Secretary’s Advisory Committee on
National Health Promotion and Disease Prevention Objectives for 2020
Social and Physical Environmental Determinants, Committee Work in the Coming Year
Via WebEx
Sixteenth Meeting: December 11, 2009
Committee Recommendations (Approved by Vote)
- No formal votes were taken during the meeting.
Next Steps
- Dr. Marmot indicated that, within the limits of his available time, he would be willing to review a Committee document on social determinants of health.
- ODPHP requested the Committee’s guidance in identifying criteria that could be used to select social determinants of health measures for inclusion in a set of Leading Health Indicators (LHIs).
- The Subcommittee on Priorities will produce materials on how to use factors, such as preventable burden, preventable fraction, preventable years of life lost, to identify priorities.
- The Committee may produce a derivative paper based on the priority-setting materials that are submitted by the Subcommittee on Priorities.
- The Subcommittees will continue to provide guidance to the HHS Secretary in the coming months in response to the following specific questions/charges.
- Subcommittee on Communications: How should the public be educated about the importance of inequalities in social determinants of health?
- Subcommittee on Implementation: How can an ecological approach to health improvement be operationalized?
- Subcommittee on Priorities: What guidance should be used to select measures, particularly LHIs?
- Subcommittee on Data and IT: Offer guidance on development of the relational database.
- Ad Hoc Group on Social Determinants: What examples can be used to illustrate the social determinants of health? How can the pubic be educated about this approach? How should objectives related to social determinants of health be selected?
- Subcommittee on Evidence: How should evidence-based action steps to achieve targets for objectives be selected?
- Subcommittees will complete their draft recommendations for review and voting at the next meeting.
- NORC will follow-up with Committee members to schedule upcoming subcommittee and Web-based Committee meetings; a meeting of the full Committee is planned for March of 2010.
I. Welcome and Desired Outcomes of the Meeting
Dr. Jonathan Fielding, Chair of the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 (the Committee), welcomed participants. He thanked Sir Michael Marmot, professor of Epidemiology and Public Health at University College London, for taking time to speak with the Committee. Dr. Fielding explained that the primary focus of the meeting would be on social determinants of health. The Committee would discuss how this approach can be operationalized and integrated into Healthy People 2020. The meeting would also cover logistical issues and an update on HHS progress in developing Healthy People objectives. The Committee would talk about recent progress and challenges in the subcommittees’ work, as well as a list of tasks feasible to accomplish in the coming months.
II. Social Determinants of Health
Dr. Fielding introduced Dr. Marmot, whose expertise as the Chair of the World Health Organization (WHO) Commission on Social Determinants of Health would be very useful to the Committee. Dr. Fielding explained that the Committee had been discussing the central role of social determinants of health for the past two years. Recently, the Committee had explored the question of how to help the U.S. Department of Health and Human Services (HHS) offer concrete guidance to users of Healthy People 2020 on taking action to address social determinants of health.
Dr. Marmot said that, in 2003, the World Health Organization (WHO) was active in disease control programs and health systems, but was not taking action on social determinants of health. Then-Director-General J.W. Lee accepted that social determinants of health were important to an equity perspective on health; he established the WHO Commission on Social Determinants of Health (chaired by Dr. Marmot). The Commission had a clear set of values that began with social justice; they argued on moral, not economic, grounds for taking action on social determinants of health. The Commission emphasized: the conditions in which people are born, grow, live, work and age; structural drivers of those conditions at the global, national, and local levels; and the importance of monitoring, training, research of capacity development. Their report included recommendations on early child development in education, healthy places, employment and social protection. Health care was addressed as only one of several vitally important influences on health.
Addressing uses of Health Impact Assessment (HIA), Dr. Marmot said the Commission has emphasized conducting not just HIA, but health equity impact assessment. HIA often looks at population averages, but even if average health status improves over time, the distribution of health may not. The Commission has emphasized health equity and determinants. The Commission published a paper comparing medical care expenditures in the U.S. and the U.K.; the U.S. spends two and a half times as much per capita on health care. Yet, comparing seven health conditions in both countries, the U.S. had more disease. These differences were not due to access to medical care.
Dr. Marmot’s second message was that health inequities are about not just the poor, but the social gradient. He showed U.S. data looking at life expectancy at age 25 by education. Those with more years of education have a longer life expectancy. Policy-makers often focus resources where the problem is greatest—with the poorest populations. He argued that health disparities cannot be effectively addressed in this way, due to the social gradient: those in the second tertile from the bottom have worse health than those in the third tertile from the bottom. It is possible to change the slope of the gradient, but doing so requires concerted action.
Dr. Marmot discussed strategies to persuade elected officials of the importance of social determinants of health. At an international meeting in London to launch the WHO report, Prime Minister Gordon Brown had announced that Dr. Marmot would undertake a similar review of health inequality in England to recommend strategies for tackling health inequalities. Dr. Marmot met with the Secretary of State for Health about this review and said to the health minister that he would need to reach out to other cabinet secretaries to address health inequities; he had an important role to play in providing leadership at the cabinet level.
Dr. Marmot said the review of health inequities in England (Fair Society, Healthy Lives) would be published on February 11, 2010. (See: http://www.ucl.ac.uk/gheg/marmotreview).  Its seeks to identify evidence, underpin future policy and action, show how evidence can be translated into practice, advise on possible objectives and measures, and build on experience with the current Public Service Agreement target on infant mortality and life expectancy. The report argues that health inequities can be narrowed if a fairer society is achieved.
Addressing the role of government in dealing with health inequities, Dr. Marmot described six policy objectives and a framework for monitoring them that would be presented in the report. Dr. Marmot has met with government ministers and senior civil servants in departments overseeing each of these areas, as well as politicians from both parties. With an election scheduled for the coming year, he hoped that the incoming administration would find this issue important if the government changes hands. Dr. Marmot has also met with the mayor of London, who agreed to partner with the Commission to create the London Health Inequities Strategy, which is intended to make London a healthier community for all. The Commission has also partnered with the northwest region of England, including Liverpool and Manchester.
III. Q&A and Discussion
Dr. Fielding thanked Dr. Marmot for his informative presentation and invited questions. He asked how Dr. Marmot has been able to convince politicians to take a long-term view when many focus on short-term issues, such as being re-elected. Dr. Marmot said that, in one case, a key official had a background of privation and understood health inequity from personal experience. Dr. Marmot approaches his discussions with officials from the standpoint of asking, “Why would you want to be in government if you didn’t want to make things better?” He then explains what the evidence suggests they need to do to make things better.
Dr. Shiriki Kumanyika said there are those who stand to lose if society is fairer; she asked Dr. Marmot to discuss whether he has overt opponents. He replied, “We do, and we don’t.” In Britain, an established Labor Party argument has been that one doesn’t need to worry how much richer the rich are, as long as the poor have enough. Opposition is not about health or a desire for poor people to be unhealthy. Rather, it is driven by the desire to “reward success” and “create incentives” to foster economic growth. He said the argument is, “Don’t stop the wealth producers; don’t stop economic growth in the interest of equity.”
Dr. Marmot discussed the results of public opinion surveys showing support for more equity in society. The public recognizes the fairness of differences in earnings for workers with different levels of responsibility, but they believe the extent of differences in income is excessive. When asked about the proposition that a fair society is one that creates the same opportunities for everybody to get ahead, 90 percent agree. They also agree that children of richer families have different opportunities to get ahead than children of poorer families. Putting these three findings together, the public endorses the propositions that: fairness means equality of opportunity, there is not equality of opportunity because of inequalities in income, and inequalities in income have gone too far. When speaking with elected officials, Dr. Marmot uses evidence of public opinion to support his arguments. Other Committee questions included:
- How can empowerment strategies be used to advance the concept of fair communities?
- How has your work been received by colleagues in the healthcare community?
- How is work on developing and producing evidence for interventions proceeding?
Responding to work on health equity, opposition politicians have asked where personal responsibility fits in. Dr. Marmot has said personal responsibility is at the center. The goal is to create conditions where people can take control of their own lives; they do not currently have those conditions. Empowerment is not just about the individual, but comes from creating the right social conditions and giving every child the best start in life. Empowerment at the individual and community levels means recognizing the social gradient in early child development. Evidence shows that the lower a child is in the hierarchy the less likely that child is to have an ideal environment or to achieve his or her physical, cognitive, social, and emotional potential. Community empowerment can mean that people want to make their own solutions. He has asked, “Even if you have no evidence that (your solutions) are effective? How do you know you are doing any good?” Communities can choose how they want to do things, but they should be informed by evidence of what is likely to work.
Dr. Marmot noted an unfortunate divide between those who think health care is everything and those who are perceived to believe that health care is nothing. When people think about health, they mainly think about health care, and the organization and funding of healthcare. It is important to advance understanding that health is not the same thing as health care. The climate of understanding on the importance of health inequalities has changed, as evidenced by Dr. Marmot’s recent appointment as President-elect of the British Medical Association. When he was asked to do this he noted that he was an odd choice, as he does not work in the healthcare system and talks about the wider determinants of health. But they asked him to do it.
Dr. Fielding thanked Dr. Marmot, and asked if he would be willing to review a document on the social determinants of health once the Committee has prepared one. Dr. Marmot would be pleased to do this, within his physical limitations. After his departure, Dr. Kumanyika said subcommittees may be able to follow-up on some of the themes that Dr. Marmot raised. She highlighted four areas: 1) There is opportunity to train public health stakeholders to make these arguments with the other sectors. 2) Even though there may be a moral argument, it is important to be concrete (e.g., how does mixed land use relate to health, or how does air quality relate to specific health problems or zoning). 3) The Commission has selected six policy areas; this group could also agree on key indicators, and then articulate specific strategies to work those pathways. 4) The Health in all Policies approach requires looking at policies that other sectors are trying to influence.
One area where this comes together is “sustainability,” now an area of focus for several sectors. The Committee should articulate that the overlap and mutuality between public health and environmental issues. She suggested that the Committee discuss how to operationalize some of Dr. Marmot’s ideas when they thinking about next steps for the subcommittees. Dr. Fielding added that until there is better public understanding that we can’t have better health and reduce inequalities without focusing on the social and physical determinants, we can’t move ahead. He emphasized the need for metrics to see where we’re going, and for analytics to help project reasonable outcomes. Such tools can help to convince politicians that, even though they may not be in office in 20 years, this could make a big difference and leave an important legacy.
IV. HHS Update
Timeline of Development Activities for Healthy People 2020
RADM Penelope Slade-Sawyer, Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion), provided an update on the timeline for HHS activities related to development of Healthy People 2020. The proposed topic areas and draft objectives were posted online for public comment from October 31, 2009 through December 31, 2009. The Federal Interagency Workgroup (FIW) was in the process of developing a target-setting methodology. HHS had several concurrent activities planned through April of 2010. The FIW would develop a narrative and specific measures to underpin all of Healthy People 2020. Simultaneously, the Topic Area Workgroups and the National Center for Health Statistics (NCHS) would partner to produce operational definitions that would be used to measure the objectives. HHS would also develop the “front matter” to Healthy People 2020. The Implementation Strategies Subgroup would continue to refine the guidance for selecting evidence-based interventions that will be linked to the objectives.
ODPHP and the NCHS would be using the Committee’s recommendations to develop the Healthy People 2020 relational database (scheduled through October, 2010). HHS Workgroups would review public comments and revise objectives between January and February, 2010. The FIW would consider the Workgroups’ proposed revisions between March and April of 2010. As objectives are finalized, their targets would be calculated using the baseline data and the target setting methodology. Between May and June 2010, Healthy People 2020 would go through HHS’ Departmental clearance. In July 2010, clearance comments would be considered, and changes would be made before the objectives were submitted for final Departmental approval of Healthy People 2020.
RADM Slade-Sawyer provided details of the process for sharing five hundred and fifty-seven (557) draft Healthy People objectives with the public, both at public meetings and online at the Healthy People 2020 Web site. Three public meetings took place (October 22, 2009, in Kansas City, Kansas; November 7, 2009, in Philadelphia, Pennsylvania; and November 20, 2009, in Seattle, Washington). Each meeting included opportunities for participants to provide oral testimony across the full set of draft Healthy People 2020 objectives. The majority of comments that were presented addressed specific issues, population groups, or other interest groups. A large number of comments reflected broad, cross-cutting interests, including the nature of health determinants and interventions, and the nature and structure of the Healthy People initiative itself. The Public Comment database for the proposed Healthy People 2020 objectives also opened on October 30, 2009 and would remain open through December 31, 2009.
RADM Slade-Sawyer discussed the FIW’s preliminary decisions about Target-Setting Methods. The Committee had recommended that target-setting methods for Healthy People 2020 be: 1) understandable and transparent; 2) based on data and projected trends; and 3) realistic, but representing a “reach” that is more than a continuation of the status quo. The FIW’s proposed recommendation is that, when the science and information are available, modeling, existing policies and laws, and consistency with other Federal targets/programs be used to set an objective’s target. When these are not available, 10 percent improvement would be used as the standard. This would make the target setting methodology transparent, simple, and easy to explain, while allowing utilization of available empirical findings from last decade. RADM Slade-Sawyer cautioned that this recommendation had not yet been submitted to the ASH for approval.
After providing an overview of FIW progress on objectives in specific topic areas, RADM Slade-Sawyer shared that the Secretary and the Assistant Secretary for Health were interested in including a set of Leading Health Indicators (LHIs) in Healthy People 2020. Like the Healthy People 2010 LHIs, this small set of objectives would enable focused efforts and facilitate public awareness. This list could include indicators that reflect social determinants of health. ODPHP asked for the Committee’s guidance in identifying criteria to select social determinant of health measures that would be added to the LHIs. RADM Slade-Sawyer opened the floor for Committee questions and discussion.
Target-setting. Dr. Fielding commented on the FIW recommendation that objectives be set using a standard level of 10 percent improvement. He acknowledged that sometimes there is not enough information available to inform target-setting. In such situations, 10 percent improvement may be an acceptable standard. However, the focus should be on interventions that we know are effective to reduce the burden of illness or injury. Objective targets should take interventions into account, indicating where we will be if we implement what may make it appear as though many objectives have been achieved.
Dr. Kumanyika added that the advantages to using this method are that it sounds like a simple, transparent approach. Yet a 10 percent improvement would represent a tremendous gain for some objectives, while for others it would be a trivial change. She asked if the FIW had considered stratifying the objectives, based on where they are now. Targets could be set at a higher level for certain objectives; if those targets are not met, they could be flagged for further analysis. Otherwise, it seems this approach lacks an element of aspiration. RADM responded that, while it does sound small, a ten percent improvement would not be achieved for about fifty percent of the objectives. She added that they were not trying to trivialize the targets, but to make the methods used for setting them transparent and consistent.
Leading Health Indicators (LHIs). A Committee member suggested that, in thinking about LHIs, the Committee should also consider indicators related to public understanding of social determinants of health, as well as those related to health information access and utilization. These would be critical factors in empowering people to take charge of their own health.
Priority-setting. Dr. Fielding said Healthy People is so big that guidance is needed for what users should concentrate on. It is important not to disenfranchise anyone, but we also need to determine what the highest yield opportunities are, and to rank the preventable burden (e.g., from one to ten). Social factors might be ranked first, but it is important to look at this question. Even by disease, or by organ system, where are the greatest opportunities based on the preventable fraction, preventable years of life lost, preventable qualities? These priorities should relate to LHIs. The same thing could be done for greatest disparities, inequities and inequalities. Even if there is not a clear solution, issues should be highlighted to give a sense of priority.
Dr. David Meltzer, Chair of the Subcommittee on Priorities, agreed with Dr. Fielding. He added that his subcommittee had been discussing these types of issues, and may be able to provide materials within the next few weeks. Dr. Fielding said the Committee would look forward to receiving these materials, and then producing a derivative article from it so that people can use it as guidance. He said it is important to give concrete examples so that others can understand the Committee’s thinking. He emphasized the need to give levels of specificity that can help the FIW and others to at least understand the Committee’s thinking. Such examples could take the reader from objectives to implementation to how it might have a feedback loop from the evaluation information collected to show how out the Action Model is a actually a basis for action.
Dr. Meltzer shared that he has being doing work for the Institute of Medicine to prioritize quality of care indicators. He noted that some interesting issues were the order of magnitude differences between interventions that focus on small dimensions of health care versus a larger system. For example, controlling hypertension as a public health intervention is huge compared to other quality indicators. This gives him hope that the priority-setting approaches being proposed by the Committee could be used to develop LHIs.
Social Determinants of Health. A Committee member asked for clarification from HHS of the status of social determinants objectives, and when those would be put forth. RADM Slade-Sawyer first recognized that there are objectives in Healthy People 2010 that address social determinants of health. She then noted that the FIW is working to expand these objectives in Healthy People 2020 by creating a separate topic area for this issue. They would keep in-mind the cross cutting nature of these objectives. Another Committee member raised concerns that it seems the social determinants are being treated as simply another set of objectives and indicators without an organizational model to make the material understandable. He was impressed with Sir Marmot’s model, which is organized into policy goals, policy objectives, and policy mechanisms. He felt the model could be useful to the Committee in presenting an approach to working with other departments.
The same Committee member raised the issue of how Healthy People would map onto national health reform. He said it appeared likely that the Senate would pass a bill and there would not be a conference Committee. This would change the focus at HHS dramatically, and that the Committee should be sure its work remains relevant within this context. For instance, it would be important to ensure that the Committee’s work on prevention and promotion is aligned with where national health reform is going on prevention and promotion. Dr. Fielding acknowledged this good point, but noted that the group should wait to see what provisions the final bill has before spending too much time discussing this matter.
V. Discussion of Committee Work in the Coming Year
Dr. Fielding asked RADM Slade-Sawyer for guidance to the subcommittees on what input would be most helpful to ODPHP, the Assistant Secretary, and the Secretary. RADM Slade-Sawyer said it would be helpful if the Subcommittee on Communications could suggest how to educate the public about the importance of improving health, especially as pertains to inequalities in social determinants of health. From the Subcommittee on Implementation, she asked for help in thinking through how to operationalize the ecological approach to health improvement, especially by providing concrete examples.
The Subcommittee on Priorities should provide guidance on the selection of measures, particularly with for LHIs. From the Subcommittee on Data and IT, RADM Slade-Sawyer asked for advice on the relational database. The Ad Hoc Group on Social Determinants should provide examples that illustrate social determinants of health, and guidance on how to educate the public about this approach. RADM Slade-Sawyer requested guidance on selecting objectives related to social determinants of health that will be added to Healthy People 2020. Lastly, RADM Slade-Sawyer asked that the Subcommittee on Evidence offer suggestions for how to select evidence-based action steps to achieve objective targets. Dr. Fielding thanked RADM Slade-Sawyer for this useful list, noting that as things progress there may be a need for increased specificity in these requests. Due to scheduling challenges he then signed off, turning facilitation of the meeting over to Vice-Chair Shiriki Kumanyika.
VI. Discussion of Subcommittee Progress and Challenges
Dr. Kumanyika led the group in reviewing the subcommittees’ work since the last Committee meeting. She said the general question to be discussed was how the Subcommittees can be most helpful, as the Committee is not the FIW and will not be able to address the “nuts and bolts” of developing Healthy People 2020. She asked each of the subcommittee chairs to comment on their group’s recent progress.
Dr. Abby King, chair of the Ad Hoc Group on Social Determinants, sought input on the operational questions Dr. Marmot’s presentation had raised. The purpose of the Ad Hoc Group was to develop and operationalize specific examples of social determinants are and how they can be included and embedded in local, regional, and national actions around different topic areas. Members of the group have been asked to submit examples that can be used as a basis for this group’s work. It is easier to obtain examples that address the built environment, because much has been done in this area related to physical activity, nutrition, and weight. NORC has assisted in identifying concrete examples that are low cost, feasible, and do not require legislative action from different reports, including the NACCHO report on Health Inequities.
Dr. King was pleased to hear of Dr. Marmot’s local-level efforts in London. She suggested it might be useful to consider strategies Sir Marmot will highlight in his report in February 2010. Dr. King noted Dr. Marmot’s use of the term “we;” it sounded like he himself was meeting with local and federal decision-makers. She thought it would be helpful if the Ad Hoc group could gain understanding of how his group is organized, and how they plan to use the report to maximize results.
Dr. Douglas Evans, Chair of the Subcommittee on Strategic Communications, said his group had met twice in the last few months and would meet again in January. The Subcommittee identified two types of strategies: those that ODPHP can realistically implement t on their own, and those where partnerships will be required The Subcommittee has done some further analysis of the audience matrix. They expanded the matrix to define communication channels, mechanisms for outreach, and what some objectives and outcomes of those communications would be. Dr. Evans noted that the Subcommittee could look at how people think about social determinants, and how Healthy People can use those frames of reference. There is some research occurring in relation to this topic now. If Healthy People is to change the way people think and act about the social determinants, the issue must be framed in ways that will be understood and will motivate change.
Dr. David Meltzer, Chair of the Subcommittee on Priorities, said his group had met once, and would schedule additional meetings. The group was working on fine-tuning a priority-setting approach, developing specific examples with measures such as population and preventable burden, and then presenting them in an article that can be distributed to the public. The Subcommittee will consider how to integrate its work with that of the social determinants group. It is challenging to think about how to develop measures of population effects of social determinants. Members discussed how to incorporate the work of the Priorities Committee into the policy process, recommending that the Secretary engage the Domestic Policy Council in identifying national priorities, since leadership from other parts of government is needed to address social determinants.
Ms. Eva Moya, Co-Chair of the Subcommittee on Implementation, addressed three key issues. First, the Subcommittee continues to struggle to make implementation recommendations within a context of limited resources. Second, they wish to offer clear guidance for local public health agencies, health departments and other core users on what realistic actions can be taken, in a time of economic retrenchment. Third, it is important to look at continuous quality improvement approaches. Ms. Moya discussed the need for consistent reference to Healthy People in HHS funding opportunities and the language used by HHS. Implementation guidance must be practical for health departments, especially at a time when they are struggling with diminishing resources. The subcommittee reorganized its recommendations to be more cost-sensitive so that users have guidance on ways that they can take action in times of economic retrenchment.
Dr. Ronald Manderscheid, chair of the Subcommittee on Data and IT, said his group has completed two phases of work, and is now moving onto phase three. First, they will develop a framework for the information technology for the U.S. public health infrastructure and, second, they will develop an outline and framework for the Healthy People 2020. Based on today’s discussion, Dr. Manderscheid suggested that the subcommittee consult with ODPHP for guidance on how they can help with the relational database.
VII. Next Steps
Dr. Kumanyika thanked the subcommittee chairs for their updates and asked RADM Slade-Sawyer to comment on anything else that ODPHP should be addressing. RADM Slade-Sawyer noted that time is limited and the Committee should stay focused on the most important items. Dr. Kumanyika suggested creating a timeline for submission of the subcommittees’ recommendations so that they can be voted on and approved in a timely manner. She suggested that by the next public meeting, the subcommittees should have recommendations that are ready to be voted on. RADM Slade-Sawyer indicated March 2010 would be a good time for the next meeting. The meeting was adjourned.
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