1990 Keynote Address

Health for All: A Public HealthVision*William H. McBeath, MD, MPH

L Introduction

John MacBeath's Regimen Sanitatis

In the early 16th century, John Mac-Beath resided in the Hebrides off the westcoast of Scotland where he was physicianto the Lord of the Isles. There he compileda Gaelic medical manuscript entitled Reg-imen Sanitatis, or the Rule of Health.1 Hismanuscript affirms that the first two rulesof health are (1) it is right to guard thehealthy state in healthy persons and (2) itis duty to foresee those going into un-health. That's how they said "health pro-motion and disease prevention" in medie-val times.

The manuscript goes on to addressseveral important aspects of contempo-rary Highlands practice, such as bloodlet-ting and religious observance; but its maintheme is healthful living, especially properdiet. One of its many aphorisms is "havea cheerful mind, a moderate diet, and takeexercise."

It includes a delightful Scottishmorning health routine, whichgoes:upon arising, one should* first stretch the arms andchest

* expel the superfluities* wash hands, face, andeyes

* rub the teeth* make moderate walking inhigh clean places

* take food, after exercise

(I suppose it's a little "clannish" forme to refer to "Uncle John's" work, butafter 400 years, he's otherwise not muchcited.)

Theme: "Forging the Future:Health Objectives for the Year2000"

This year our annual meeting pro-gram theme is "Forging the Future:Health Objectives for the Year 2000." It isa rich theme, calling us to move forwardboldly with both purpose and force-purpose guided by the goals we define,and force arising from a commitment toshape the future that can be. It's been saidthat goals and objectives are descriptionsof the future we desire.2 In future-orientedendeavors like disease prevention andhealth promotion, these targets can moti-vate action and give direction to interven-tions.

This morning, let us consider to-gether a bold vision for budding a greathealth future for the public and the goalswe choose to describe it.

Envisioning the Future-2000 asMetaphor

It is the nature of public health tosearch out the causes of "unhealth" in thecommunity so as to prevent them, and todiscern the determinants of health so as topromote them. Periodically, we make spe-cial concerted efforts to "foresee un-health" that can be expected and to"guard health" that can be achieved. Weplan ahead.

William H. McBeath is the Executive Directorof the American Public Health Association. Re-quests for reprints should be sent to William H.McBeath, Executive Director, American Pub-lic Health Association, 1015 Fifteenth Street,Washington, DC 20005.

*This Convention Keynote Address and15th Margaret Baggett Dolan Lecture was pre-sented on October 1, 1990, during the OpeningGeneral Session of the 118th Annual Meeting ofthe American Public Health Association inNew York City.

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1990 Keynote Address

Annual reports and 5-year plansabound. The close of each decade invitesus to mark its passage with a review ofpast perfornance and a preview of futureprospects; even more so the coming andgoing of a century. But now we sense theapproaching oftheyear 2000-a milestoneof monumental symbolic importance. Foryears our imagination has been drawn tothoughts of "the 21st century." "2000"and "2001" have become metaphors for anascent future ofvast potential, emergingwith dramatic possibilities for weal or forwoe. In the imagery of biblical language,the dawning of a new millennium excitesvisions of a new and golden age of prom-ise.3 And that apocalyptic literature alsoprovides the motto on the APHA seal-"and the leaves of the tree were for thehealing of the nations."

Today's World Health Needs

As this new epoch approaches, thenations of the earth are in great need ofhealing.

* Tuberculosis is raging with 1.7 bil-lion of the world's inhabitants now in-fected, 20 million with active disease, and3 million dying annually.4

* Malaria is staging a comebackwith270 million cases in some hundred coun-tries putting at risk about40% ofthe worldpopulation.4

* Throughout the world, at least 8million people have HIV infection. Morethan half of these will develop AIDSwithin the decade. Nearly a half millionare already ill with HIV disease.4

* In the developing countries, everyminute six children under 5 years die andanother six are seriously disabled fromone of the six diseases that can be pre-vented by immunization: diphtheria,whooping cough, tetanus, measles, polio,and tuberculosis. That's three and a quar-ter million preventable child deaths a year.Another three and a half million such chil-dren die each year from acute diarrhea-the largest single cause of death of youngchildren.5

* Worldwide eradication of polio istechnically possible by the year 2000, but200 000 new cases are still being reportedannually.4

* The killer diseases of western af-fluence are spreading, with cardiovasculardisease and cancer now accounting, re-spectively, for 12 million and 5 milliondeaths annually worldwide.4

* Unless global spread ofthe "brownplague" is reversed, 500 million personsliving today will be killed by a singledrug-tobacco.4

* WHO reports that if current trendscontinue, 200 million people may die pre-maturely from preventable causes in the1990s.4

* At UNICEF's World Summit forChildren, which is closing today in thiscity, reports indicate 15 million childrenunder 5 die each year, most from prevent-able causes.

II. Prevention Renaissance ofthe 1970s

There is reason to hope these trendswill be improved, in part because of am-bitious global efforts led by WHO andUNICEF,6 and in part because of a veri-table renaissance of national preventioninitiatives that emerged during the 1970s.

1974-Lalonde's A New Perspectiveon the Health of Canadians

In 1974, the Canadian Minister ofHealth and Welfare issued a working pa-per entitled A New Perspective on theHealth of Canadians. 7 It became a clas-sic. While acknowledging the Canadianhealth care system as "the equal of any inthe world," the Lalonde report drew at-tention to other determinants of Canadianhealth which were "of equal or greaterimportance." Health determinants wereportrayed in the now popular "health fieldconcept" with its elements of human bi-ology, environment, life-style, and healthcare organization.

1974-1976-DHEW's Forward Planfor Health

In the same year (1974) our US De-partment of Health, Education and Wel-fare published a Forward Plan forHealth-FY 1977418 with the depart-ment's 5-year projection for health pro-gramming. The major theme or emphasisarea of the plan was prevention.

1976-UK's Prevention & Health:Everybody's Business

In British fashion, the government ofthe United Kingdom launched its preven-tion renaissance with a Parliamentary"white paper" on prevention, followed in1976 by a popular health department doc-ument: Prevention and Health: Every-body's Business. 9

1978-CDC's National StrategyforDisease Prevention

Back in the United States, the Cen-ters for Disease Control (CDC) was vig-orously asserting its role as lead federalagency for prevention. In 1977, CDC pub-lished proportional allocations of the con-tributing factors of mortality to Lalonde'sfour "health field elements."10 This pro-duced the often-cited observation that, inthe United States, about 50% of prema-ture mortality is deemed attributable tolife-style, 20% to human biology, 20% toenvironment, and 10% to health care. Thenext year CDC published Recommenda-tions for a National Strategyfor DiseasePrevention, 11 which prioritized 31 impor-tant preventable health problems in thefields of environment, life-style, and med-ical services-in effect, predicting the out-line of today's national health objectives.

1979- PHAP's Model Standards

Earlier, CDC began collaborationwithAPHAand the national organizationsof state and local health officials to de-velop "model standards" for community-oriented preventive health services. In lo-cal application, the standards take theform of quantifiable community-specificobjectives for reducing present levels ofpreventable morbidity and mortality.

The HEW secretary officially sub-mitted the first volume of Model Stan-dards to the Congress in 1979. CDC hascontinued support for the model standardswork group to test, refine, and expand thestandards. A second editionl2 was pub-lished byAPHA in 1985 and is now in usein scores oflocal and state agencies acrossthe country. A third edition of the modelstandards, entitled Healthy Communities2000,13 will be published in a few monthsas the local implementation companion toHealthy People 2000.14

1977-WHO's Global StrategyforHealth forAll by the Year 2000

During this period, the preventioninitiative of grandest scale was interna-tional.15 In 1977, the World Health As-sembly resolved that "the main social tar-get of governments and WHO in thecoming decades should be the attainmentby all citizens of the world by the year2000 of a level of health that will permitthem to lead a socially and economicallyproductive life."'5'P15)

A major means toward the attain-ment of this goal has been the promotionof primary health care, newly defined as"essential basic health services," made

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1990 Kynote Address

accessible to everyone, given in away ac-ceptable to individuals, families, and com-munities, requiring their full participation,and provided at a cost the community canafford.

Essential health services weredeemed to be basic environmental sanita-tion, adequate supply of safe water, pro-motion ofproper nutrition, control of localendemic disease, health education, familyplanning services, maternal and childcare, immunization against major dis-eases, and treatment forcommon diseasesand injuries.

Each WHO member state was in-vited to formulate "national policies,strategies, and plans of action" for attain-ing the Health for All 2000 goals, andmany have. Particularly in developingcountries these national plans build on thenew "primary health care." Among de-veloped countries, several governmentsdemonstrating a heightened interest inprevention programming have adopted oradapted features from the Health for All2000 movement.

Although our US government sup-ported initiation of the Health for All 2000programs, over the last several years thiscountry has violated its treaty obligationsand withheld over $150 million of its basicdues to WHO.

There is evidence the world healthsituation has been improving in recentyears. For example, life expectancy hasrisen in the developing countries, nowstanding at almost 60 years (compared to73.4 years in the developed countries).The proportion of the world's children re-ceiving immunizations hasgrown from5%to 60% during the last decade.

HI. Heal Pmmoion in the1980s1979-Swgeon General's HealthyPeople

Today in the United States, a majorstream of Public Health Service preven-tion activity flows from the 1979 surgeongeneral's report on health promotion anddisease prevention, entitled Healthy Peo-ple.16 That report declared health goals forAmerican infants, children, youth, adults,and elderly, and proposed 15 "actions forhealth."HealthyPeople became the basisand guide for expanded Public Health Ser-vice activities in health promotion and dis-ease prevention throughout the 1980s. Thecenterpiece of that effort was to be the"national health objectives."

1980-Promoting Health, PreventingDisease: Objectives for the Nation

For 1990, there were 226 specific andquantifiable objectives deemed necessaryto attain the goals established in HealthyPeople, covering all priority areas. Theywere published in 1980 as PromotingHealth, Preventing Disease: Objectivesfor the Nation,17 and immediately beganto draw both praise and criticism. Overtime, the 1990 objectives gained wide ac-ceptance and official standing within thehealth field, their value increasingly dem-onstrated by reference and use amongpublic health professionals.

Assessment at middecade18,19showed that about half the objectiveswould probably be achieved by 1990, onefourth would probably not be achieved,and one fourth still could notbe measured.

* How shall we interpret such re-sults?

* Were some objectives set too highor too low?

* Was the effort to achieve them suf-ficient?

* For each objective, were the ef-fects achieved proportionate to effort ex-pended?

* Were the best objectives chosen?* Were important objectives omit-

ted?* In the end, was more disease pre-

vented and better health promoted be-cause these objectives existed?

IV. Health Objectivesfor the1990-sHealthy People 2000Pro: Suvival and Continuation

That these initial objectives survivedthe difficult 1980s relatively intact is onemeasure of their success. So is the con-tinuing interest and involvement dis-played in preparation of the new nationalhealth objectives for the year 2000.

Pro: The Development ProcessThree years ago, the decision to ad-

vance to a second generation of decadeobjectives launched an arduous, multi-stage, deliberative process that included22 expert working groups, regional andnational hearings, and review and com-ment by a consortium of 300 national or-ganizations, includingAPHA, several fed-eral agencies, and all state healthdepartments.

Regrettably, in a recent move thatshows callous disregard for the consensusopinion of hundreds of professionals who

participated in that review process, keyadministration officials have arbitrarilydeleted and diluted several important ob-jectives from the review draft at the lastmoment, rather than displease powerfulcorporate interests and far right extrem-ists.APHAhas already petitioned the sec-retary to respect the professional reviewprocess and to restore objectives on guncontrol, family planning, and tobacco totheir postreview wording.

The development phase culminatedearlier this month when the new objec-tives were introduced to the public at anational Washington conference called forthat purpose.

Pm: Three Broad National GoalsBy most measures, Healthy People

2000: National Health Promotion andDisease Prevention Objectivesl4 is a ma-jor accomplishment with many positiveattributes.

Most notably, it begins with threebroad national health goals for the decade:

* increasing the span of healthy lifefor Americans

* reducing health disparities amongAmericans

* achieving access to preventiveservices for all AmericansThese are worthy goals, which deserveour support and should challenge our pro-fessional commitment.

Pmo: T7e Aura of OfficialAdoptionFederal endorsement of these goals

and objectives lends importance to themas national priorities. The whole objec-tives process and the resulting documentwill raise professional and public con-sciousness of important national healthneeds.

Pro: Succinct and Tangible Plew ofProblems

For the year 2000, there are 298unique objectives in 22 priority areas,showing a balance between outcome andprocess measures. The brevity and clarityof most objectives give a concrete realityto health problems and potentials and willequip various publics to appreciate andembrace prevention goals.

Pm: Toolfor Health ProgramDevelopment

The broad range and targeted natureof the objectives provides an importanttool for program development by provid-ing national validation of local effort andfor program evaluation by providing com-

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1990 Keynote Address

parative measures to justify support, tomonitor progress, and to revise course ifindicated.

Pro: Continuing Platform for PublicAccountability

Assurance of a second cycle tends toinstitutionalize an ongoing objectives pro-cess that will remain open for continuingdialogue. This will encourage and equippublic accountability by providing refer-ence standards for affirming or challenginggovernmental plans and actions.

Because they are goals for the nationthat is APHA's home, and because theyare being made public so close to thismeeting, you can expect to hear muchanalysis and criticism of Healthy People2000 throughout this week. Sessions willprobe the special interests of each APHAsection, and subplenary special sessionswill afford a rare opportunity for all of usto be oriented and challenged. Also re-member thatAPHA is not only this annualmeeting; it is your collective professionalpresence throughout the year. In themonths ahead, our Program DevelopmentBoard will be undertaking a more defini-tive review of Healthy People 2000, withall APHA components participating.

Because Healthy People 2000 is sobig and so new, most comments on theobjectives will have to await more delib-erate review; but it is already clear thatHealthy People 2000 will be an imperfectguide for forging the health future in thenext decade.

Con: No Action ImplementationPlan

It has been said that perfection ofmeans and confusion ofgoals characterizeour age. Healthy People 2000 can claim toclarify our confusion of goals, but it con-tributes little to a perfection ofour means.Wanting is an action plan for implemen-tation to achieve the goals and objectivesset. The document seems to draw us apicture of the "Emerald City," but nevershows us a "yellow brick road." The ob-jectives themselves deserve more. Theydeserve clear delineation of actions re-quired to achieve them; and they deservecareful projection of the resources andcollective effort required to support them.

Compared with other national pre-vention plans mentioned earlier, HealthyPeople 2000 must be given a grade of "in-complete" because it lacks a coherent im-plementation scheme or action agenda.

In 1974, the Lalonde report closedwith 74 specific proposals for national gov-

emmental action in health promotion, reg-ulation, research, health care, and goal set-ting.

Fifteen years ago, during the Nixonadministration, DHEW's Forward Planfor Health8 proposed 83 specific "optionsfor action"-over half of them in the cat-egories of "legislation, enforcement, andregulation," and "social and economic in-centives." That Fonvard Plan revealed astronger leaning toward assertive govern-mental action for health than can readilybe discerned in departmental pronounce-ments of the 1980s.

CDC'sNationalStrategyforDiseasePrevention"1 in 1978 recommended 115major steps for intervening on high prior-ity health problems. Almost all of themcalled for governmental implementationactions by CDC with other federal, state,and local health agencies.

The potential ofHealthy People 2000is sold short by the Administration's timid-ity to address the tough issues involvedwith implementation. In a 672-page docu-ment, no space is found to call for increasedfunding. It may be said that was not theintent of the objectives process. If so, ourfederal health leadership owes us a corol-lary effort immediately. As it stands,Healthy People 2000 may be filled withgood stuff; but it is a cup half empty.

Con: Overemphasis on IndividualResponsibility

A second major problem withHealthy People 2000 is its pervasive over-emphasis on individual responsibility forhealth. Since Lalonde popularized theterm "life-style" in referring to the healtheffects of human behavior patterns, manyhave reinforced and compounded the er-roneous assumption that personal behav-ior is largely subject to voluntary controlby individual choice.

Of course, the major fallacy in thatassumption is that one's life-style is al-ways heavily influenced by one's life sit-uation. As public health people, we knowbetter, and we must say so.

To a large extent, health depends onthe political, social, cultural, economic,and physical environments in which welive. These environments can and do limitthe health choices open to any of us, andthey are increasingly influenced by publicpolicy and corporate practices which con-trol or promote products that damagehealth. For many, their life environmentdoes not encourage capacities nor affordopportunities for adopting healthy life-styles.

If you

have decent air to breathe,live in a low-crime neighborhood,have a meaningful job with ade-

quate pay,work in a safe environment,have money to choose good foodand time to enjoy preparing it,

can afford to take vacations,have a safe place for your children

to play,enjoy life and look forward to the

future;then (maybe) you can choose

health.20

Millions of Americans have no suchchoice.

Certainly individuals have a duty toact in the best interest of their own health,but we also share a community obligationto act collectively for the health of all. Thelatter is largely ignored in most health pro-motion efforts in this country today.

Con: An Abrogation ofGovernmental Responsibility inHealth

"While interest (in prevention) ishigher and commitment greater than it hasever been, the organization of public re-sources to prevent the dependency asso-ciated with disease and injury has not metthe challenges of the end of the twentiethand the beginning of the twenty-firstcentury. "2l(p95)

One thing is clear, in this country wehave seen a broad scale retreat of govern-ment from public health over this period.One status quo ante underlying HealthyPeople 2000 is neglect of support forAmerica's public health infrastructure.Although state and local health depart-ments are called upon to help reach theobjectives, their limited resources andbudgetary needs are ignored. This silenceonly encourages the continuing erosion oflocal public health support in this country.

An ambitious initiative led by the As-sociation of State and Territorial HealthOfficials intends to tie the year 2000 ob-jectives to a new federal/state program de-signed to attain them. The Health Objec-tives 2000Act will fund disease preventionand health promotion programs aimed atpriority objectives of states and localities.

Is it coincidence that over the last 15years national prevention initiatives em-phasizing individual responsibility haveparalleled the rise of conservative govern-ments seeldng to reduce public expendi-tures and privatize, even commercialize,the delivery of health services, e.g., inCanada, the United States, and the United

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1990 Keynoe Address

Kingdom? In a time of rising health carecosts and tight budgets, itmayseem cheapand expedient for governments to "blamethe victims" by preaching individual life-style change. It certainly would be moredemanding to adopt "healthy public poli-cies" that make "the right choices, theeasy choices." It's also clearly more ex-pensive in the short run to adequately fundhealth service programs.

Elsewhere: A New HealthPromotion and the New PublicHealth"

In parts ofCanada, Great Britain, andScandinavia, governmental and privategroups are repenting of exaggerated stresson individual life-style, and embracing anexpanded concept of health promotion.22It emphasizes active public participationin the adoption of multisectoral healthypublic policies to create supportive envi-ronments that potentiate the determinantsof health.23,24 The result is health promo-tion affirming a community life-style thatmakes "healthy choices" the "easychoices." This new public health recog-nizes that most influences on health liebeyond the reach ofmedical care and pub-lic health education.25 It redirects our en-ergies to the importance of policies thatpromote public action toward improvingthe several aspects of ordinary daily lifethat are the real precursors to health.

V. Health Prio,itesfor the 21stCentuy

Some have expressed disappointmentthat no definitive national priorities wereadvanced from among the objectives for1990 or 2000. The broad participation of somany specalized interests in developingthis inclusive list of objectives would havemade it difficult to reach consensus on afew ranked priorities, even if that had beenan intended outcome of the process.(APHA, with its diverse interests and mul-tiple intentions, has a similar problem.)

Top Ptiority: Health EquityBut the absence of priorities invites

others to propose their own. I believe ourtop priority in the decade ahead, as anassociation, as public health profession-als, and as a nation, must be the pursuit ofhealth equity.

The WHO constitution says: "Theenjoyment of the highest attainable stan-dard of health is one of the fundamentalrights of every human being without dis-tinction of race, religion, political belief,

economic or social condition."26(Pl) It'sbeen over 40years since the United Statessigned that treaty. Still, for too manyAmericans, that "fundamental right" istoday an empty phrase, a false hope, anda broken promise. In the decade aheadwemust move vigorously to make health afundamental right in this country, and nota fundamental wrong.

Remember that one of the threebroad national goals espoused byHealthyPeople 2000 is to "reduce health dispari-ties among Americans." We also com-mend the way it assesses several healthdisparities by income level, educationalattainment, and race and ethnicity, andsets special population targets for severalobjectives. It is left for us to proclaimthese health gaps as an indictment againstour society-and declare our determina-tion to address this intolerable injusticewhich somehow we continue to tolerate.

The topic for this year's nationalDelta Omega essay contest is "PublicHealth as Social Justice." If public healthis social justice, we must dare to dream ofequity in health by the 21st century. Allhuman beings must be assured equal ac-cess to health opportunity. The presentinequalities in group health status are un-acceptable because they largely reflect un-bearable social inequities in the distribu-tion of food, housing, education,employment, income, and medical care-inequities that are inexcusable in an afflu-ent, democratic society. They must be re-dressed as fast and as far as possible.

Piority: A National HealthProgram

Few will be surprised that HealthyPeople 2000 did not call for a nationalhealth program with universal coverageand comprehensive benefits; but no oneshould be surprised that such a program isa primary APHA objective for this dec-ade. We want a national health programfor everyone-one that responds to indi-vidual needs, emphasizes prevention, anddoes not discriminate.27 We will seek noless, and we want it now.

As time passes, Medicare pays forless, Medicaid covers fewer people, pri-vate health insurance costs more, and in-creasing millions of Americans still haveno health care protection at all. Shame onanymember ofCongresswho runs on spe-cial interest money, bails outS&L crooks,and then freezes out support for decenthealth care.

To its credit, as another of its broadnational goals, Healthy People 2000 seeksto "achieve access to preventive services

for all Americans." That very desirablegoal and its related objectives specificallycall for the financing of services recom-mended by the US Preventive ServicesTask Force.28

Assuring that all Americans receiveall the clinical preventive services theyneed would truly be a major achievement.While the objectives don't say how thatcan be accomplished, the only rationalscenario is inclusion of such serviceswithin the comprehensive benefits ofa na-tional health program with universaleligibility-or, as APHA puts it, "healthcare for all of us." Let's exploit this goalin our fight for national health care reform.

Pniority: Access to Better LivingStandards

Our concerns for equity will not let usslacken our efforts until all share unfet-tered access to quality health care basedon need. It is inexcusable for Americansstill to be denied essential medical carebecause they lack money. But removingbarriers to care will not, by itself, bringhealth.

As professed experts on the determi-nants of health, we know that personalhealth services are an essential, but mar-ginal contributor to improved health sta-tus. Recently, a sequel to the noted BlackReport in Great Britain dramatically dem-onstrated that after decades of universalaccess to health services, health inequal-ities not only persist, but are increasing.29We must assure access, not only of med-ical care, but also to a better standard ofliving-assuring nutritious food, basic ed-ucation, safe water, decent housing, se-cure employment, and adequateincome-these are the prerequisites of ahealthy life-style.

V. CAll to LearshiqThe most pervasive risk factor for

disease and injury in America today ispoverty. How can we launch and sustainthe massive effort needed to prevent thediseases ofpoverty, and topromote healthamong the disadvantaged? Answer: Wemust prod our governments, especiaLlythe federal government, to give priority tothis crisis.

Leadeship by GovernmtsTo quote again from the WHO con-

stitution: "Governments have a responsi-bility for the health of their peoples whichcan be fulfilled only by the provision ofadequate health and social measures. "26(p')More recently the Institute of Medicine's

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1990 Keynote Address

Committee on the Future of Public Healthhas found that one core function of publichealth agencies at all levels of governmentis to assure their constituents that neces-sary health services are provided.30

We look particularly to our federal,state, and local officials for leadership inflfilling all the essential functions: assess-ment, policy development, and assurance.

Leadershi by Public HealthProfessionals

Whether employed in the public orprivate sectors, each ofus as public healthprofessionals owes a dual responsibility toscientific validity and to social advocacy,employing both technical and politicalskills in the fight against poverty.

Margaret Dolan, for whom this an-nual lectureship is named, was just such acommitted professional-as nurse,teacher, administrator, and organizationalleader. She was complete scientist andconsummate advocate. She, and otherslike her who have served with distinctionin the leadership of this Association,would call us to develop a new vision ofhealth for all and to shape tomorrow'sworld for its fufilfmnent.

Leadeship byAPHAAPHA cannot be satisfied with sim-

ply calling others to lead. Our own con-stitution calls for the Association itself to"exercise leadership with health profes-sionals and the general public in healthpolicy development and action, with par-ticular focus on the interrelationship be-tween health and the quality of life."

In exercising such leadershipwe usu-ally rely upon the authority inherent inprofessional expertise. Does our expertiseprepare us for this mission? Achieving op-timal health for all our people will requirestrong political will and broad public con-sensus that such a goal should, can, andwill be achieved. Most of us will have todevelop political skills now lacking if weare to mobilize constituency support andinfluence social policy for such a cause.

Let's do it together. APHA pledgesto be a faithful advocate in this cause.Come join in.

VH. Clsin VlsionIn closing, I paraphrase a pledge from

the European TargetsforHealthforAl3las a health vision deserving of this Asso-ciation, of our public health profession,and of the American people.

* We shall seek to forge a future-with all being born healthy to parents who

want them and who have the time, themeans, and the skills needed to bring themup and care for them properly.

* We shall seek to forge a future-with all being educated in societies thatendorse the basic values of healthy living,encourage individual choice, and allow itto be exercised freely.

* We shall seek to forge a future-with all being assured the basic require-ments for health, and being effectivelyprotected against disease and accidents.

* We shall seek to forge a future-with all living in a stimulating environmentof social interaction, free from the fear ofwar, with full opportunities for playing sat-isfying economic and social roles.

* We shall seek to forge a future-with all growing old in a society that sup-ports the maintenance of their capacities,provides for a secure, purposeful retire-ment, offers carewhen care is needed, andfinaLly allows them to die with dignity.

By working together, we shallachieve such a vision, and future genera-tions will rise up to call us "blessed." O

References1. Gillies HC. Regimen Sanitatis. Glasgow,

Scotland: Robert MacLehose & Co, Ltd,University Press; 1911.

2. Blum HL.PlanningforHealth. NewYork,NY: Human Sciences Press; 1981.

3. Naisbitt J, Aburdene P. Megatends 2000.New York, NY: William Morrow & Co;1990. a

4. World Health Organization. 200 millionmay die prematurely in the 1990s. WHOFeatures. 1990.

5. United Nations Children's Fund. Factsand Figures 1989. New York, NY:UNICEF; 1989.

6. McBeath WH. Visions ofHealth for AlLValley Forge, Pa: American BaptistChurches USA; 1987.

7. Lalonde M. A New Perspective on theHealth ofCanadians. Ottawa, Ontario: In-formation Canada; 1974.

8. US Public Health Service. Forward PlanforHeakth-FY1977-81. Washington, DC:US Government Printing Office; 1975.DHEW Publication (OS) 76-50024.

9. Department of Health and Social Security.Prevention and Health Everybody's Bus-iness. London, UK: Her Majesty's Statio-nety Office; 1976.

10. TenLeadingCausesofDeath in the UnitedStates, 1975. Atlanta, Ga: Centers for Dis-ease Control, Health Analysis and Plan-ning for Preventive Services; 1977.

11. Program & Policies Advisory Committee.Recomunendationsfora National Strategyfor Disease Prevention. Atlanta, Ga: Cen-ters for Disease Control; 1978.

12. APHA Task Force. Model Standards: AGuide for Commuit Preventive HealthSeivices. 2nd ed. Washington, DC: Amer-ican Public Health Association; 1985.

13. APHA.Healty Comnitis20000:Model

Standards. 3rd ed. Washington, DC:American Public Health Association; 1991.

14. US Public Health Service. Healthy People2000(: National Health Promotion and Dis-ease Prevention Objectives. Washington,DC: US Government Printing Office; 1990.Conference edition.

15. World Health Organization. Global Strat-egy for Health for All by the Year 2000.Geneva, Switzerland: World Health Orga-nization; 1981.

16. Office of Assistant Secretary for Healthand Surgeon General. Healthy People.Washington, DC: US Government PrintingOffice; 1979. DHEW (PHS) Publication 79-55071. The Surgeon General's Report onHealth Promotion and Disease Prevention.

17. US Public Health Service. PromotingHealth, PreventingDisease: Objectivesforthe Nation. Washington, DC: US Govern-ment Printing Office; 1980. DHHS Publi-cation.

18. US Public Health Service. The 1990HealthObjectives for the Nation. A MidcourseReview. Washington, DC: Department ofHealth and Human Services; November1986.

19. Andersen R, Muilner R. Assessing thehealth objectives of the nation. Health Af-fairs. 1990;9(2):152-162.

20. Mitchell J. Looking after ourselves: an in-dividual responsibility? J Royal SocHealth 1982;102(4):169-173.

21. Picket G, Hanlon J. Public Health-Admninisration & Practice. St Louis, Mo:Times Mirror/Mosby; 1990.

22. WHO Working Group on Concept andPrinciples of Health Promotion. HealthPromoton-A Discussion Document. Co-penhagen, Denmark: World Health Orga-nization Regional Office for Europe; 1984.Pamphlet.

23. Milio N. Promoting Health Through Pub-lic Polcy. Ottawa, Ontario: Canadian Pub-lic Health Association; 1986.

24. International Conference on Health Promo-tion. Ottawa charter for health promotion.Can JPublic Health 1986;77(6):425-430.

25. Ashton J, Seymor H. The New PublicHealth. Milton Keynes, UK. Open Uni-versity Press; 1988.

26. World Health Organization. Basic Docu-ments. 34th ed. Geneva, Switzerland:World Health Organization; 1984.

27. American Public Health Association. ANational Health Program for All of Us.Washington, DC: American Public HealthAssociation; 1988. Pamphlet.

28. US Preventive Services Task Force. Guideto ClinicalPreventive Senvices:AnAssess-ment ofthe Effectiveness of 169 Interven-tions. Baltimore, Md: Williams & Wilkins;1989.

29. Whitehead M. The Health Divide, Inequal-ities in Health. London, UK: PenguinGroup; 1988.

30. Institute of Medicine Study Committee.The Futwue ofPublic Health. Washington,DC: National Academy Press; 1988.

31. World Health Organiization. Targets forHealth for All. Copenhagen, Denmark:World Health Organization Regional Officefor Europe; 1985.

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