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*****

Healthy People. Citizens Chart the Course Edited by M. Stoto, R. Behrens and C. Rosemont Washington D.C., National Academy Press, 228 pp., 1990, ISBN O-309-04340-9, c20.75

This volume has truly been written by American citizens: the text is based on testimony provided by more than 1000 individuals around the United States. It was prepared under the guidance of the Institute of Medicine’s Committee on Health Objectives for the Year 2000 and the IOM’s Board on Health Promotion and Disease Prevention, but the project leading to the book essentially was a co-production by the IOM and the U.S. Public Health Service. In 1980 the PHS published its health promotion and disease prevention objectives for the year 1990 in ‘Promoting Health/Preventing Disease: Objectives for the Nation’. The objectives were expressed as quantitative measures; for example, reducing the national rate of infant mortality from 12 per 1000 live births to 9 in 1990. The range of endpoints expressed by the objectives included improved health status, reduced risk factors, improved services and protection, etc. During the 1980s these objectives provided a common strategy and a frame of reference for state and local governments, community organizations and professional bodies.

Although many of the 1990 objectives have not been fully met, the ‘1990 Objectives’ on the whole are regarded as a success, because they captured public interest in health promotion and increased interagency and intergovernmental cooperation.

The present volume builds further on the ‘1990 Objectives’ initiative. It is an effort to develop new objectives to be achieved by the year 2000.

Many people felt that the ‘ 1990 Objectives’ had been formulated too exclusively on the general level and that it would be worthwhile to try to obtain a wider commitment from all levels of government as well as from private sources. To this purpose, the Pubic Health Service and the Institute of Medicine held day-and-a-half-long hearings in seven cities across the country in 1988. They also convened a consortium of more than 300 national professional and voluntary organizations and state and local health departments to help guide the hearing process. In addition to the hearings, many individuals and organizations submitted written testimony. In preparing their testimony, testifiers were asked to address such question as: What targets for disease prevention and health promotion should be identified for achievement by the year 2000? What measures do you propose? In reviewing the 1990 Objectives in your area of interest, what revisions do you suggest? What data are available?

It must have been a difEcult job for the editors to structure the oral and written material horn the more than 1000 testifiers in order to produce a cohesive and readable report. In this effort they have succeeded remarkably well.

The Est part deals with the process of developing and implementing health objectives at the state and local levels. These chapters provide useful reading matter for those developing similar objectives for their own countries.

The second part of the report contains four chapters that deal with particular groups of the population: children and adolescents, older adults, people with disabilities, and racial or ethnic minorities.

The third part summarizes the testimony on health promotion and disease in special settings: the health care system, schools, the worksite and the community.

The remainder of the material is organized according to the substantive priorities for which the

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Public Health Service has decided to formulate national objectives. There are 18 such priorities, organized into three groups: (1) tobacco, alcohol and drugs, nutrition, physical fitness, mental health; (2) injuries, violence, environment, occupational safety; and (3) HIV. sexually transmitted diseases, infectious diseases, maternal and infant health, adolescent pregnancy, heart disease and stroke, cancer, chronic diseases and disabilities, oral health.

Because of the process by which the report was prepared, its character is mainly subjective: it contains more opinions than facts. This does not mean that the individual testimonies cited do not reflect the truth, but the reader has little possibility of checking this, because of the scarcity of references to the literature. Moreover, the information provided by the testifiers is usually of a qualitative nature only. A typical example is the paragraph on perinatal mortality. The 1990 objective was to bring the figure down from 12 per 1000 live births to 9. The present report only states that, although there has been some overall decline in the past decade, there is now concern that progress is slowing and that infant mortality rates for some subpopulations may actually be increasing.

The practical usefulness of this volume for the people for whom it was written (those in the U.S. attempting to adopt and implement health objectives at the national, state or local level) is probably sufficiently great to warrant the considerable effort of preparing the report. For those outside the U.S. engaged in similar efforts it provides an interesting example of how to engage a wide public commitment to a process for which many countries feel a pressing need: setting objectives and priorities to allocate the limited resources for health promotion and disease prevention.

Dr. E. Borst-Eilers The Health Council

The Hague, The Netherlands