A decade of health progress… or not

By some measures, Americans are healthier than they were a decade ago. But there’s still a considerable way to go, suggests a preliminary assessment of the Healthy People 2010 initiative.

Yes, it’s 2010 already, and the U.S. Department of Health and Human Services is starting to analyze the progress made over the past decade toward the goals set forth on the Healthy People agenda. The results are decidedly mixed: A series of reviews by the National Center for Health Statistics found that among 635 of nearly 1,000 Healthy People goals for the past decade, only 117 of the targets had been met, and there actually was backsliding on nearly one-fourth of the goals.

Although it’s too soon to know how the final report will look, it appears as if about 20 percent of the overall goals have been achieved. There has been backsliding here as well: In 1990, about 41 percent of the measurable goals were achieved; in 2000, it was 24 percent.

To back up for a minute, the Healthy People initiative was started in the late 1970s. The idea was to set a national public health agenda and provide a framework for developing health initiatives at state and local levels. Ultimately, the goal is to achieve longer, healthier lives for Americans and eliminate disparities in health status.

Needless to say, this is a pretty ambitious undertaking. Over the years the Healthy People objectives have morphed into an increasingly broad agenda that includes hundreds of targets in areas ranging from cancer and diabetes to occupational safety, mental health and family planning.

At first glance, it’s disappointing there hasn’t been more progress. For instance, one of the 2010 goals was to reduce the number of adults with high blood pressure from 28 percent to 16 percent. According to the most recent data, however, not only did Healthy People 2010 fail to reach this goal but the incidence of hypertension among American adults actually increased to 29 percent. The number of caesarean sections went up, not down, and the percentage of premature births also increased.

It’s not entirely clear how these numbers should be interpreted. For one thing, they’re an average. If you break down the data by individual states, differences in performance begin to emerge, with some states doing well on some of these measures and others doing not so well. The same goes for demographic subgroups such as rural Americans and populations of color.

I’d also be curious to know how the indicators tracked from one year to the next. If they worsened, as in the case of hypertension, was this a continual trend across the decade, or did most of the backsliding occur within the span of a year or two? The link between income levels and health status has been well documented, and it’s entirely possible that the recession of the past couple of years, coupled with unemployment, loss of health insurance and tight household budgets, may have undone whatever progress was achieved earlier in the decade. Indeed, many aspects of health are closely interwoven, and it’s often hard to make progress in a single area without addressing other things too, some of which may simply be out of our control.

There’s a certain amount of human behavior involved as well – and changing people’s behavior has always been notoriously challenging. Getting more Americans to be physically active, for instance, isn’t just a matter of telling them to be active and assuming they’ll do it. It requires people to make changes in their behavior that are not only conscious but sustained. It also generally requires a supportive environment; someone who lives in an unsafe neighborhood, for example, is probably going to be less likely to walk for daily exercise. Although many of us would like to think we’d all be healthier if we just tried harder, the reality is that it’s not always this easy.

If I have a criticism of the Healthy People initiative, it’s that it’s just too large and ambitious. A decade doesn’t seem long enough to accomplish hundreds of public health goals, let alone address how to sustain any progress that might be made. The initiative unfortunately comes with zero funding to implement any of it. It’s also fuzzy around the edges when it comes to explaining how state and local agencies and providers are actually supposed to achieve any of the targets.

That said, we all need goals, otherwise we have nothing to aim for and no way of measuring progress in the journey. Healthy People 2010 has in fact resulted in health improvements. The rate of childhood vaccinations is up, fewer Americans are dying of cancer and workplaces have become safer. All told, some degree of progress has been measurably achieved on 70 percent of the Healthy People 2010 objectives.

And we always have a chance to try again. Work has already started on developing the goals for Healthy People 2020. Most of the targets are unlikely to change, but many of the goals will be refined, expanded and perhaps modified to reflect emerging concerns and new evidence-based knowledge. There’ll be another new decade during which we can hope to keep doing better.

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