 Economic measures include:
— excise taxes on alcoholic beverages and
other means of affecting the price of alcohol;
— tax incentives or disincentives to control
levels of advertising expenditures for alco-
holic beverages.

b. Relative strength of the measures

0 Systematic evaluation of the effects of education
and yearly intervention programs targeted at
children and youth and populations at special
risk is at an early stage.

0 Regulatory measures have been the Nation’s
primary tool of drug abuse prevention during
most of the 20th century. There is much debate

about the overall cost-beneﬁt assessment of the
current prohibitions. From a more limited per-
spective, however, some recent trends tend to
support claims that regulatory approaches have
had an impact on the extent of drug use.

Heroin addiction in this country has been de—
clining in recent years, coincident with reduced
supplies on the illegal market and the extensive
availability of treatment services. Late in 1979,
however, the supply and incidence of heroin use
increased in several Eastern cities. Also, bar-
biturate-related mortality has been declining
steadily as a result of increased legal controls,
greater physician awareness of the most efﬁca-
cious uses of these drugs, and improved public
awareness of the hazards associated with the
use of barbiturates in combination with other
depressants.

Mass media campaigns that have focused public
attention upon alcohol use and abuse may have
contributed to a period of relative stability in
alcohol consumption during the seventies (al-
though economic conditions were also a likely
signiﬁcant factor). Alcohol problems, as noted
by several indicators (cirrhosis mortality rate
decline, survey data on alcohol consumption
among youth and adults), appear also to have
leveled off during this period of apparent stabil-
ity. While direct causal attribution is not possi-
ble, the creation of a National alcoholism treat-
ment network and early intervention services in
the workplace probably played a role in the
stabilization of cirrhosis deaths.

Alcoholic beverage regulation has not tradition-
ally been focused on public health considera-
tions, but data concerning the impact of regula-
tory initiatives on tobacco smoking may be
transferable to the alcohol area. Research here
and in other countries suggests that the avail-
ability of alcohol may affect the level and type
of alcohol problems, particularly physical health
problems consequent to long-term excessive
drinking. Consumption, in turn, has been linked
fairly conclusively to the relative price of alco-
hol, and less conclusively to such factors as the
legal purchase age, number and dispersion of
retail on-premise and off-premise outlets, and
hours of sale. Also “Dram Shop” laws can offer
powerful incentives for alcoholic beverage licen-
sees to try to reduce the likelihood of intoxica-
tion among their patrons.

In general, alcohol and drug education programs
can increase information levels and modify
attitudes. Their effect on drinking or drug-using
behavior has not yet been demonstrated conclu-
sively, although recent studies have yielded en-
couraging preliminary ﬁndings.

3. Speciﬁc Objectives for 1990

0 Improved health status
a. By 1990, fatalities from motor vehicle accidents

*d.

involving drivers with blood alcohol levels of
.10 percent or more should be reduced to less
than 9.5 per 100,000 population per year. (In
1977, there were 11.5 per 100,000 population.)
By 1990, fatalities from other (non-motor ve-
hicle) accidents, indirectly attributable to alco-
hol use, e.g., falls, ﬁres, drownings, ski mobile,
aircraft) should be reduced to 5 per 100,000
population per year. (In 1975, there were 7 per
100,000 population.)

By 1990, the cirrhosis mortality rate should be
reduced to 12 per 100,000 per year. (In 1978,
the rate was 13.8 per 100,000 per year.)

By 1990, the incidence of infants born with the
Fetal Alcohol Syndrome should be reduced by
25 percent. (In 1977, the rate was 1 per 2,000
births, or approximately 1,650 cases.)

*NOTE: Same objective as for Pregnancy and
Infant Health.

By 1990, other drug-related mortality should be
reduced to 2 per 100,000 per year. (In 1978,
the rate was about 2.8 per 100,000.)

By 1990, adverse reactions from medical drug
use that are sufﬁciently severe to require hospi-
tal admission should be reduced to 25 percent
fewer such admissions per year. (In 1979, esti-
mates range from approximately 105,000 to
350,000 admissions per year.)

0 Reduced risk factors

g.

By 1990, per capita consumption of alcohol
should not exceed current levels. (In 1978,
about 2.82 gallons of absolute alcohol were con-
sumed per year per person age 14 years and
over.)

By 1990, the proportion of adolescents 12 to 17
years old who abstain from using alcohol or
other drugs should not fall below 1977 levels.
(In 1977, the proportion of abstainers was:
46 percent for alcohol; for other drugs, ranging
from 89 percent for marijuana to 99.9 percent
for heroin.*)

*NOTE: A person is deﬁned as not using alcohol
or other drugs if he or she has never used the
substance or if the last use of the substance
was more than one month earlier.

By 1990, the proportion of adolescents 14 to 17
years old who report acute drinking-related
problems during the past year should be reduced
to below 17 percent.* (In 1978, it was estimated
to be 19 percent based on 1974 survey data.)

*NOTE: Acute drinking-related problems have
been deﬁned as problems such as episodes of
drunkenness, driving while intoxicated, or
drinking-related problems with school authori-
ties.

By 1990, the proportion of problem drinkers
among all adults aged 18 and over should be

70

reduced to 8 percent. (In 1979, it was about 10
percent.)

By 1990, the proportion of young adults 18 to 25
years old reporting frequent use of other drugs
should not exceed 1977 levels. (In 1977, it was
less than one percent for drugs other than mari-
juana and 19 percent for marijuana.*)

*NOTE: “Frequent use of other drugs” means
the non-medical use of any speciﬁc drug on 5
or more days during the previous month.

By 1990, the proportion of adolescents 12 to 17
years old reporting frequent use of other drugs
should not exceed 1977 levels. (In 1977, it was
less than 1 percent for drugs other than mari-
juana and 9 percent for marijuana.)

0 Increased public/ professional awareness
m. By 1990, the proportion of women of childbear-

ing age aware of risks associated with pregnancy
and drinking, in particular, the Fetal Alcohol
Syndrome, should be greater than 90 percent.
(In 1979, it was 73 percent.)

By 1990, the proportion of adults who are
aware of the added risk of head and neck can-
cers for people with excessive alcohol consump-
tion should exceed 75 percent. (Baseline data
unavailable.)

. By 1990, 80 percent of high school seniors

should state that they perceive great risk asso-
ciated with frequent regular cigarette smoking,
marijuana use, barbiturate use or alcohol intoxi-
cation. (In 1979, 63 percent of high school
seniors perceived “great risk” to be associated
with 1 or 2 packs of cigarettes smoked daily, 42
percent with regular marijuana use, 72 percent
with regular barbiturate use, and only 35 per-
cent with having 5 or more drinks per occasion
once or twice each weekend.)

By 1990, pharmacists ﬁlling prescriptions
should routinely counsel patients on the proper
use of drugs designated as high priority by the
FDA, with particular attention to prescriptions
for pediatric and geriatric patients and to the
problems of drinking alcoholic beverages while
taking certain prescription drugs. (Baseline
data unavailable.)

0 Improved services/protection
q. By 1990, the proportion of workers in major

ﬁrms whose employers provide a substance
abuse prevention and referral program (em-
ployee assistance) should be greater than 70
percent. (In 1976, 50 percent of a sample of
the Fortune 500 ﬁrms offered some type of
employee assistance program.)

By 1990, standard medical and pharmaceutical
practice should include drug proﬁles on 90 per-
cent of adults covered under the Medicare pro-
gram, and on 75 percent of other patients with
acute and chronic illnesses being cared for in

all private and organized medical settings.
(Baseline data unavailable.)

0 Improved surveillance/ evaluation systems

s. By 1990, a comprehensive data capability
should be established to monitor and evaluate
the status and impact of misuse of alcohol and
drugs on: health status; motor vehicle acci-
dents; accidental injuries in addition to those
from motor vehicles; interpersonal aggression
and violence; sexual assault; vandalism and
property damage; pregnancy outcomes; and
emotional and physical development of infants
and children.

4. Principal Assumptions

0 The Federal emphasis on research and technical

assistance will continue, with primary reliance on
State and local governments and the voluntary sec-
tor for delivery of alcohol and drug abuse preven-
tion services.

Resources and services devoted by State and local
governments, and voluntary groups, for drug and
alcohol prevention programs and services will ex-
pand.

Federal funding for research and evaluation in drug
and alcohol prevention will modestly increase, with
special attention to the priority areas reﬂected in
the proposed objectives.

Federal information initiatives will continue to
sensitize the public to the adverse social and health
consequences of heavy or frequent use of alcohol
and other drugs.

Strong and varied initiatives both public and pri-
vate, will seek to minimize use of tobacco, alcohol
and other drugs by children and adolescents—in-
cluding coordinated efforts with alcohol producers,
distributors, retailers and State alcohol control com-
missions.

The allocation of resources by alcohol producers,
distributors and retailers to the marketing, promo-
tion and distribution of alcoholic beverages will
probably increase.

No dramatic shift in tax or regulatory policies to-
ward availability and consumption of alcoholic
beverages will occur, unless consumption trends
require reconsideration.

There will be no dramatic or permanent shift in the
availability of controlled substances outside legiti-
mate medical and scientiﬁc channels.

The trend will continue toward modiﬁcation of the
criminal law and its less punitive administration in
cases involving arrests for personal possession of
marijuana and other drugs.

Data Sources
a. To National level only

0 Health Interview Survey (HIS). Accidental in-
juries, disability, use of hospital, medical and
other services, and other health-related topics.

71

DHHS-National Center for Health Statistics
(NCHS). NCHS Vital and Health Statistics,
Series 10, selected reports, and Advance Data,
selected reports. Continuing household inter-
view survey; National probability samples.
Health Examination Survey (HES) and the
Health and Nutrition Examination Survey
(HANES). Alcohol and drug related condi-
tions. DHHS-NCHS. Vital and Health Statistics,
Series 11, selected reports. Periodic surveys;
National probability samples; data obtained
from physician’s examinations.

National Hospital Discharge Survey (HDS).
Utilization of hospital services related to misuse
of alcohol and drugs. DHHS—NCHS Vital and
Health Statistics, Series 13. Continuing; Na-
tional probability sample, short stay hospitals.

National Ambulatory Medical Care Survey
(NAMCS). Alcohol and drug related patient-
physician encounters. DHHS-NCHS. NCHS
Vital and Health Statistics, Series 13. Continu-
ing survey; National probability sample, oﬂice
based physicians.

The lifestyle and values of youth. Non-medical
use of substances in 12 categories including
marijuana, barbiturates, cocaine, prescription
drugs, alcohol, cigarettes. DHHS-NIDA. Drugs
in the Class of (survey year date), Behaviors,
Attitudes and Recent National Trends, series
Number 20. Annual surveys since 1975 of high
school seniors in a National sample of public
and private schools.

The National Survey on Drug Abuse. Estimates
of the levels of illicit and legal drug use in the
United States: marijuana-hashish, cocaine, hal-
lucinogens, heroin and other opiates; summary
of data on use of inhalants, alcohol, cigarettes
and the non-medical use of psychotherapeutic
drugs legally prescribed. DHHS-NIDA. High-
lights from the National Survey on Drug Abuse,
1977. Continuing survey since 1971; National
sample.

Drug Abuse Warning Network (DAWN). Drug
abuse encountered in emergency rooms and
medical examination oﬂices. DHHS-NIDA and
the Drug Enforcement Administration. Quar-
terly reports of provisional data Series G,
NIDA. Continuing survey in 26 standard metro-
politan statistical areas.

National Prescription Audit (NPA). Drug sales,
including barbiturates, tranquilizers; source of
prescription; payment status, provider type. IMS
America, Ltd., Ambler, Pennsylvania. IMS re-
ports. Continuing audit of pharmacies on IMS
panel.

Third Special Report to the US. Congress on
Alcohol and Health, June 1978. Subsequent
reports will be available approximately every
three years.

b. To State and/ or local level

National Vital Registration System

— Mortality. Deaths by cause (including alco-
hol and drug related), by age, sex and race,
DHHS-NCHS. NCHS Vital Statistics of the
United States, Vol II, and NCHS Monthly
Vital Statistics Reports. Continuing report-
ing from States; National full count. (Many
States issue earlier reports.)

Hospitalized illness discharge abstract systems.

— Professional Activities Study (PAS). Pa-
tients in short stay hospitals; patient charac-
teristics, alcohol and drug related diagnoses,
procedures performed, length of stays. Com-
mission on Professional and Hospital Activi-
ties, Ann Arbor, Michigan. Annual reports
and tapes. Continuous reporting from 1900
CPHA member hospitals; not a probability
sample, extent of hospital participation var-
ies by State.

— Medicare hospital patient reporting system
(MEDPAR). Characteristics of Medicare
patients, diagnosis, procedures. DHHS-

72

Health Care Financing Administration,
Ofﬁce of Research, Demonstration and Sta-
tistics (ORDS). Periodic reports. Continu-
ing reporting from hospital claim data; 20
percent sample.

—— Other hospital discharge systems as locally
available.

Area Resource File (ARF). Demographic,
health facility and manpower data at State and
county level from various sources. DHHS-
Health Resources Administration Area Re-
source File: A Manpower Planning and Re-
search Tool, DHHS—HRA-80—4, Oct. 79. One
time compilation.

Annual Census of State and County Mental
Hospitals. Resident patients and new admissions
to mental institutions; costs, diagnoses of alco-
hol psychoses. DHHS-ADAMHA, National In-
stitute of Mental Health (NIMH). Mental
Health Statistical Notes, selected issues; special
reports and tabulations furnished to the Center
for Disease Control. Continuing reporting; Na-
tional full count of patients in State and county
mental hospitals.

NUTRITION

1. Nature and Extent of the Problem

Issues related to nutrition and food consumption in-
volve complex interactions among social, cultural,
economic and physiological factors. Adequate intakes
of sources of energy and of essential nutrients are
necessary for satisfactory rates of growth and develop-
ment, physical activity, reproduction, lactation, recov-
ery from illness and injury and maintenance of health
through the life cycle. Deﬁcits of essential nutrients
or energy sources can lead to several speciﬁc diseases
or disabilities and increased susceptibility to others.
Excessive or inappropriate consumption of some nu-
trients may contribute to adverse conditions, such as
obesity, or may increase the risk for certain diseases
(e.g., heart disease, adult-onset diabetes, high blood
pressure, dental caries and possibly some types of
cancer). Such chronic diseases are clearly of complex
etiology, with substantial variation in individual sus—
ceptibility to the factors involved. While the role of
nutrients in these diseases is not deﬁnitively estab—
lished, epidemiologic and laboratory studies offer im-
portant insights which may help people in making food
choices so as to enhance their prospects of maintaining
health. See High Blood Pressure, Physical Fitness and
Exercise, and Fluoridation and Dental Health.

a. Health implications

0 Obesity increases the risk for adult-onset dia-
betes and high blood pressure, both of which
are associated with cardiovascular disease. Obe-
sity also increases risk of gallbladder disease,
degenerative joint diseases, and some types of
cancer (e.g. endometrial cancer). (Obesity is
deﬁned in this discussion as signiﬁcant over-
weight, i.e., 120 percent or more of “ideal”
weight.)

0 Frequent consumption of highly cariogenic foods
(those containing fermentable, orally-retentive
carbohydrates), especially between meals, can
nullify some of the caries preventive beneﬁts of
adequate ﬂuoride intake and/ or can cause ramp-
ant caries in children with a ﬂuoride deﬁciency.

0 Inadequate nutrition may be one factor asso-
ciated with poor pregnancy outcome, including
some fraction of low birth weight infants, and
suboptimum mental and physical development.

0 Excessive sodium intake has been associated
with high blood pressure in susceptible individ-
uals.

73

0 Total dietary fat, saturated fat and cholesterol
may inﬂuence risk factors for heart disease.

0 Eating more foods high in ﬁber may reduce the
symptoms of chronic constipation, diverticulosis
and some types of “irritable bowel” in some
individuals.

0 Dietary fat has been associated epidemiologic-
ally with some cancers, but better understand-
ing of the strength of the relationship must
await the outcome of ongoing studies.

0 Breast fed infants appear to enjoy signiﬁcant
health advantages when compared with infants
fed with breast milk substitutes, in particular,
the immunologic characteristics of breast milk
may increase resistance to infections and per-
haps certain allergies.

0 Poor nutrition may enhance susceptibility or
impair host response to infections.

0 See Misuse of Alcohol and Drugs, and Preg-
nancy and Infant Health.

b. Status and trends

0 Over the 10 years from 1963 to 1973, mean
body weight of American men and American
women, ages 18 to 74, increased by an average
of six pounds and three pounds, respectively.
Height did not play an appreciable role in ac-
counting for the increase.

0 Iron and folic acid deﬁciencies are particularly
common among pregnant or lactating women.

0 Average blood cholesterol levels in the United
State among men of all age groups declined
slightly between surveys conducted in 1960—62
and 1971—74; among women, blood cholesterol
levels declined as much as 7 percent in the
age group 55 to 64, and 6 percent in the age
group 65 to 74.

0 Some subsets of the population are more prone
to obesity than others:

— for people ages 20 to 74, about 14 percent
of men and 24 percent of women meet the
criterion for obesity (120 percent of
“idea 9:) ;

— of men who are not poor, about 12 percent
of blacks and 13 percent of whites ages 45
to 64 are obese;

—- of men who are poor, only 4 percent of
blacks and 5 percent of whites ages 45 to
64 are obese;

—- of women who are not poor, 40 percent of
blacks and 29 percent of whites ages 45 to
64 are obese;

-—— of women who are poor, 49 percent of
blacks and 26 percent of whites ages 45 to
64 are obese.

Prevalence of breast feeding declined from 65
percent in the late 19405 to 26 percent in 1969.
In the past decade, prevalence of breastfeeding
has increased to 45 percent of newborns, at
least initially. In contrast to the past, however,
women of lower socioeconomic status are now
less likely to breastfeed than women of higher
socioeconomic status.

manufactured foodstuffs, from production
through consumption;

— changing livestock practices to produce
leaner meat;

— fortifying certain foodstuffs;

— developing and making readily available
new products lower in fat, saturated fat,
cholesterol, sodium and sugars;

— positioning products in supermarkets so that
key information on caloric, cholesterol,
sodium and sugar contents of products is
readily apparent.

Legislative and regulatory measures include:
— promulgation of guidelines to maintain or
improve the nutritional quality of the food

2. Prevention / Promotion Measures supply;

a. Potential measures ——- requiring nutrition labeling on foods about

. . . . which nu ri ion claims r '
0 Education and information measures include: t t a e made or to thh

—— increasing awareness of ideal weight ranges
and safe weight reduction and weight con-
trol strategies based on energy balance
concepts;

— increasing awareness of the science base
regarding relationships between diet and
heart disease, high blood pressure, certain
cancers, diabetes, dental caries and other
conditions;

—- providing information and behavioral skills
to select and prepare more healthful diets;

— developing more effective means of com-
municating nutrition information to people
in different age and ethnic groups;

— providing nutrition information and educa-
tion about healthy food choices in the home
(via the media), in schools, at the worksite,
by and to health care providers, at the point
of purchase, as a part of government food
service programs (such as Project Head
Start, school lunch and WIC Programs) and
by appropriate advertising;

——— providing appropriate information on the
advantages and techniques of breastfeeding
and when appropriate, alternatives, particu-
larly for low income women.

0 Service measures include:

— nutritious breakfast and lunch programs for
school children and meals for senior citizens;

—— food stamps for low income populations;

— food supplements for low income women,
infants and children at risk for nutritional
problems;

— nutritious food offered in business and insti-
tutional settings;

—- counseling related to dietary practices rou-
tinely oﬂered to high risk individuals through
the health care system, schools and work-
places;

—— psychosocial support groups focused on
weight control and weight maintenance;

— counseling regarding the merits of breast-
feeding and appropriate techniques.

0 Technologic measures include:

— ensuring nutritional quality and content of

74

nutrients are added, including information
on calories, fat, carbohydrate, protein,
cholesterol, sugars, sodium and other nutri-
ents of public health concern;

— providing explicit discretionary authority to
regulate fortiﬁcation of foods when it is of
public health signiﬁcance;

— regulation of food vending practices in
schools and health facilities to reduce or
eliminate highly cariogenic foods and snacks;

— grading standards to give greater emphasis
to lower fat products;

— regulating televised advertisements which
promote cariogenic and non-nutritious foods
and snacks and which are directed at young
children.

Economic measures include:

— studying possibilities for adjusting insurance
premiums, in relation to relative risk, for
corporations offering employee health pro-
motion programs with a nutrition com-
ponent;

— government food purchasing support prac-
tices;

— assessing feasibility and cost beneﬁts of re-
imbursement by third party payers of coun-
seling services which meet appropriate
standards; .

— reducing or eliminating local sales taxes on
staple foods.

b. Relative strength of the measures

0 Service programs are likely to be effective in

improving the nutritional status of pregnant
women and children and, perhaps in reducing
the incidence of low birth weight infants.
Certain segments of the public have responded
to educational and informational messages about
fats and cholesterol by reducing their intakes.
On the other hand, some recent messages have
been mixed and contradictory, leaving the pub-
lic confused. The DHHS/ USDA Dietary Guide-
lines for Americans provide a simple set of
practical recommendations.

Technologic measures hold real promise, par-
ticularly if governmental policies could be gen-

erated in support of such measures and if re-
sultant products are acceptable to consumers.
With the exception of food sanitation, regulation
and economic incentives have not been em-
ployed and are, therefore, of uncertain potential.
Education and counseling programs regarding
breastfeeding have been successful in increasing
the prevalence of breastfeeding among middle
and upper income women. It is reasonable to
expect similar results from programs targeting
low income women.

smaller population sample in 1972—75, mean
blood plasma cholesterol levels were about 211
mg/dl for males aged 40 to 59 and about 210
mg/dl for females aged 40 to 59.)

By 1990, the mean serum cholesterol level in
children aged 1 to 14 should be at or below 150
mg/dl. (In 1971—74, for children aged 1 to 17,
the mean serum cholesterol level was 176 mg/
d1. For a smaller population sample in 1972—75,
the mean blood plasma cholesterol level for
children aged 10 to 14 was about 160 mg/dl.)
By 1990, the average daily sodium ingestion (as

measured by excretion) by adults should be
reduced at least to the 3 to 6 gram range. (In
1979, estimates ranged between averages of 4
and 10 grams sodium. NOTE: One gram salt

3. Speciﬁc Objectives for 1990 or Earlier

0 Improved health status
— Improvements in nutrition may yield reduced

rates of infant mortality, cardiovascular disease,
dental caries and possibly some cancers. Certain
quantiﬁed health status objectives are speciﬁed
in the sections on High Blood Pressure Control,
Pregnancy and Infant Health, and Flouridation
and Dental Health. Others are noted below. Still
others (particularly those related to heart dis-
ease and cancer) are not stated, due to uncer-
tainties in quantifying the exposure-to-disease
relationship.

By 1990, the proportion of pregnant women
with iron deﬁciency anemia (as estimated by
hemoglobin concentrations early in pregnancy)
should be reduced to 3.5 percent. (In 1978, the
proportion was 7.7 percent.)

. By 1990, growth retardation of infants and chil-
dren caused by inadequate diets should have
been eliminated in the United States as a public
health problem. (In 1972—73, it was estimated
that 10 to 15 percent of infants and children
among migratory workers and certain poor rural
populations suffered growth retardation due to
diet inadequacies.)

0 Reduced risk factors
*c. By 1990, the prevalence of signiﬁcant over-

weight (120 percent of “desired” weight) among
the U.S. adult population should be decreased
to 10 percent of men and 17 percent of women,
without nutritional impairment. (In 1971—74,
14 percent of adult men and 24 percent of
women were more than 120 percent of “de-
sired” weight.)

*NOTE: Same objective as for High Blood Pres-
sure Control.

. By 1990, 50 percent of the overweight popula-
tion should have adopted weight loss regimens,
combining an appropriate balance of diet and
physical activity. (Baseline data unavailable.)

By 1990, the mean serum cholesterol level in
the adult population aged 18 to 74 should be at
or below 200 mg/dl. (In 1971—74, for male
and female adults aged 18 to 74, the mean
serum cholesterol level was 223 mg/dl. For a

75

provides approximately .4 grams sodium.)

*NOTE: Same objective as for High Blood Pres-
sure Control.

By 1990, the proportion of women who breast-
feed their babies at hospital discharge should be
increased to 75 percent and 35 percent at six
months of age. (In 1978, the proportion was
45 percent at hospital discharge and 21 percent
at 6 months of age.)

0 Increased public/ professional awareness

i.

k.

By 1990, the proportion of the population which
is able to identify the principal dietary factors
known or strongly suspected to be related to
disease, should exceed 75 percent for each of
the following diseases: heart disease, high
blood pressure, dental caries and cancer. (Base-
line data largely unavailable. About 12 percent
of adults are aware of the relationship between
high blood pressure and sodium intake.)

By 1990, 70 percent of adults should be able to
identify the major foods which are: low in fat
content, low in sodium content, high in calories,
good sources of ﬁber. (Baseline data unavail-
able.)

By 1990, 90 percent of adults should understand
that to lose weight people must either consume
foods that contain fewer calories or increase
physical activity—or both. (Baseline data un-
available.)

0 Improved services/ protection

1.

By 1990, the labels of all packaged foods should
contain useful calorie and nutrient information
to enable consumers to select diets that pro-
mote and protect good health. Similar informa-
tion should be displayed where nonpackaged
foods are obtained or purchased.

. By 1990, sodium levels in processed food

should be reduced by 20 percent from present
levels. (Baseline data unavailable.)

By 1985, the proportion of employee and school
cafeteria managers who are aware of, and ac-
tively promoting, USDA/DHHS dietary guide-
lines should be greater than 50 percent.

o. By 1990, all States should include nutrition
education as part of required comprehensive
school health education at elementary and sec-
ondary levels. (In 1979, only 10 States man-
dated nutrition as a core content area in school
health education.)
By 1990, virtually all routine health contacts
with health professionals should include some
element of nutrition education and nutrition
counseling. (Baseline data unavailable.)
Improved surveillance/ evaluation system
q. Before 1990, a comprehensive National nutri-
tion status monitoring system should have the
capability for detecting nutritional problems in
special population groups, as well as for obtain-
ing baseline data for decisions on National
nutrition policies.

4. Principal Assumptions

0

Eﬂorts to promote the DHHS/USDA Dietary
Guidelines for Americans will involve wide public
and private sector participation and support.
Governmental efforts in nutrition education will be
continued and improved.

Public and private efforts to make the population
aware of the science base with respect to diet and
chronic disease will be expanded, including those
areas for which controversy exists.

Current research efforts to improve the science
base with respect to diet and disease will continue
to grow, with improved dissemination of informa-
tion.

Research to identify effective measures of nutrition
education will be productive.

Chirrent efforts to develop a National nutrition
monitoring and surveillance system will be main-
tained.

Programs to promote economic and physical access
to high quality foods will be continued and im-
proved.

Cooperation between Government and the private
health care sector will increase on nutrition related
issues.

Major food processors and distributors will incor-
porate nutrition principles and concepts into their
food and marketing strategies and messages.

Public and private sector efforts to maintain the
wholesomeness of the food supply will continue.
Better methods to monitor the population’s knowl-
edge and understanding of nutrition will be devel-
oped.

Nutrition messages aired over television and radio
will continue, and will be more explicit as to
healthful diets.

Comprehensive school health education, including
nutrition education, will become a more integral
part of the K—12 curriculum.

Health professionals will play a larger role in the
provision of nutrition information.

A set of principles of. human nutrition will be de-
ﬁned and used as a basis for public policy decisions.

76

5. Data Sources
a. To National level only

Health and Nutrition Examination Survey
(HANES). Height, weight, skinfold thickness;
serum cholesterol values and breast feeding.
DHHS-National Center for Health Statistics
(NCHS). HANES I, 1971—1974; HANES II,
1979. NCHS Vital and Health Statistics, Series
11. Periodic surveys; data obtained from physi-
cal examinations, National probability sample.
Health Interview Survey (HIS). Food practices,
food habits, based on data collected in a con-
tinuing nationwide survey through personal
household interviews. DHHS-NCHS. Vital and
Health Statistics, Series 10. Continuing survey;
household interview, National probability sam-
ple.

Lipid Research Clinics. Prevalence of dyslipi-
demias in deﬁned populations, and cholesterol
levels in hypercholesterolemic men and women
between 35-59 years. DHHS—National Heart,
Lung, and Blood Institute (NHLBI). Continu-
ous reporting from 10 international clinics.
Hypertension Detection and Follow Up Pro-
gram. Nutrition related risk factors among per-
sons at high risk of coronary and vascular
diseases. DHHS-NHLBI. NHLBI-(NIH)
Hypertension Task Force Reports, Numbers 8
and 9. One time survey.

Multiple Risk Factor Intervention Trial
(MRFIT). Testing whether nutrition and other
risk reduction interventions in men 35—54 years
of age who are above average risk of death from
coronary disease, can yield signiﬁcant reduction
in mortality from coronary heart disease.
DHHS—NHLBI. Reports due 1983.

Marketing Research Survey. Prevalence and
trends of breastfeeding at one week of age.
Marketing Research Department, Ross Labora-
tory, Columbus, Ohio. Reported in Pediatrics,
November 1979. Continuing survey; representa-
tive sample of short stay hospitals; recall re-
sponse of mothers after six months.

Nationwide Food Consumption Survey (NFCS).
Food intake of individuals and households. Na-
tional Food Consumption Survey Report.
USDA-Consumer and Food Economics Insti-
tute, Human Nutrition Center (I-INC). Collected
nationally about every 10 years since 1935.
National survey of sample of households.

National Survey of Family Growth (NSFG).
Prevalence of breastfeeding. DHHS—NCHS,
Vital and Health Statistics, Series 23, selected
reports. Interview survey of 10,000 women in
National probability sample representing Ameri-
can women 15—44 years of age.

Nutrient Composition Data. Tabular analysis of
nutrient composition of speciﬁc food products.
USDA-Consumer and Food Economics Insti-

tute. Agriculture Handbook Number 8: Com-
Position of Foods—Raw, Processed and Pre-
pared. Continuous reporting.

Food Labeling. Use of nutrition labeling; nutri-
tion content; impact of numerous regulatory
actions related to nutrition labeling. DHHS-
Food and Drug Administration (FDA). Contin-
uing surveys.

Consumer Price Index (CPI). Price changes
across Nation for a ﬁxed market basket of foods
and services. Department of Labor-Bureau of
Labor Statistics (BLS). Monthly CPI Reports.
Continuing survey; National sample.

Nutrition surveillance report. Selected indices of
nutritional status from ten selected States, health
department clinics, WIC screening, and Head
Start Programs. CDC Nutrition Surveillance Re-
ports. DHHS—Center 'for Disease Control (CDC).
Continuous reporting from selected sources.
National Menu Census. Tabulation of about 460
food items sold away from home as to “good,”
“slow,” or “never sell,” including demographic
data. Institutions Magazine. Chicago, Illinois.
Reporting annually in April lst issue of Insti-
tutions. Continuing survey; National sample of
eating establishments.

Nutritional Status Monitoring System (NSMS).
Comprehensive National nutrition status moni-
toring system to be developed and implemented
jointly by DHHS and USDA. A coordinated
system drawing on health and other vital sta-
tistics from DHHS, and food use and consump-
tion data from USDA and DHHS. DHHS-Ofﬁce
of the Assistant Secretary for Health (OASH),
Nutrition Coordinating Ofﬁce.

. To State and/ or local level
0 National Vital Registration System

— Mortality. Deaths by cause (including fetal
and infant mortality), by age, sex, and race.

77

DHHS-NCHS. NCHS Vital Statistics of the
United States, Vol. II, and NCHS Monthly
Vital Statistics Reports. Continuing report-
ing from States; National full count. (Many
States issue earlier reports.)

— Natality. Births and birth rates by place of
occurrence and by the mother’s place of
residence, age, race and parities. DHHS-
NCHS. NCHS Vital and Health Statistics,
Series 21, selected reports, and Monthly
Vital Statistics Report. Birth data obtained
from certiﬁcates of live births to US. resi-
dents ﬁled throughout the United States.
Birth rates calculated on the basis of the
number of women 14—49 years of age resid-
ing in the respective areas enumerated in
census years, and estimated for inter-census
years. ‘

0 National Morbidity and Mortality Reporting

System. Numbers of 46 reportable diseases (in-
cluding foodborne outbreaks) deaths in 121
US. cities. DHHS-CDC. CDC Morbidity and
Mortality Weekly Report, and annual reports.
Morbidity: continuous reporting from State
health departments on basis of physician reports.
(Completeness of reporting varies greatly, since
not all cases receive medical care and not all
treated conditions are reported.) Mortality:
continuous reporting; volunteer panel of health
departments in 121 US. cities, full count.
Selected health data. DHHS-NCHS. NCHS
Statistical Notes for Health Planners. Compila-
tions and analysis of data to State level.

Area Resource File (ARF). Demographic,
health facility and manpower data at State and
county level from various sources. DHHS-
Health Resources Administration. Area Re-
source File: A Manpower Planning and Re-
search Tool, DHHS—HRA—80—4, Oct 79. One
time compilation.

 

PHYSICAL FITNESS AND

1. Nature and Extent of the Problem

The health beneﬁts associated with regular physical
ﬁtness and exercise have not yet been fully deﬁned.
Based on what is now known it appears that substan-
tial physical and emotional beneﬁts, direct and indi-
rect, are possible. Yet most Americans do not engage
in appropriate physical activity, either during recrea-
tion or in the course of their work. For the purposes
of this discussion, “appropriate physical activity” re-
fers to exercise which involves large muscle groups in
dynamic movement for periods of 20 minutes or
longer, three or more days per week, and which is
performed at an intensity requiring 60 percent or
greater of an individual’s cardiorespiratory capacity.
Exercise to improve ﬂexibility and muscular strength
may reduce the frequency of musculoskeletal problems
and is an important supplement to cardiovascular
conditioning activities.

a. Health implications

0 Most people feel better when they exercise.

0 Physical inactivity can result in decreased physi-
cal working capacity at all ages, with concomit-
ant decreases in physiologic function and health
status.

0 Physical inactivity is associated with an in-
creased risk of developing obesity and its disease
correlates.

0 Physical inactivity is associated with increased
risk of coronary heart disease.

0 Appropriate physical activity may be a valuable
tool in therapeutic regimens for control and
amelioration (rehabilitation) of obesity, coro-
nary heart disease, hypertension, diabetes, mus-
culoskeletal problems, respiratory diseases,
stress and depression/ anxiety. Such physical ac—
tivity, however, is still not routinely prescribed
for the treatment of these conditions.

b. Status and trends

0 Though physical ﬁtness and exercise activities
have increased in recent years—and over 50
percent of adults reported regular exercise in
popular opinion polls—~generous estimates place
the proportions of regularly exercising adults
ages 18 to 65 at something Over 35 percent.

0 Regular runners include approximately 5 per-
cent of all Americans over age 20, and 10 per-
cent of men aged 20 to 44.

79

EXERCISE

0 About 36 percent of adults ages 65 and older
were estimated in 1975 to take regular walks.

0 Only about a third of children and adolescents
ages 10 to 17 are estimated to participate in
daily school physical education programs, and
the share is declining.

0 Many high school programs focus on competi-
tive sports that involve a relatively small pro-
portion of students.

0 Though growing, the awareness of the health
beneﬁts of regular exercise is limited.

0 Only a small proportion (about 2.5 percent) of
companies and institutions with greater than 500
employees offer ﬁtness programs for their
workers.

0 Certain groups demonstrate disproportionately
low rates of participation in appropriate physical
activity, including girls and women, older peo-
ple, physically and mentally handicapped people
of all ages, inner city and rural residents, people
of low socioeconomic status and residents of
institutions.

2. Prevention/Promotion Measures

3. Potential measures

0 Education and information measures include:

— using television and radio public service
announcements to provide information on
appropriate physical activity and its beneﬁts;

— providing information in school and college-
based programs;

— providing information in health care delivery
systems, including incorporation of queries
about exercise habits into the routine clini-
cal history;

— encouraging health care providers, especially
in HMOs, community health centers and
other organized settings, to prescribe appro-
priate exercise in weight loss regimens as a
complementary treatment modality in the
management of several chronic diseases, and
to give patients 65 years and older and the
handicapped more detailed information on
appropriate physical activity together with
warnings about starting up exercise too fast;

— adopting an exercise component by com-
munity service agencies (such as the Ameri-
can Red Cross, the American Heart Asso-
ciation);

— assuring that all programs and materials re-
lated to diet and weight loss have an active
exercise component;

— tailoring education programs to the needs
and characteristics of speciﬁc populations.

0 Service measures include:

— providing physical ﬁtness and exercise pro-
grams to school children, and ensuring that
those programs emphasize activities for all
children rather than just competitive sports
for relatively few;

— providing physical ﬁtness and exercise pro-
grams in colleges;

—-— providing worksite-based ﬁtness programs
which are linked to other health enhance—
ment components (e.g., smoking cessation,
nutrition improvement) and which have an
active outreach effort;

—- incorporating exercise and ﬁtness protocols
as regular clinical tools of health providers.

0 Technologic measures include:

— increasing the availability of existing facili-
ties and promoting the development of new
facilities by public, private and corporate
entities (e.g., ﬁtness trails, bike paths, parks,
pools);

—- upgrading existing facilities, especially in
inner city neighborhoods, and involving the
population to be served at all levels of plan-
ning.

0 Legislative and regulatory measures include:

— city council support for bicycle and walking
paths for use in trips to work and school;

— developing and operating local, State and
National park facilities which can be used
for physical ﬁtness activities in urban areas;

— increasing the number of school-mandated
physical education programs that focus on
health-related physical ﬁtness;

— establishing State and local councils on
health promotion and physical ﬁtness;

— allowing expenditure of funds for ﬁtness-
related activities under Federally funded
programs guided by Federal regulations.

0 Economic measures include:

— tax incentives for the private sector to offer
physical ﬁtness programs for employees;

— encouraging employers to permit employees
to exercise on company time and/or giving
employees ﬂexible time for use of facilities;

— offering health and life insurance policies
with reduced premiums for those who par-
ticipate in regular vigorous physical activity.

b. Relative strength of the measures

0 Programs which are most likely to be successful
in recruiting new participants to appropriate
physical activity include those which offer serv-

80

ices and facilities to individuals, and economic
incentives to groups and individuals.

On the other hand, programs which can more
easily be implemented include those related to
the provision of public information and educa-
tion and improving the linkages with other
health promotion efforts.

The effectiveness of all measures is handicapped
by the limitation in knowledge with respect to:

— the relation between exercise and physical
and emotional health;

— the optimum types of exercises for various
groups of people with special needs;

— the appropriate way to measure levels of
physical ﬁtness for various age groups.

3. Speciﬁc Objectives for 1990

0 Improved health status

— Increased levels of physical ﬁtness may con-
tribute to reduced heart and lung disease
rates, possibly reduced injuries among the
elderly, and, more broadly, an enhanced
sense of well-being which may reinforce
positive health behaviors in other areas. Cur-
rently, however, few quantiﬁable health
status objectives for physical ﬁtness and ex-
ercise can be developed.

Reduced risk factors

a. By 1990, the proportion of children and
adolescents ages 10 to 17 participating reg-
ularly in appropriate physical activities, par-
ticularly cardiorespiratory ﬁtness programs
which can be carried into adulthood, should
be greater than 90 percent. (Baseline data
unavailable.) ‘

b. By 1990, the proportion of children and
adolescents ages 10 to 17 participating in
daily school physical education programs
should be greater than 60 percent. (In
1974—75, the share was 33 percent.)

c. By 1990, the proportion of adults 18 to 65
participating regularly in vigorous physical
exercise should be greater than 60 percent.
(In 1978, the proportion who regularly ex-
ercise was estimated at over 35 percent.)

d. By 1990, 50 percent of adults 65 years and
older should be engaging in appropriate
physical activity, e.g., regular walking, swim-
ming or other aerobic activity. (In 1975,
about 36 percent took regular walks.)

0 Increased public/professional awareness

e. By 1990, the proportion of adults who can
accurately identify the variety and duration
of exercise thought to promote most effec-
tively cardiovascular ﬁtness should be
greater than 70 percent. (Baseline data un-
available.)

f. By 1990, the proportion of primary care
physicians who include a careful exercise

history as part of their initial examination
of new patients should be greater than 50
percent. (Baseline data unavailable.)

0 Improved services/ protection

g. By 1990, the proportion of employees of
companies and institutions with more than
500 employees offering employer—sponsored
ﬁtness programs should be greater than 25
percent. (In 1979, about 2.5 percent of
companies had formally organized ﬁtness
programs.)

0 Improved surveillance/ evaluation systems

h. By 1990, a methodology for systematically
assessing the physical ﬁtness of children
should be established, with at least 70 per-
cent of children and adolescents ages 10 to
17 participating in such an assessment.

i. By 1990, data should be available with
which to evaluate the short and long-term
health effects of participation in programs of
appropriate physical activity.

j. By 1990, data should be available to evalu-
ate the effects of participation in programs
of physical ﬁtness on job performance and
health care costs.

k. By 1990, data should be available for regu-
lar monitoring of National trends and pat-
terns of participation in physical activity,
including participation in public recreation
programs in community facilities.

4. Principal Assumptions

Increased physical activity by the American public
will result in overall improvements in health.
Personal commitment to enhance health will become
a prominent factor promoting increased participa—
tion in exercise activities in the United States.
Voluntary agencies, private corporations and gov—
ernment will expand their commitment to physical
ﬁtness programs.

Private industry and retailers will support activities
promoting physical ﬁtness, which will also promote
increased sales of their products.

Environmental, cultural and behavioral differences
inﬂuence attitudes toward, and participation in, reg-
ular exercise.

Inner city residents will continue to have fewer ade-
quate facilities and appropriate activity programs.
Special attention will be required to make gains in
participation among lower socioeconomic groups.
There will be a reversal of the trend in reductions
of school-based programs aimed at promoting physi-
cal ﬁtness. However, these programs will not neces-

81

sarily be founded in the traditional physical educa-
tion mold.

0 New school-based programs will embrace activities
which expand beyond competitive sports.

0 The increasing costs associated with health care will
compel public policy to emphasize measures such as
physical ﬁtness. to enhance health.

0 Reduced levels of physical ﬁtness in the work force
may result in increased absenteeism from acute ill-
ness and, accordingly, decreased productivity. Thus,
employers have incentives for offering physical ﬁt-
ness programs to their employees.

5. Data Sources

a. To National level only

0 Health Interview Survey (HIS). Extent of regu-
lar exercise; job related physical activity; regular
participation in exercise DHHS-National Center
for Health Statistics (NCHS). NCHS Vital and
Health Statistics, Series 10, selected reports, and
Advance Data from Vital and Health Statistics,
No. 7 8—1250. Continuing survey; National
probability sample.

0 Extent of regular exercise. (Non-work related
only.) Regular participation in exercise reported
in household survey, and self-reported change
over previous year. Survey for General Mills,
conducted by Yankelovich, Skelly and White.
Family Health in an. Era of Stress. General
Mills, Inc., 9200 Wayzata Boulevard, Minne-
apolis, Minnesota, 1979. One time survey; Na-
tional probability sample.

0 Extent of regular exercise. (Non-work related
only.) Survey for Paciﬁc Mutual Life Insurance
Company, conducted by Louis Harris and As-
sociates, Inc. Health Maintenance, 1978. Paciﬁc
Mutual Life Insurance, Newport Beach, Cali-
fornia.

0 Public attitudes regarding physical ﬁtness. Atti—
tudes, knowledge and behavior regarding physi-
cal ﬁtness and exercise. Survey for Great Waters
of France, conducted by Louis Harris and Asso-
ciates, Inc. The Perrier Study; Fitness in Amer-
ica, 1979. One time survey; representative sam-
ple and special sample of runners.

b. To State and/ or local level

0 Exercise programs in schools. Student enroll-
ment in physical ﬁtness activities; program con-
tent and scheduling. Councils on Physical Fit-
ness, selected States only.

0 Student physical ﬁtness levels. Councils on Phys-
ical Fitness, selected States only.

 

 

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CONTROL OF STRESS AND VIOLENT BEHAVIOR

1. Nature and Extent of the Problem

Some stress may be beneﬁcial. On the other hand,
stressful conditions can result in substantial dysfunc-
tion. Public perception of the role of stress as a con-
tributor to major illness and diminished quality of life
focused considerable attention upon the need to pro-
vide practical and ethical means of favorably inﬂu-
encing this pervasive condition of 20th century life.
As used here, the term stress refers to those pressures
and tensions (whether behaviorally, biologically, eco-
nomically or environmentally induced) which, unless
suitably managed, can lead to psychological or physio-
logical maladaptations manifested in phenomena such
as fatigue, headache, obesity, absenteeism, illness,
accident-proneness or violence.

Because the socioeconomic impact of contemporary
psychosocial stress and its biologic devastation is prob-
ably enormous, comprehensive public health programs
aimed at stress management are of high priority. How-
ever, it would be unwise to mount extensive programs
on the basis of beliefs rather than evidence. The major
responsibility and challenge for a stress management
strategy is to ﬁnd the means to identify individuals or
groups especially vulnerable to stress, to provide
health professionals and the public with whatever
accurate information exists on stress identiﬁcation and
management and, when the answers are not known,
to formulate the questions that will offer the best
chance for obtaining rational answers.

Violent behavior—in its many forms—exacts a
huge toll on America’s physical and mental health.
Suicide and homicide lead to thousands of premature
deaths annually. Assault, including rape and child and
spouse abuse cause much injury and emotional suffer-
ing. Numerous factors underlie these violent forms of
behavior. Health programs alone cannot deal with
these factors. Many major aspects of American social
structure are involved—the family, the community, the
system of stratiﬁcation, the educational system and
the economic structure. Much remains unknown re-
garding means of reducing mortality associated with
violent behavior. Even in the absence of such informa-
tion important steps can be taken.

a. Health implications

0 Evidence linking psychosocial and behavioral
factors to major health disorders seems persua-
sive enough to justify the conclusion that stress
is importantly involved. However, there is a

83

clear need to study and evaluate the interaction
of psychological, environmental and biological
factors in laboratory, clinical, industrial and
school settings.

There is much evidence that many causes of
stress (situational external demands, challeng-
ing life events) have clearly measurable physio-
logic and psychological effects.

Usually, however, reactions or responses to
stress are short-term; homeostasis is restored
through various coping mechanisms without
perceptible damage.

Much remains to be elucidated about the vari-
ability of people’s vulnerability to stress, includ-
ing their developmental histories, their psycho-
logical defenses and coping capabilities. While
most people face life’s stresses with appropriate
resistances, a minority do not. For these highly
susceptible groups and individuals, stress inter-
vention programs would be desirable.

Whether stress becomes a problem for any given
individual depends on a combination of factors,
unique to that person, that may bolster resist-
ance and/or resilience. Also, any individual’s
perception of stress and reaction to it may vary
with time, circumstance and environmental
factors.

Some groups in the population appear to be
particularly vulnerable to stress overload (ado-
lescents, the elderly, the unemployed, workers
in certain occupations, people who experience
major disruptions in their lives such as death of
a spouse or job change).

Stress may function as a precipitator of dysfunc-
tion or illness, as a predisposing factor or as a
sustaining factor in chronic conditions, or as a
precipitator of violent behavior.

Evidence on the disease effects of stress is
strongest for depression, coronary heart disease,
peptic ulcer, asthma and diabetes.

Evidence is also available regarding the rela-
tionship of stress to mental health problems,
substance abuse, accidents, lower back pain,
terminal renal failure, skin rashes, tuberculosis,
multiple sclerosis, cancer and childhood strep-
tococcal infections.

Unmanaged stress plays a major role in suicides
and homicides which are leading causes of death
among youth in the 15 to 24 age group.

0 Stress is also related to family violence, includ-
ing child abuse.

0 A possible major mechanism for the relationship
of stressful life events on certain disease states
is through suppression of the normal immune
response of the organism. However, precise
knowledge of the mechanisms relating stress to
psychological and physical dysfunction is not
clearly identiﬁed.

b. Status and trends

0 In one recent National survey, 82 percent of
those polled indicated that they “need less
stress in their lives.”

0 In 1978 there were 5,100 deaths from suicide
among people ages 15 to 24.

0 In recent years suicide has ranked as the ninth
leading cause of death for all age groups. It
ranks as the second leading cause of death
among youths 15 to 24. Increasingly it is also
an important cause of death among the aged.

0 It is estimated that 200,000 to 4 million cases
of child abuse occur each year and that 2,000
children die each year in circumstances suggest-
ing abuse or neglect.

0 Hundreds of thousands of cases of violent (but
non—fatal) assault occur each year. These in-
clude instances of spouse abuse and rape.

0 The death rate from homicide among black
males ages 15 to 24 increased from 46.4 per
100,000 population in 1960 to 72.5 in 1978.

0 Minority groups have a greater risk of death
from homicide than whites. An estimated 60 to
80 percent of homicides occur as the result of
personal disagreements and conﬂicts. Firearms
were used in 63 percent of murders occurring
in 1977, with handguns used in half.

0 There are few (if any) deﬁnitive measures
identiﬁed of the prevalence of harmful stress.

0 There is increasing public awareness that stress
may be harmful.

0 The public has limited accurate knowledge and
information about what can be done to control
(reduce) stress. This leads to simplistic per—
ceptions and techniques which may be harmful
and/or impede successful long-term manage-
ment.

2. Prevention / Promotion Measures

Programs of any nature directed at stress management
must ﬁrst relate to the individual perception, motiva-
tion, evaluation and response to the stress. A sense of
well-being and good stress management usually ac-
company some combination of the following life cir-
cumstances: job satisfaction; people who provide
affection and mutual assistance; adequate income;
sense of belonging to a social group; time for self;
physical ﬁtness; adequate sleep; and freedom from
disease.

Certain approaches seem prudent for the manage-
ment of stress:

— individually focused efforts (exercise, relaxation
techniques, adequate sleep, general “self-care”,
improved psychological coping mechanisms);

— social group focused efforts (mutual aid, self—help
support groups);

— societally or institutionally focused efforts to
change unsatisfactory environmental conditions
such as overcrowded housing, pollution, stressful
working conditions; to modify social norms or
values such as in relation to smoking and drinking;
and to inform the public regarding the role of
stress.

A major aim is to enhance dignity, and thus to pro-
vide the will to strive for self-management and self-
mastery.

It appears that violent behavior, while occurring in
all strata of American society, exacts a far greater toll
among minority and other economically deprived
groups in the United States. Thus many measures
which would improve the economic and social position
of these groups might well be accompanied by a reduc-
tion of rates of homicide.

a. Potential measures

0 Education and information measures include:

— increasing the public’s awareness, through
planned campaigns utilizing the appropriate
media, that stress can be an antecedent of
illness and that stress management can be an
important component of health;

— creating new educational pathways for de-
veloping enhanced professional skills in
bio-behavioral ﬁelds of medicine and public
health;

— developing the capacities of health care pro-
fessionals in stress diagnosis and manage-
ment;

—— helping parents recognize and deal with
stress;

— training secondary, elementary and pre-
school teachers to include discussion of
stress recognition and management in school
health curricula;

— training of police in handling calls involving
domestic and interpersonal disputes which
would potentially lead to violent behavior;

—— public education, especially for high risk
groups, on steps to take to reduce risks of
rape;

— training all “helping” professionals regard-
ing signs which indicate high risk for suicide;

—-- helping the public be aware of indicators of
possible suicide.

— See Pregnancy and Infant Health.

0 Service measures include:
—— hotlines for people under acute stress (sui-
cide, child abuse prevention);

— stress management programs in work places;

-— stress management programs targeted to ado-
lescents, parents and the elderly;

— stress appraisal analysis (self-administered
or performed by a legitimate objective out-
side source);

— professional and social support systems to
assist in resolution of stressful life events,
including mutual aid and self-help groups
such as Reach for Recovery, child abusing
parents, bereavement groups, single parent
groups;

— information and counseling with regard to
individually appropriate leisure and stress-
reducing activities including exercise;

— a variety of self-help relaxation and bio-
feedback techniques, which can be individ-
ualized in concert with a diversity of life-
styles and work requirements;

— psycho-physiologic tests to aid in assisting
employees who are having difficulty adjust-
ing to their work and to their co-workers;

— support services for inevitable or necessary
life change events—especially in relation to
death, separation, job changes and geo-
graphic relocation;

— domestic crisis teams to defuse domestic
disputes;

— targeting the above measures to high risk
populations and individuals with low coping
abilities;

-— evaluating intervention efforts;

— follow-up services for persons who have at-
tempted suicide; .

— shelters for abused wives (and husbands);

— training all health (and other human serv-
ices—including educational) personnel to
be alert to evidence of child abuse.

Technologic measures include:

—— actions by employers, labor and government
to reduce stress-creating work environments;

— reducing stressful aspects of the environ-
ment such as noise pollution and overcrowd-
ing.

Legislative and regulatory measures include:

— activities to create employment opportunities
for youth;

— action to limit the availability of handguns,
to reduce homicides and suicides that occur

sisting their patients to modify their lifestyles or
behavior.

Many stress prevention measures call for exten-
sive modiﬁcations in public attitudes and com;
plex cultural reappraisals at all levels, public
and private. These cannot be expected to take
place quickly.

At a minimum, vigorous efforts at early detec-
tion and assistance will be necessary at common
sites where this is possible—Le, schools and
worksite.

Little is known about the relative strength of
potential efforts to reduce rates of violent be-
havior. There is some evidence that suicide
prevention and rape prevention efforts do have
an impact—at least with certain populations.

3. Speciﬁc Objectives for 1990 or Earlier

0 Improved health status
a. By 1990, the death rate from homicide among

black males ages 15 to 24 should be reduced
to below 60 per 100,000. (In 1978, the homi-
cide rate for this group was 72.5 per 100,000.)
By 1990, injuries and deaths to children in-
ﬂicted by abusing parents should be reduced by
at least 25 percent. (Reliable baseline data un-
available—estimates vary from 200,000 to 4
million cases of child abuse occurring each year
in this country.)

c. By 1990, the rate of suicide among people 15 to

24 should be below 11 per 100,000. (In 1978,
the suicide rate for this age group was 12.4 per
100,000).

0 Reduced risk factors
—- Certain risk factors for stress are well-identiﬁed.

Some have been addressed in the sections on
Family Planning (unintended pregnancies), Oc-
cupational Safety and Health, Misuse of Alco-
hol and Drugs, and Physical Fitness and Exer-
cise. Other risk factors for stress such as those
imbedded in family history and major life
changes, are not easily controlled or quantiﬁed
and therefore are not speciﬁed as measurable
objectives.

. By 1990, the number of handguns in private

ownership should have declined by 25 percent.
(In 1978, the total number of handguns in pri-
vate ownership was estimated to be 30 to 40
million.)

during stressful periods;
— strengthening mandatory child abuse report-
ing laws.

0 Increased public/ professional awareness

e. By 1990, the proportion of the population over
the age of 15 which can identify an appropriate
community agency to assist in coping with a
stressful situation should be greater than 50
percent. (Baseline data unavailable.)
By 1990, the proportion of young people ages
15 to 24 who can identify an accessible suicide
prevention “hotline” should be greater than 60
percent. (Baseline data unavailable.)

b. Relative strength of the measure

0 The relative strength of potential stress inter-

vention efforts (measures) is not yet known. f.
0 Stress reduction and management often require

behavioral changes, but most physicians and

other health professionals are not trained in as-

85

g. By 1990, the proportion of the primary care
physicians who take a careful history related to
personal stress and psychological coping skills
should be greater than 60 percent. (Baseline
data unavailable.)

0 Improved services/ protection

h. By41990, to reduce the gap in mental health
services, the number of persons reached by mu-
tual support or self-help groups should double
from 1978 baseline ﬁgures. (In 1978, estimates
ranged from 2.5 to 5 million; depending on the
deﬁnition of such groups.)

i. By 1990, stress identiﬁcation and control should
become integral components of the continuum
of health services offered by organized health
programs. (Baseline data unavailable.)

j. By 1990, of the 500 largest US. ﬁrms, the pro-
portion oﬁering work-based stress reduction
programs should be greater than 30 percent.
(Baseline data unavailable.) '

0 Improved surveillance/ evaluation systems

k. By 1985, surveys should show what percentage
of the US. population perceives stress as ad-
versely affecting their health, and what propor-
tion of these are trying to use appropriate stress
control techniques.

1. By 1985, a methodology should have been de-
veloped to rate the major categories of occupa-
tion in terms of their environmental stress loads.

m. By 1990, the existing knowledge base through
scientiﬁc inquiry about stress effects and stress
management should be greatly enlarged.

11. By 1990, the reliability of data on the incidence
and prevalence of child abuse and other forms
of family violence should be greatly increased.

4. Principal Assumptions
0 Much of stress and stress-related illness is the result

of fundamental socioeconomic status over which the
health system has limited control.

0 Further research will establish the relationship of

stress to illness. , -

0 Research will identify and demonstrate effective
stress-control measures.

0 The role of physical ﬁtness and nutrition in success-
fully managing stress will be better understood.

86

0 Various health care systems will be willing to assist
patients in making the changes in their lifestyles
that may be necessary to reduce stress and to im-
prove coping with stress.

0 Health professionals, health organizations, industry
and labor will devote increased attention to under-
standing the relation of stress to illness and to vio-
lent behavior, as well as to better methods of stress
reduction and management.

0 Medical and nursing schools will offer instruction
targeted at understanding the pathophysiology of
stress and its management; training of other health
professionals will also include stress education, as
will continuing education programs for all health
professionals.

0 Hotlines and community support groups will prove
effective in aiding individual efforts to cope with
personal crises.

0 Actions at the individual and community levels will
foster measures to reduce the availability of hand-
guns.

0 Actions will be taken at the Federal, State, and local
levels to increase the employment opportunities for
youth.

Data Sources
a. To National level only

0 National Vital Registration System—Mortality.
Deaths by cause (including homicides and sui-
cides), by age, race, and sex. DHHS—NCHS.
NCHS Vital Statistics of the United States, Vol-
ume II, and NCHS Monthly Vital Statistics Re-
ports. Continuing reporting from States; full Na-
tional count. (Many States issue earlier reports).

0 Public attitudes regarding stress. Perceptions of
how problems of everyday life relate to health
and mental health. Survey for General Mills,
conducted by Yankelovich, Skelly and White,
Inc. Family Health in an Era of Stress. General
Mills, Inc., 9200 Wayzata Boulevard, Minne-
apolis, Minnesota. One time survey; National
probability sample.

b. To State and/ or local level

0 No data sources unless questions on State or
local household interview surveys.

ACKNOWLEDGEMENTS

Preparation of this document was a joint eﬁort of the Center for Disease Control and the Health Resources Administra-
tion, coordinated by the Ofﬁce of Disease Prevention and Health Promotion. Contributions were made by a wide variety
of agencies and individuals, listed below. Special acknowledgement should be given to the staff work of Katharine G.
Bauer and Martha Katz of the Ofﬁce of Disease Prevention and Health Promotion; Julia M. Fuller, James W. Stratton
and Dennis Tolsma of the Center for Disease Control; Laurel Carson Shannon, Peggy McManus, and Cheryl Polansky
of the Health Resources Administration; and Ronald W. Wilson of the National Center for Health Statistics.

PARTICIPATING AGENCIES

Public Health Service (HHS)

Alcohol, Drug Abuse, and Mental Health Administration
Gerald L. Klerman, M.D., Administrator

Center for Disease Control
William H. Foege, M.D., Director

Food and Drug Administration
Jere Goyan, Ph.D., Commissioner

Health Resources Administration
Henry A. Foley, Ph.D., Administrator

Health Services Administration
George I. Lythcott, M.D., Administrator

National Institutes of Health
Donald S. Fredrickson, M.D., Director

Ofﬁce of Adolescent Pregnancy Programs
Lula Mae Nix, Ed.D., Director

Oﬂice of Dental Aﬂairs
John C. Greene, D.M.D., Chief Dental Oﬂicer

Ofﬁce of Disease Prevention and Health Promotion
J. Michael McGinnis, M.D., Deputy Assistant Secretary
for Health

Ofﬁce of Environmental Affairs
James F. Dickson, III, M.D., Senior Advisor

Oﬁice of Health Maintenance Organizations
Howard Viet, Director

Ofﬁce of Health Planning and Evaluation
Susanne Stoiber, Deputy Assistant Secretary for Health

Oﬂice of Health Research, Statistics, and Technology
Ruth S. Hanft, Deputy Assistant Secretary for Health

National Center for Health Services Research
Gerald Rosenthal, Ph.D., Director

National Center for Health Statistics
Dorothy P. Rice, Director

87

OﬂiCe of Intergovernmental Affairs
Alonzo S. Yerby, M.D., Deputy Assistant Secretary for
Health

Ofﬁce of International Health
John H. Bryant, M.D., Deputy Assistant Secretary for
Health

Ofﬁce of Population Affairs
Ernest Peterson, Acting Deputy Assistant Secretary for
Health

Ofﬁce of Public Aﬁairs
Mort Lebow, Director

Oﬁice on Smoking and Health
John M. Pinney, Director

Health Care Planning Administration (HHS)
Howard Newman, Administrator

Oﬂice of Human Development Services (HHS)
Cesar A. Perales, Assistant Secretary for Human
Development Services

Social Security Administration (HHS)
William J. Driver, Commissioner

Department of Agriculture
Carol Tucker Foreman, Assistant Secretary for Food
and Consumer Services

Consumer Product Safety Commission
Susan B. King, Chairman

Department of Defense
John H. Moxley, III, M.D., Assistant Secretary for
Health Aﬁairs

Department of Education
Floretta D. McKenzie, Acting Deputy Assistant Secre-
tary, Oﬂice of School Improvement

Environmental Protection Agency
Douglas M. Costle, Administrator

Federal Trade Commission
Michael Pertschuk, Chairman

Department of Housing and Urban Development
Father Geno Baroni, Assistant Secretary for Neighbor-
hoods, Voluntary Associations and Consumer Protec-
tion

Department of the Interior
Margaret G. Maguire, Deputy Director, Heritage, Con-
servation, and Recreation Service

Department of Labor
Eula Bingham, Ph.D., Assistant Secretary for Occupa-
tional Safety and Health

Department of Transportation
Joan Claybrook, Administrator,
Traﬂic Safety Administration

National Highway

Department of the Treasury
Richard J. Davis, Assistant Secretary for Enforcement
and Operations

The following individuals participated in various stages of the development of the document. Chairpersons and Recorders
of the 15 Work Groups of the 1979 Atlanta Conference are noted with an asterisk.

Herbert K. Abrams, M.D., M.P.H.
Health Sciences Center
The University of Arizona

Michael Adams, M.D.
Office of Program Planning and Evaluation
Center for Disease Control -

Chung-Hae Ahn
Ofﬁce of International Health
Ofﬁce of the Assistant Secretary for Health

E. H. Ahrens, Jr., MD.
The Rockefeller University

David T. Allen, MD.
Department of- Public Health
State of Tennessee

Archie E. Allen
Domestic Operations Oﬂice
ACTION

*Myron Allukian, D.D.S., M.P.H.
Bureau of Community Dental Programs
City of Boston

Ronald Altman, MD.
New Jersey Department of Health

George R. Anderson, M.D.

Bureau of State Health Planning and
Resource Development

Texas Department of Health

Linda Andreasen
Division of Health
Nevada Department of Human Resources

*Nicholas A. Ashford, Ph.D., J.D.
Center for Policy Alternatives
Massachusetts Institute of Technology

Dean A. Austin, Ph.D.
Lincoln Public Schools
Lincoln, Nebraska

Karen J. Axnick, R.N.
Department of Infection Control
Stanford University Hospital

Matilda A. Babbitz
School of Public Health
University of South Carolina

John Bagrosky
Ofﬁce of Smoking and Health
US. Public Health Service

Lillian Bajda
Department of Health
State of New Jersey

Ned E. Baker, M.P.H.
Health Planning Association of Northwest Ohio

Susan Sorem Baker
Ofﬁce of Health Planning and Evaluation
US. Public Health Service

Wendy Baldwin, Ph.D.

National Institute of Child Health and
Human Development

National Institutes of Health

Linda Balog
School of Public Health
University of South Carolina

Albert Balows, Ph.D.
Bureau of Laboratories
Center for Disease Control

Diane Barhyte
American Public Health Association

Kathryn E. Barnard, RN, Ph.D.
University of Washington
Seattle, Washington

Carolyn Barnes
Bureau of Training
Center for Disease Control

*Helen B. Barnes, MD.
Department of Obstetrics and Gynecology
University of Mississippi Medical Center

*Patricia 2. Barry, Dr.P.H.
Department of Health Administration
University of North Carolina

James R. Beall, Ph.D.
US. Department of Labor

Lynn Beasley
Palmetto-Lowcountry Health Systems Agency, Inc.
Summerville, South Carolina

Dan E. Beauchamp, Ph.D.
School of Public Health
University of North Carolina

Ruth A. Behrens
Center for Health Promotion
American Hospital Association

Selina Bendix, Ph.D.
Department of City Planning
City and County of San Francisco

Ira Bernstein
College of Medicine
University of Vermont

Donald A. Berreth
Ofﬁce of Information
Center for Disease Control

Fay R. Biles, Ph.D.
Department of Health and Safety Education
Kent State University

*Henry Blackburn, M.D.
School of Public Health
University of Minnesota

Chris Bladen

Ofﬁce of the Assistant Secretary for Planning and
Evluation

Department of Health and Human Services

*Howard T. Blane, Ph.D.
University of Pittsburgh

Ronald G. Blankenbaker, M.D.
Indiana State Board of Health

Nick Blaskovich, Jr., Ph.D.
National Institute for Occupational Safety and Health
Center for Disease Control

*William L. Blockstein, Ph.D.
University of Wisconsin

Joseph H. Blount
Bureau of State Services
Center for Disease Control

*William B. Bock, D.D.S.
Bureau of State Services
Center for Disease Control

F. James Boehm, M.P.H.
Department of Human Resources
State of North Carolina

*Sue Bogner, Ph.D.
Health Services Administration

89

Frank P. Bolden
D.C. Public Schools
Washington, DC.

*Richard J. Bonnie, L.L.B.
School of Law
University of Virginia

Joyce Borgmeyer, R.D.
Iowa State Department of Health

Gilbert J. Botvin, Ph.D.
American Health Foundation

Susan Boucher
Division of Cancer Prevention
Baltimore City Health Department

Frank Bowyer, D.D.S.
American Dental Association

Philip S. Brachman, M.D.
Bureau of Epidemiology
Center for Disease Control

Robert C. Bradbury, Ph.D.
Central Massachusetts Health Systems Agency
Shrewsbury, Massachusetts

Windell R. Bradford
Bureau of State Services
Center for Disease Control

Allen G. Brailey, Jr., MD.
Personnel Department
Burlington Northern

*Elaine Bratic
National Cancer Institute
National Institutes of Health

Tameron E. Brink, R.D., M.P.H.
Division of Health
Nevada Department of Human Resources

Seiko Baba Brodbeck
American Public Health Association
Washington, DC.

Edward M. Brooks
Ofﬁce of Toxic Substances
Environmental Protection Agency

Wayne G. Brown
Bureau of Training
Center for Disease Control

Audrey K. Brown, MD.
Downstate Medical Center
Brooklyn, New York

Sara Brown, Ph.D.
Select Panel on the Promotion of Child Health

Helen B. Brown, Ph.D.
Cleveland Clinic
Cleveland, Ohio

Richard Bryan
Indian Health Service
Health Services Administration

Dawn Bryan
American Heart Association
Dallas, Texas

Elsworth R. Buskirk, Ph.D.
Laboratory for Human Performance Research
Pennsylvania State University

Earl B. Byme, M.D.
Bryn Mawr, Pennsylvania

Harry P. Cain, II, Ph.D.
American Health Planning Association

Antonio Calarco
Butte County Department of Health
Chico, California

David Calkins, M.D.
Oﬂice of the Secretary
Department of Health and Human Services J

C. Wayne Callaway, M.D.
Nutrition Coordinating Committee
US. Public Health Service

Joseph Cameron
National Highway Trafﬁc Safety Commission
US. Department of Transportation

Miriam M. Campbell, M.P.H.
Health Education Consultant
Orono, Maine

Richard Carleton, MD.
The Memorial Hospital
Pawtucket, Rhode Island

Paula L. Carney

Food and Nutrition Service

US. Department of Agriculture

Charlotte Catz, MD.

National Institute of Child Health and Human

Development
National Institutes of Health

Dewey Cederblade
American Social Health Association

Don B. Chaﬂin, Ph.D.

Industrial and Operation Engineering
University of Michigan

Daniel Chatﬁeld

Ohio Department of Health

*James Chin, M.D.
California Department of Health Services

William B. Cissell, Ph.D.

School of Public and Allied Health

East Tennessee State University

Ray A. Ciszek, Ed.D.

American Alliance for Health, Physical Education, and
Recreation

90

James W. Clark, J r.
American Optometric Association
Washington, DC.

Linda Clemmings
American Public Health Association

Carl F. Coﬂelt, M.D.
County Health Department
Los Angeles, California

Dennis L. Colacino, Ph.D.
PepsiCo, Incorporated

Valerie Coleman
Heritage Conservation and Recreation Service
US. Department of the Interior

Durward R. Collier, D.D.S., M.P.H.
Department of Public Health
State of Tennessee

Gere Collosky

Blue Cross and Blue Shield

Chicago, Illinois

Bonnie A. Connors

American College of Obstetricians and Gynecologists

C. Carson Conrad
The President’s Council on Physical Fitness and Sports

James P. Cooney, Jr., Ph.D.
Ofﬁce of the Center Director
National Center for Health Statistics

John A.D. Cooper, M.D.
Association of American Medical Colleges

. Claire M. Coppage, R.N., M.P.H.

Bureau of Training
Center for Disease Control

Robert D. Corwin, M.D.
American Heart Association

Audrey Cross
Ofﬁce of the Secretary
US. Department of Agriculture

Jeffrey F. Cross
National Environmental Health Association and
Ferris State College

*James W. Curran, M.D.
Bureau of State Services
Center for Disease Control

Russell W. Currier, D.V.M.
Division of Disease Prevention
Iowa Department of Health

Irvin M. Cushner, MD.
US. Public Health Service

David A. Dammann
ACTION

Suzanne Dandoy, M.D., M.P.H.
Arizona Department of Health Services

Helen Darling
Institute of Medicine
National Academy of Sciences

Robert M. Daugherty, Jr., MD.
Subcommittee on Smoking
American Heart Association

Ann Davis, R.N., B.S.N.
Overlook Hospital
Summit, New Jersey

Runyan Deere, Ph.D.
Cooperative Extension Service
University of Arkansas

John B. DeHoff, M.D., M.P.H.
Health Department
City of Baltimore

Sarah L. Diamond
Bureau of Health Education
Center for Disease Control

Gene Dickey
Food and Nutrition Service
US. Department of Agriculture

Ernest M. Dixon, M.D.
Celanese Corporation

*Ronald D. Dobbin
National Institute for Occupational Safety and Health
Center for Disease Control

Jane Dolkart, J.D.
Division of Advertising Practices
Federal Trade Commission

Charles L. Donahue, Jr.
Center for Health Planning
Boston University

Susan E. Donald
Bureau of Training
Center for Disease Control

Deborah Drudge, Esq.

Healthy America

Washington, District of Columbia

James M. Dunning, D.D.S., M.P.H.

Massachusetts Citizens’ Committee for Dental Health
Robert L. DuPont, M.D.

Institute for Behavior and Health, Inc.

Bethesda, Maryland

Merlin K. Duval, MD.

National Center for Health Education

San Francisco, California

Lucy Eddinger

Ofﬁce of Adolescent Pregnancy Programs

US Public Health Service

Robert Edelman, MD.

National Institute of Allergy and Infectious Diseases
National Institutes of Health

Mary Egan, R.D., M.S., M.P.H.

Program Ofﬁce for Maternal and Child Health
Health Services Administration

91

*Robert S. Eliot, M.D.
Cardiovascular Center
The University of Nebraska Medical Center

Efﬁe 0. Ellis, M.D.
American Medical Association and National Founadtion
March of Dimes

Mary Enig
Department of Chemistry
University of Maryland

James H. Erickson, M.D., M.P.H.
Bureau of Medical Services
Health Services Administration

Caswell Evans, D.D.S.
Seattle-King County Department of Public Health

Beth Ewy
Division of Cancer Prevention
Baltimore, Baryland

Ivan J. Fahs, Ph.D.
Rural Sociologist
Rochester, Minnesota

Robert C. Faine, D.D.S.
Bureau of State Services
Center for Disease Control

Henry A. Falk, M.D.
Bureau of Epidemiology
Center for Disease Control

Gerald Feck
Burn Injury Control Program
New York State Department of Health

Charles E. Feigley, M.D.
School of Public Health
University of South Carolina

Yehudi M. Feldman, M.D.
Bureau of Venereal Disease Control
City of New York Department of Health

Barry Felrice
National Highway Trafﬁc Safety Administration
US. Department of Transportation

Joe Fenwick, D.D.S. ,
Health Planning Association of Northwest Ohio

Bernice Ferguson, R.N., M.P.H.
Department of Health
State of New Jersey

Harry L. Ferguson, M.D., Ph.D.
Science and Education Administration—Extension
US Department of Agriculture

Conrad P. Ferrara
Bureau of Training
Center for Disease Control

Claudia E. Finney, M.T. (ASCP)
Saint Elizabeth’s Hospital
Washington, District of Columbia

John R. Fleming
School of Allied Health
Ferris State College

Gordon Flint
Bureau of Health Education
Center for Disease Control

Dee Flynn
Bureau of Alcohol, Tobacco, and Firearms
US. Department of the Treasury

Peter Fraleigh
Health Planning Association of Northwest Ohio

Herman M. Frankel, M.D.
Health Services Research Center
Kaiser Foundation Hospitals

Todd M. Frazier
National Institute for Occupational Safety and Health
Center for Disease Control

Jack Friel
Bureau of Epidemiology
Center for Disease Control

Wendy Frosh, M.S.
Union Hospital
Lynn, Massachusetts

Lois W. Gage, Ph.D.
Medical School
The University of Michigan

George Galasso, Ph.D.
National Institute of Arthritis and Metabolic Diseases
National Institutes of Health

Judy Gartin, R.D.
Georgia State University
Atlanta, Georgia

Kristine M. Gebbie
Health Division
State of Oregon

Stephen D. Gelineau, APR
Union Hospital
Lynn, Massachusetts

Elizabeth C. Giblin
University of Washington
Seattle, Washington

Dottie Gillon, R.N., F.P.N.P.
Division of Health
Nevada Department of Human Resources

Charles Gish, D.D.S.
Indiana State Board of Health

’irginia M. Gladney, R.D., M.P.H.
‘epartment of Health Services
County of Los Angeles
David Glasser, M.D., M.P.H.
Bureau of Disease Control
3altimore, Maryland

92

Edwin M. Gold, M.D.
Women and Infants Hospital
Providence, Rhode Island

Willis B. Goldbeck
Washington Business Group on Health
Washington, DC.

Frank Goldsmith, M.P.H.
New York State School of Industrial and Labor Relations
Cornell University

Jan Richard Goldsmith, D.M.D.
US. Public Health Service
Region II

Aurel Goodwin, Ph.D.
Mine Safety and Health Administration
US. Department of Labor

Janice Gordon
Food and Beverages Trades Department
AFL-CIO

Millicent Gorham
Ofﬁce of the Honorable Louis Stokes
US. House of Representatives

Deane F. Gottfried, M.D.
Northern California Cancer Program
Palo Alto, California

Stanley N. Graven, MD.
Department of Pediatrics and OB-GYN
University of South Dakota

Gareth M. Green, MD.
Department of Environmental Health Sciences
Johns Hopkins University

Lawrence W. Green, Dr.P.H.

Ofﬁce of Health Information, Health Promotion and
Physical Fitness and Sports Medicine

US. Public Health Service

Kenneth Greenspan, M.D.

College of Physicians and Surgeons
Columbia University

Joel R. Greenspan, M.D.

Bureau of Epidemiology

Center for Disease Control

Roy Grifﬁn

Texas Area V Health Systems Agency, Inc.
Irving, Texas

Billy G. Griggs

Bureau of Health Education
Center for Disease Control

Stephen Grossman, J .D.
V.A. Scholars Program
Washington, District of Columbia

Susan R. Guarnieri
Baltimore City Health Department

Dale Hahn
Blue Cross and Blue Shield
Chicago, Illinois

Thomas J. Halpin, M.D., M.P.H.
Bureau of Preventive Medicine
Ohio Department of Health

Lee Hand, M.D.
VA Medical Center
Decatur, Georgia

Jean H. Hankin, Dr.P.H.
School of Public Health
University of Hawaii at Manoa

Dea Hanson, R.D.
Georgia State University
Atlanta, Georgia

Robert L. Harrington, M.D.
Permanente Medical Group
San Jose, California

Jeffrey E. Harris, M.D., Ph.D.
Department of Economics
Massachusetts Institute of Technology

Michael J. Hartford
School of Nursing
Georgetown University

L. Howard Hartley, M.D.
Committee on Exercise
American Heart Association

William L. Haskell, Ph.D.
School of Medicine
Stanford University

Dale Hattis, Ph.D.
Massachusetts Institute of Technology

Patricia Hausman, M.S.
Center for Science in the Public Interest
Washington, DC.

Stephen W. Havas, MD.
National Heart, Lung, and Blood Institute
National Institutes of Health

Victor M. Hawthorne, M.D.

School of Public Health

University of Michigan

Maxine Hayes, M.D.

Hinds-Rankin Urban Health Innovation Project
Brandon, Massachusetts

*Clark W. Heath, Jr., MD.
Bureau of Epidemiology
Center for Disease Control

Mark Hegsted
Science and Education Administration
US. Department of Agriculture

Herman A. Hein, M.D.
Iowa Perinatal Program
The University of Iowa Hospitals and Clinics

Victor Herbert, M.D., J.D.
SUNY Downstate Medical Center and Bronx VA

Medical Center

93

M. Ward Hinds, M.D., M.P.H.
Cancer Center of Hawaii
University of Hawaii at Manoa

*Alan R. Hinman, M.D.
Bureau of State Services
Center for Disease Control

Robert S. Hockwald, M.D.
American Occupational Medical Association
Chicago, Illinois

Hap Hodd

Ofﬁce of the Assistant Secretary for Management
and Budget

Department of Health and Human Services

Barbara Holloway
Bureau of Epidemiology
Center for Disease Control

Debbie Holman, R.N.
Outpatient Clinic
Center for Disease Control

Priscilla B. Holman
Bureau of Health Education
Center for Disease Control

King K. Holmes, M.D., Ph.D.
US. Public Health Service Hospital
—Seattle and University of Washington

Frank M. Hoot
Environmental Health
Baltimore, Maryland

Joann Horai, Ph.D.
American Psychological Association

Thomas J. Home
Bureau of State Services
Center for Disease Control

Arthur E. Hoyte, MD.
Department of Health Aﬂairs
Washington, DC.

Susan Hubbard
Georgia State University
Atlanta, Georgia

Sara M. Hunt, Ph.D.
Georgia State University
Atlanta, Georgia

*Robert Hutchings
Ofﬁce on Smoking and Health
US. Public Health Service

James N. Hyde, M.P.H.
Division of Preventive Medicine
Massachusetts Department of Public Health

Robert Isman, D.D.S., M.P.H.
Dental Health Services
Multomah County, Oregon

Jack Jackson
Bureau of State Services
Center for Disease Control

George J. Jackson, Ph.D.
Division of Nutrition
Food and Drug Administration

Andrew B. James, M.S., Dr. P.H.
Department of Public Health
City of Houston

Ronnie S. Jenkins
Georgia Department of Human Resources

Robert E. Johnson, MD.
Bureau of State Services
Center for Disease Control

Lloyd D. Johnston, Ph.D.
Institute for Social Research
The University of Michigan

Steven Jonas, M.D.
School of Medicine
State University of New York at Stoney Brook

Stephen B. Jones (Retired )
Missouri Department of Social Services
State of Missouri

Barbara L. Kahn
Department of Human Resources
State of North Carolina

John T. Kalberer, Jr., Ph.D.
Ofﬁce of the Director
National Institutes of Health

Norman M. Kaplan, MD.
The University of Texas Health Science
Center at Dallas

Snehendu B. Kar, Dr. P.H.
Center for Health Sciences
University of California, Los Angeles

Stanislav V. Kasl, Ph.D.
School of Medicine
Yale University

Judith Katz
National Foundation March of Dimes

Abraham J. Kauver, M.D.
Denver Department of Health and Hospitals

Mark Keeney
Department of Chemistry
University of Maryland

James A. Keith
School of Public Health
University of South Carolina

Bruce C. Kelley, Ph.D.
Department of Health
Providence, Rhode Island

94

Douglas Kellogg, Ph.D.
Bureau of Laboratories
Center for Disease Control

Lorin E. Kerr, MD.
Department of Occupational Health
United Mine Workers of America

Samuel Kessel, MD.
US. Public Health Service

Anne Kiefhaber, B.S.N.
Washington Business Group on Health
Washington, DC. ‘

Major John E. Killeen

Oﬂice of the Assistant Secretary of Defense
(Health Affairs)

Department of Defense

James R. Kimmey, M.D.
Midwest Center for Health Planning
Madison, Wisconsin

Stephen H. King, MD.
Division of Health Sciences
PHS Regional Ofﬁce (Atlanta)

George M. Kingman
National Institute of Environmental Health Sciences
National Institutes of Health

Robert J. Kingon
Bureau of State Services
Center for Disease Control

Janie Ann Kinney, J .D.
Blum and Nash
Washington, DC.

Ardine Kirchhofer
Georgia State University
Atlanta, Georgia

John Kirscht, Ph.D.
School of Public Health
University of Michigan

Lawrence A. Klapow, Ph.D.
State Water Resources Control Board
State of California

Stuart A. Kleit, MD.
National Kidney Foundation

John J. Klumb
Department of Education
State of California

Ruth N. Knollmueller, R.N., M.P.H.
School of Nursing
Yale University

Sam Knox
American Social Health Association

Dieter Koch-Weser, MD.
Department of Preventive and Social Medicine
Harvard Medical School

Ross L. Koeser
US. Consumer Product Safety Commission

Roz Kohn
Baltimore City Health Department

Lloyd J. Kolbe, Ph.D.
National Center for Health Education

Gretchen Kolsrud, Ph.D.
Ofﬁce of Technology Assessment
US. Congress

John M. Korn
Bureau of Health Education
Center for Disease Control

Paul Kotin, MD.
J ohns-Manville Corporation

Mary Grace Kovar
National Center for Health Statistics
US. Public Health Service

David P. Kraft, MD.
University Mental Health Service
University of Massachusetts

Dorine G. Kramer, M.D.
Bureau of Health Education
Center for Disease Control

Helen Krause, M.P.H.
District V Health Department
Twin Falls, Idaho

Kathtleen Kreiss, M.D.
Bureau of Epidemiology
Center for Disease Control

Lawrence J. Krone, Ph.D., R.S.
National Environmental Health Association

W. Stanley Kruger
U.S. Oﬂice of Education

Saul Krugman, MD.
Department of Pediatrics
New York University Medical Center

F. A. Kummerow
College of Agriculture
University of Illinois at Urbana-Champaign

Katherine Lacy

Oﬂice of Disease Prevention and Health Promotion

Robert E. Lamb, D.D.S.

Council on Dental Health and Health Planning

American Dental Association

Louis C. LaMotte, Sc.D.
Bureau of Laboratories
Center for Disease Control

J. Michael Lane, M.D.
Bureau of Smallpox Eradication
Center for Disease Control

Herbert G. Langford, MD.

The University of Mississippi Medical Center

Laurent P. LaRoche, M.D.
Western Electric Company

Judith H. LaRosa, R.N., M.N.Ed.
National Heart, Lung, and Blood Institute
National Institutes of Health

Dolores Lemon
Joint Commission on Accreditation of Hospitals

John D. Lenton, M.D.
VA Medical Center
Decatur, Georgia

Carl Leukefeld, Ph.D.
Division of Resource Development
National Institute on Drug Abuse

Cora S. Leukhart
Bureau of State Services
Center for Disease Control

Gilbert A. Leveille
Department of Food Science and Human Nutrition
Michigan State University

Richard A. Levinson, M.D.
Veterans Administration

Richard Light, M.D.
Indian Health Service
Health Services Administration

Marc B. Lipton, Ph.D., M.P.A.
Mental Health and Addictions
City of Baltimore Health Department

*Frank S. Lisella, Ph.D.
Bureau of State Services
Center for Disease Control

J. William Lloyd, Sc.D.
Occupational Safety and Health Administration
US. Department of Labor

Keith R. Long, Ph.D.
College of Medicine
University of Iowa

Katherine S. Lord
Ofﬁce of Information
Center for Disease Control

Cliff E. Lundberg
National Headquarters for American Red Cross

Karen M. Lynch
South Carolina Department of Health and Environmental
Control

John C. MacQueen, MD.
Department of Pediatrics
University of Iowa

George F. Mallison, M.P.H.
Bureau of Epidemiology
Center for Disease Control

Arnold M. Malmon
Milwaukee Blood Pressure Program
Milwaukee, Wisconsin

Robert B. Mancke
Bureau of Health Education and Information
City of Baltimore Health Department

Edgar K. Marcuse, M.D.
Children’s Orthopedic Hospital and Medical Center/
Seattle

Louise Markley
American Public Health Association

Russell (Bud) Mason
Indian Health Service
Health Services Administration

James 0. Mason, M.D., Dr. P.H.
Utah State Department of Health

Kathleen A. McBurney, R.D., M.P.H.
Department of Human Resources
State of Nevada

J ermyn F. McC'ahan, MD.

Department of Environmental, Public and Occupational
Health

American Medical Association

David B. McCallum, Ph.D.
South Carolina Department of Health and Environmental
Control

John J. McCarthy, Jr., MD.
National Family Planning Federation of America

Roger McClain
Indiana State Board of Health

William M. McCormack, MD.
Massachusetts State Laboratory Institute

William J. McCurry
Division of Preventive Health Services
Public Health Service Region IX

Philip R.B. McMaster, M.D.
Bureau of Laboratories
Center for Disease Control

Simon A. McNeeley
Bureau of Elementary and Secondary Education
US. Ofﬁce of Education

Donald McNellis, M.D.‘
Bureau of Community Health Services
Health Services Administration

Kristen W. McNutt, Ph.D.
National Nutrition Consortium, Inc.

Robert Mecklenburg, D.D.S.
Indian Health Service
Health Services Administration

96

Antonio S. Medina, M.D., M.P.H.
School of Public Health
University of California, Berkeley

Marie C. Meglen, M.S., C.N.M.
Department of Health and Environmental Control
State of South Carolina

Harold R. Metcalf
Drug Enforcement Administration
Department of Justice

Anna Cay Milfeit
Health Systems Agency
Pittsburgh, Pennsylvania

Nancy Milio, Ph.D.
School of Nursing
The University of North Carolina at Chapel Hill

Joan M. Miller
Program Development Department
Blue Cross & Blue Shield Associations

*C. Arden Miller, MD.
School of Public Health
University of North Carolina

Anita Mills
Oﬂice of Dental Affairs
US. Public Health Service

Lloyd Millstein, Ph.D.
Food and Drug Administration

Jane Mitcham
School of Public Health
University of South Carolina

J. Henry Montes
Ofﬁce of Disease Prevention and Health Promotion

Debby Moore
Region IV—ACTION

*Lenora Moragne, Ph.D.
Nutrition Coordinating Ofﬁce
Department of Health and Human Services

Douglas H. Morgan, M.P.A.
Department of Health and Welfare
City of Newark

Gary E. Morigeau
Indian Health Service
Health Services Administration

Naomi M. Morris, MD.
University of Health Sciences
The Chicago Medical School

Robert F. Murphy
Sierra Club (New England)

Clayton R. Myers, Ph.D.
National Board of YMCAs
New York, New York

Kitty Naing, M.D.
Bureau of Community Health Services
Health Services Administration

Rose Navarro
American Public Health Association
Washington, DC.

Larry Needham, Ph.D.
Bureau .of Laboratories
Center for Disease Control

Jane W. Neese, Ph.D.
Bureau of Laboratories
Center for Disease Control

Mark Nelson, M.D.
Bureau of Epidemiology
Center for Disease Control

Elaine Nemoto
American Public Health Association
Washington, DC.

*Robert O. Nesheim, Ph.D.
The Quaker Oats Company

Stephen H. Newman, Ed.D.
Charlotte Drug Education Center
Charlotte, North Carolina

Ervin E. Nichols, M.D., FACOG
The American College of Obstetricians and Gynecologists
Washington, DC.

Patricia K. Nicol, MD.
Department for Human Resources
Commonwealth of Kentucky

Elena O. Nightingale, M.D., Ph.D.
Institute of Medicine
National Academy of Sciences

Joel L. Nitzkin, M.D.
Monroe County Department of Health
Rochester, New York

Arthur Norris
National Center for Toxicological Research
Food and Drug Administration

Cynthia Northrop, R.N., M.S., J .D.
Community Health Nursing
University of Maryland

Helen H. Nowlis, Ph.D.
Oﬂine of School Health
US. Ofﬁce of Education

Patricia O’Gorman
National Institute on Alcohol Abuse and Alcoholism
Alcohol, Drug Abuse, and Mental Health Administration

Godfrey Oakley, M.D.
Bureau of Epidemiology
Center for Disease Control

97

Robert E. Olson, M.D.
School of Medicine
St. Louis University Medical Center

Gilbert S. Omenn, M.D.
Ofﬁce ,of Management and Budget
Executive Ofﬁce of the President

Edward 0. Oswald
School of Public Health
University of South Carolina

Elizabeth Owen
Heritage, Conservation, and Recreation Service
US. Department of the Interior

Fran Owen, M.P.H.
South Carolina Department of Health and Environmental
Control

George M. Owen, M.D.
School of Public Health
University of Michigan

Richard L. Parker, D.V.M., M.P.H.

Bureau of Epidemiology

South Carolina Department of Health and Environmental
Control

Russ Pate
School of Public Health
University of South Carolina

Linwood J. Pearson, MD.
Department of Health
Commonwealth of Pennsylvania

A.M. Pearson
Department of Food Science and Human Nutrition
Michigan State University

Terry F. Pechacek, Ph.D.
School of Public Health
University of Minnesota

Barbara Perman
Yale University

*Thomas F. A. Plaut, Ph.D.
National Institute of Mental Health
National Institutes of Health

Richard N. Podell, M.D., M.P.H.
Overlook 'Family Practice Association
Overlook Hospital (Summit, NJ)

Michael R. Pollard
Ofﬁce of Policy Planning and Evaluation
Federal Trade Commission

Marion B. Pollock, Ed.D.
Department of Health Science
California State University

Lawrence E. Posey
Bureau of Health Education
Center for Disease Control

E. Charlton Prather, MD.
Department of Health and Rehabilitative Services
State of Florida

Richard A. Prescott
Health Systems Agency of South Central Connecticut

Shirley S. Preston
American Cancer Society

James H. Price, Ph.D., M.P.H., FASHA
Department of Health and Safety Education
Kent State University

Jeanne M. Priester
U.S. Department of Agriculture

Milton Puziss, Ph.D.
National Institute of Allergy and Infectious Diseases
National Institutes of Health

David L. Rabin, M.D., M.P.H.
Georgetown University School of Medicine
Washington, DC.

David E. Raley
Directorate of Aerospace Safety
Department of Defense

John Rankin, M.D.
School of Medicine
University of Wisconsin

Gil Ratcliff, Jr., MD.
West Virginia Committee for Perinatal Health

H. Dickinson Rathbun
Christian Science Committee on Publications
Boston, Massachusetts

Elizabeth B. Rawlins
Simmons College

William E. Rawls, MD.
Department of Pathology
McMasters University

Jack Recht
National Safety Council

James Q. Regnier
Blue Cross and Blue Shield of Minnesota

*Robert L. Retka
National Institute on Drug Abuse
U.S. Public Health Service

Gladys H. Reynolds, Ph.D.
Bureau of State Services
Center for Disease Control

Y.B. Rhee
US Public Health Service, Region VII

Anne M. Rhome, M.P.H., R.N.
American Nurses’ Association
. Houston, Texas

Gina Ries, R.D.
Iowa State Department of Health

98

Elizabeth W. Riggs, R.N., CNM
Georgia Department of Human Resources
Atlanta, Georgia

Adonna A. Riley
Commission on Health and Welfare
National PTA

David Rimland, M D.
VA. Medical Center
Decatur, Georgia

William P. Ringo, Ph.D.
Birmingham Regional Health Systems Agency
Birmingham, Alabama

Hania W. Ris, MD.
Department of Pediatrics
University of Wisconsin Medical School

Sherrill W. Ritter, Jr.
Ofﬁce of Human Development Services
Department of Health and Human Services

Hilda H. Robbins
Mental Health Association
Arlington, Virginia

Frances T. Roberts
Ofﬁce of Child Day Care
State of Connecticut

Susan Roberts, R.D.
Iowa {State Department of Health

H. Clay Roberts
Educational Service District #121
Seattle, Washington

Jack Robertson, D.D.S.
Ofﬁce of Dental Affairs
U.S. Public Health Service

Donald H. Robinson, M.D.
South Carolina Department of Health and Environmental
Control

Edward Roccella, Ph.D.
National Heart, Lung, and Blood Institute
National Institutes of Health

Roger W. Rochat, M.D.
Bureau of Epidemiology
Center for Disease Control

Ava Rodgers, Ph.D.
Science and Education Administration—Extension
U.S. Department of Agriculture

Maria L. Rodriguez

Guadalupe Family Health Clinic
Toledo, Ohio

Milton I. Roemer, M.D.

School of Public Health

University of California, Los Angeles

Vincent C. Rogers, D.D.S., M.P.H.
Bureau of Dental Care

William N. Rom, M.D., M.P.H.
College of Medicine
University of Utah

*Judith P. Rooks
Ofﬁce of Population Affairs
US. Public Health Service

William L. Roper, M.D.
Jefferson County Health Department
Birmingham, Alabama

Patricia F. Roseleigh, R.D., M.S.
Indian Health Service
Health Services Administration

Gerald Rosenthal, Ph.D.
National Center for Health Services Research

John Roskis, Pharm. D.
Mercer University Southern
Atlanta, Georgia

Jeannie II. Rosoﬂ
Alan Guttmacher Institute

Sheldon Rovin, D.D.S., M.S.
V.A. Scholars Program
Washington, DC.

George Rubin, MD.
Bureau of Epidemiology
Center for Disease Control

David D. Rutstein, M.D.
Countway Library
Harvard University

Ronald K. St. John, MD.
Bureau of State Services
Center for Disease Control

James H. Sammons, M.D.
American Medical Association
Chicago, Illinois

Joseph Sampugna
Department of Chemistry
University of Maryland

Anthony V. Sardinas, M.A., M.P.H.
Ofﬁce of Public Health

State of Connecticut

Roger Sargent

School of Public Health
University of South Carolina

John W. Scanlon, M.D.

Columbia Hospital for Women

Washington, DC.

William Schaffner, M.D.

Departments of Medicine and Preventive Medicine
Vanderbilt University Hospital

Renee Schick
Capital Systems Group
Rockville, Maryland

99

Roger Schmidt
American Lung Association

Stephen C. Schoenbaum, M.D.
Peter Bent Brigham Hospital
Boston, Massachusetts

James A. Schoenberger, M.D.
Rush-Presbyterian-St. Luke’s Medical Center
Chicago, Illinois

Marc Schuckit, M.D.
Veterans Administration Hospital
San Diego, California

Myron G. Schultz, M.D.
Bureau of Epidemiology
Center for Disease Control

Catherine Schutt, R.N., M.S.
Union Hospital
Lynn, Massachusetts

Barbara Scott, R.D., M.P.H.
Division of Health
Nevada Department of Human Resources

Robert H. Selwitz, D.D.S., M.P.H.
Region III
Department of Health and Human Services

John C. Sessler, Ph.D.
Ofﬁce of Health Planning and Evaluation
US. Public Health Service

Iris R. Shannon, R.N., M.S.
American Public Health Association

Alvin P. Shapiro, MD.
Department of Medicine
University of Pittsburgh School of Medicine

Marion Sheehan
Metropolitan Life

Susan B. Shelton
Bureau of Training
Center for Disease Control

Cecil Sheps, M.D.
Health Services Research Center
University of North Carolina

Edward Shmunes
School of Public Health
University of South Carolina

Clyde E. Shorey, Jr.
The National Foundation March of Dimes

Naseeb L. Shory, D.D.S.
Bureau of Dental Health
Alabama Department of Public Health

Carole J. Sieverson
Metropolitan Health Board
St. Paul, Minnesota

Artemis P. Simopoulos, M.D.
Nutrition Coordinating Committee
National Institutes of Health

Louis Slesin, Ph.D.
Natural Resource Defense Council

John Scott Small
National Institute of Dental Research
National Institutes of Health

Jessie M. Smallwood
Health Systems Agency, Inc.
New Orleans, Louisiana

Johnnie W. Smith
South Carolina Department of Health and Environmental
Control

*W. McFate Smith, MD.
Department of Medicine
University of California at San Francisco

Roy G. Smith, MD.
School of Public Health
Univeresity of Hawaii at Manoa

James M. Sontag, Ph.D.
National Cancer Institute
National Institutes of Health

Harrison C. Spencer, M.D.'
Bureau of Tropical Diseases
Center for Disease Control

Dick Spruyt, MD.
Division of Health Services
North Carolina Department of Human Resources

Harry Stafﬁleno, J r., D.D.S.
The American Academy of Periodontology

Rose Stamler
The Medical School
Northwestern University

Charles S. (Jack) Stanley
Bureau of Training
Center for Disease Control

Fredrick J. Stare, M.D.
School of Public Health
Harvard University

William B. Stason, M.D.
School of Public Health
Harvard University

Chedwah J. Stein, MS, RD.

Nutrition Unit

Oregon State Health Division

Jeanne M. Stellman, Ph.D.

Women’s Occupational Health Resource Center
American Health Foundation

Pauline G. Stitt, M.D.
School of Public Health
University of Hawaii at Manoa

100

T. Wayne Stott
National Family Planning and Reproductive Health
Association

Angela Strickland
American Public Health Association

David F. Striﬂier, D.D.S.
School of Public Health
University of Michigan

Phyllis E. Stubbs, MD.
Baltimore City Health Department

A. T. Sturdivant
Atlanta Area Oﬂice
Consumer Product Safety Commission

Mary E. Sullivan
Bureau of Health Education
Center for Disease Control

Jim Summers
Metairie, Louisiana

John David Suomi, D.D.S.
Oﬂice of Dental Affairs
US. Public Health Service

Juris M. Svarcberg, D.M.D., M.P.H.
Henry J. Austin Health Center
Trenton, New Jersey

*Glen Swengros
President’s Council on Physical Fitness and Sports

Donald A. Swetter, M.D.
Indian Health Service
Health Services Administration

C. Barr Taylor, MD.
Department of Psychiatry and Behavior Science
Stanford Medical Center

L. David Taylor
Oﬂice of the Secretary
Department of Health and Human Services

Andy Tepper—Rasmussen
Oklahoma Health Systems Agency, Inc. '

Stephen Teret, J.D.
School of Hygiene and Public Health
Johns Hopkins University

*Stephen Thacker, M.D.
Bureau of Epidemiology
Center for Disease Control

Caroline B. Thomas, MD.
School of Medicine
Johns Hopkins University

Flora L. Thong
Department of Health
State of Hawaii

Hugh H. Tilson, M.D.
North Carolina Division of Health Services

Marian Tompson
La Leche League International

Carl W. Tyler, Jr., MD.
Bureau of Epidemiology
Center for Disease Control

Louise B. Tyrer, M.D.
Planned Parenthood Federation of America, Inc.

John E. Vanderveen, Ph.D.
Division of Nutrition
Food and Drug Administration

Betty Vanta, R..D.
Georgia State University
Atlanta, Georgia

Jamese D. Vargo, M.D.
VA Medical Center
Decatur, Georgia

*Tom M. Vernon, M.D.
Colorado Department of Health

Murray Vincent
School of Public Health
University of South Carolina

John R. Viren, Ph.D.
Ofﬁce of Health and Environmental Research
US. Department of Energy

Frank J. Vocci, Ph.D.
Drug Abuse Staff
Food and Drug Administration

Thomas M. Vogt, M.D., M.P.H.
Kaiser Foundation Hospitals
Portland, Oregon

Jane Voicheck, Ph.D.
Science and Education Administration—Extension
US Department of Agriculture

Hiawatha B. Walker, Ph.D.
School of Public and Allied Health
East Tennessee State University

Lawrence M. Wallack, M.S.
School of Public Health
University of California, Berkeley

Julian A. Waller, M.D.
Dpartment of Epidemiology and Environmental Health
University of Vermont Medical School

Elli Walters
Environmental Policy Institute

Virginia Li Wang, Ph.D.
School of Hygiene and Public Health
Johns Hopkins University

101

*Graham Ward
National Heart, Lung and Blood Institute
National Institutes of Health

Beverly G. Ware, Dr. P.H.
Ford Motor Company

Kenneth E. Warner, Ph.D.
School of Public Health
University of Michigan

*David H. Wegman, M.D.
School of Public Health
Harvard University

John H. Weisburger, Ph.D.
American Health Foundation
Naylor Dana Institute for Disease Prevention

Jerrold L. Wheaton, M.D.
Riverside County Health Department
Riverside, California

Patricia F. Whitmore, M.S.W.
Department of Mental Health/ Mental Retardation
State of Tennessee

Paul J. Wiesner, M.D.
Bureau of State Services
Center for Disease Control

K.D. Wiggers
Iowa State University of Science and Technology

Charlotte Wilen
Select Panel for the Promotion of Child Health

Jean C. Wilford
Bureau of Training
Center for Disease Control

Jane Williams
Environmental Policy Institute

*Jack Wilmore, Ph.D. _
Department of Physical Education and Athletics
University of Arizona

Ronald W. Wilson
Division of Analysis
National Center for Health Statistics

John J. Witte, M.D.
Bureau of Health Education
Center for Disease Control

Ilene Wolcott, Ma.Ed.
Women and Health Round Table
Washington, DC.

Frederick S. Wolf, M.D.
Alabama Department of Public Health

Joan M. Wolle
Health Education Center
Maryland Department of Health and Mental Hygiene

George J. Wolnez, C.S.P., P.E.
Sanderson Safety Supply
Portland, Oregon

Sidney Wolverton
Division of Prevention
Alcohol, Drug Abuse, and Mental Health Administration

Catherline Woteki, Ph.D.
Ofﬁce of Technology Assessment
US. Congress

102

William L. Yarber, HSD
Department of Health Education
Purdue University

Eleanor A. Young, Ph.D.
Department of Medicine
University of Texas Health Science Center

Steven Ziﬁerblatt, Ph.D.
National Heart, Lung, and Blood Institute
National Institute of Health

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