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Aiming for a healthier population by 2020

January 1, 2009
by Ronald W. Manderscheid, PhD
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Moving our fields toward prevention, early intervention, and population health

With the initiation of work on Healthy People 2020, the mental health and substance use care fields are being presented a wonderful opportunity to develop and address our newly emerging joint public health agenda. The Healthy People series (1980, 1990, 2000, 2010 and, now, 2020) is a continuing initiative of the U.S. Department of Health and Human Services (HHS), in collaboration with state and local public health agencies, key associations concerned with public health, and public health advocates in the community, to define core national health goals and objectives, as well as related measures and performance standards.

The ten-year Healthy People plan sets in motion a broad array of activities at the national, state, and local levels that seek to implement core health goals and meet related performance standards. For Healthy People 2020, I have the honor of serving on the HHS secretary's Advisory Committee, which is working collaboratively with departmental staff to develop and implement the plan for 2020.

The Healthy People series is based on core public health concepts: population surveillance, population health, prevention and early intervention, identification of root causes, outcome assessment, and continuous feedback so that interventions can be adjusted appropriately. As more has been learned over time, research has highlighted the important roles that risk factors and health determinants play in health status. For example, poverty is a risk factor for poor health status, and a disparity in healthcare, such as racial discrimination, can be a social determinant that exacerbates poor health status.

In my own view, the Healthy People initiative should touch the lives of every person living in America. We should aspire to the best health possible for everyone. Good public health practice dictates this. Furthermore, when this does not occur for particular groups, we should ask why not.

Clearly, in both the mental health and substance use care fields a need exists to focus much more attention and effort on prevention and early intervention, in addition to our current emphasis on acute care. Such efforts are very worthwhile in both human and financial terms. Why not prevent substance use conditions rather than treat them after they appear? Why not prevent or intervene early in depression rather than confront potentially life-threatening acute symptoms? Why not develop population interventions (in distinction to personal interventions) to mitigate risk factors' negative effects? Each of these questions opens up exciting new possibilities for the mental health and substance use care fields.

Similarly, recognition is growing outside of our fields that mental health and substance use conditions are themselves risk factors for other chronic illnesses, such as heart disease and diabetes. This recognition makes it much more likely that other fields will be receptive to partnership overtures from us in the future.

The Healthy People 2020 framework is complete, and its overall goal is to foster a long and healthy life for everyone (See PhaseI/default.htm). A primary focus will be the risk factors and the determinants of health, with a secondary focus on diseases and other health conditions.

The risk factor/determinants focus fits mental health and substance use conditions particularly well. Social determinants that lead to major disparities in health status, such as race or gender, and primary risk factors, such as poverty, are closely linked to mental health and substance use conditions. For example, we have known for more than 50 years that the rate of mental disorders in the lowest socioeconomic class is several magnitudes larger than in the highest class. Social determinants and risk factors are implicated in many other chronic illnesses, too, and may, in fact, help explain the strong relationship between depression and diabetes, for example.

Risk factors and determinants also can provide a way for us to begin to address the 25-year life-span disparity experienced by public mental healthcare recipients. We must build linkages with primary care, as outlined in the Institute of Medicine's report Improving the Quality of Health Care for Mental and Substance-Use Conditions, but we also must move upstream to address this tragic disparity's causes. Remedying primary care deficits, offering good mental healthcare, developing evidence-based practices to address the differing metabolic effects of medications, building healthy lifestyles, and restoring hope are each key actions. We all would agree that prevention is a better strategy. Healthy People 2020 can help us get there.

Thus, throughout the mental health and substance use care fields, we need to participate in an active and vocal way in Healthy People 2020′s development and implementation. Information is available at or by calling (240) 453-8280. At the Web site, you can sign up for a Listserv and receive directions for providing comments electronically. Also, each meeting of the HHS secretary's Advisory Committee is open to the public.

I hope that I have convinced you of the importance of participating in Healthy People 2020. The initiative has much to offer us as we move into the second decade of the 21st century.