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1970 decline was 25 percent; and the 1970 to 1978 decline, an addbional 33 percent. Theqe achieve- ments cart be attributed both to improvements in treatment of individuals with these conditions and to pre'centlon activities that reduce the incidence of such conditions; however, the relative contribu- tions of prevention and treatment have not been determined. The Federal contribution to reducing heart disease and stroke deaths has a long history, dur ing which the role of prevention has continually increased relative to that of treatment. Major epidemiologic studies supported by the National Institutes of Health and conducted in the 1950s and I960s provided the evidence for defining cer lain risk fat(ors associated with heart disease and stroke, and for developing intervention strategies that are associated with reduced morbidity. For example, these studies identified high blood pressure not only as the most important risk factor for stroke but also as a major contributor to cor- onary heart disease. Recent successes in control- ling high blood pressure have clearly contributed to the decline in deaths from stroke and heart disease. In the early 1970s, the National High Blood Pressure Education Program began, with partici- pation by government agencies, private industry, voluntary health associations, and professional groups. This public and professional education program--coordinated by the National Heart, Lung, and Blood Institute has been effective in decreasing the proportion of undetected cases of high blood pressure and in increasing the level of ~ontrol for those cases detected, While progress has been substantial, the opportunity for even greater advances in the control of high blood pressure is reflected in the following section about the Hypertension Detection and Follow-up Program. Another major risk factor identified in these studies and targeted for special attention is cigarette smoking. The I964 Surgeon General's Report on Smoking and Health was a landmark in identifying this major contributor to both heart dise~.qe and cancers--indeed, uRimatdy as the single most important preventable cause of death. Efforts by DHHS to reduce smoking and its risks continue to expand, and have produced positive results. AduIts are quitting smoking at a greater rate than they are taking it up, and those who do smoke are choosing dgarettes with lower tar and nicotine. Among teenagers, the proportion of smokers has declined substantially. The sole ex ception is teenage females aged 17 to 18, among whom the proportion currently smoking has re- mained stable during the past five years. Studies also identified dietary factors important in heart disease. Premature heart disease is dearly associated with elevated blood cholesterol levels. Heart attacks are five times as frequent among men and women aged 35 to 4,1 who have choles- terol levels above 265 milllgrams/deciliter as among those with levels bdow 220. Recent trends indicate an overall reduction in consumption of saturated fats and cholesterol. This decline, combined with increasing public awareness of the relationship between diet and health, may also contribute to decreases in heart disease deaths. The fact that cardiovascular dlsease---our Na- tion's leading killer-- has been declining, and that the rate of decline has been accelerating in associa- tion with enhanced efforts directed at the major risk factors, is especially encouraging. Additional progress can be expected as the knowledge base deepens with respect to the involved risk factors, and with respect to effective ways of addressing those risk factors. Hypertension Detection and Follow-up Program A prominent exam#e of the potential for addi- tional gains resulting from an expanded knowl- edge base is found in the results of the Hyperten- sion Detection and Follow-up Program, announced in December IWl9. This study has been a five-year, randomized clinical trial and provides new insights into the possibility of reducing mortality for the large numbers of people with hypertension, in- cluding those with mild hypertension. The systematic intensive detection, treatment. and follow-up program undertaken nationally in various centers resulted in a significant decline in mortality from all causes and showed clearly the benefits of treatment for persons with mild as well as moderate to severe high blood pressure. People with mild high blood pressure~iastollc blood pressure 90 to 104 at the baseline clinic visit--whose high blood pressure was subjected to aggressive control, experienced death rates 17 per cent below those with similar levels who were not participating in the intensive intervention pro- gram. Moreover, it was noted that the aggressive follow-up program was even more successful for blacks. Mortality rates for blacks in the program declined 22.4 percent relative to those of the con- trol group, while rates for the others in the ex- perimental groups declined by I0 percent. The implications of these results for the health of Americans are substantial. High blood pressure is widely prevalent in the United States: An estimated 60 million Americans have blood pres- sure readings higher than 140/~. An important contributor to stroke, hearl disease, and renal disease, high blood pressure is estimated to cost the Nation more than $g billion each year in medical care costs, lost productivity, and lost wages. 5

Although Faderal]y ftmded studies in the late 1960s and early 1970s clearly demonstrated that high blood pressure co~Id be controlled, and that related disease and death for whire middle-aged males would decrease accordingly, the National llealth and Nutrition Examination Survey indi eared that about 50 ~.er cent of affected individuals were ~naware that they bad high blood pr~sure. In 1972 the Public Health Service, through the National Heart, Lung, and Blood [osthule, ap- pointed a special panel to examine these problems and to recommend addldona[ studies as; needed. A large-scale clinical trial was recommended to pro- vide data On the ef~cacy of a.ntlhyperteilsive therapy in controlllng disease and prcventlng death [or the general population. This study, the Hypertension Detection arm Follow-up Program, began in 1973 and has tn- vdived 14 clinical centers and nearly 11,000 hypertensive patlenls. The ~calicnts were then be- tween 30 and 69 years of age, Of both ~exgs. and ineluded both blacks and whites. They were ran- domly assigned to the c[Idical centers for therapy, or they were referred to their usual sources of earc. Deaths flora all causes w~re tracked, ~tnd the re~ults t~vealed the dramatic f/re year mortality reduet[on$ noted above for thos~ treated by the ~l]nical c~ater$ as ~ompare~ with those referred for lreat~nent of hypertension by customary ~ourees Of care. One of the important next step~ is the applicallon of these ~ndings in regdiar Primary care settings to determine which com- ponents of the lreatment and fo{low-up reglmetl ~an ¢ontrlbutc to ~ner~bed eon!rbl r~te~ amon~ high-rlsk groups. Smallpox eradlcatio~, immutdzat[on i~prove- ment~, reductions in infant Inortalfiy, declines in 6 h~art disease and stroke mortality, and the sue~ cessful reduction of mortality though by~r~en- ~iotl detection at~d [ollowott p arc five achlevcmert t s that demonstrate, by example, the ~trides that can be ~de against all the prevefitabl¢ disease~ through a combination of enhanced prev~ntioll s~)rvlces+ changers in the environment, and tht adoption of risk-reduclng lifestyles. Based on an assessment of the prospects offered by these and similar opportunitles to prevent un~ necessary disease and disability, specific godis were established in Healthy People for im- provements in the health of Americans in each of the major life stages: Healthy [n[ant~: To continue to improve bl- fant health, and by 199Q to reduce infant mortality by a least 35 percent. ~ealthy Chadian: To improve child health, foster optimal childhood development, and by 1990 reduce deaths among children aged 1 In 14 years by at least 20 ~erccnt. Htadlhy Adolese~;t~ ~ Youn~ Adidt~: To improve the health and health habits of adolescents and young aduRs, and by 19~0 to reduce deaths among people from 15 to 24 years old by at least 20 percent, Healthy Adot~: To improve the health of adults, and by 1990 to reduce deaths among people aged 25 to 64 by at least 25 perc~m. Healthy Older Aduh~: To improve the health and quality of life for older adults, and by 1990 to reduce the average annudi number of days of restricted activity because of acute and chronic illness by 20 percent, to fewer than 30 days pet year for people aged 65 and older. ~,oth Healthy People and Promoti,~g Health/ Preventing Disease: Objectives for the Nation. the volnme issued the following year to sveci~ the ob- jectives more comp[e~ely, have been directed to the identification of nadonalsas distlnct from Federal--goals arid opportunities. Bqt, as noted in th~ five examples just reviewed, a great d~al carl be cot~trlhut~ by vari~zls Federal program~. Tha~ is largely the subject of this report. ]~'e~¢ntio~ "80 is the first in a series Of annual reports that will highlight the leading acCom- plishments in prevention during the previous year, me, asur~ the Nation's p~ngres~ toward ~L~ preven- tiort objectives, and summarizt the Federal eon- trlbudons ¢o achievemen~ of the objectlves. This lirst chapter has pre~ented several significant recent accomplishments. The remainder of the report will detail the programs and the progress. Chapter Two a~ses~,es our Progres~ in Oahanelng bexlth by re0orfing treads in healt/x ~tatul ir~ dicator$ [or five ag~ groups: infant~, children, adolescents and young adults, adults, and older adults. Chapter Thr~e chonlcles the effort~ of Federal agencies in the broad range of prevention priority areasmnot ably lhe work of the Del~art- ment of Health and Human ~ervlce~, but alga ac- tivisie~ of other Federal ogenc/e~ at~d deparlmCnta, Chapter ~¢ot~r provides a complete inventory of prevention acllvitfes, argot db~g to prevoltion pro- gram categories, within the D~artment of Health and Human Services, Taken a~ a whole, the effort~ described in these chapters represent stlbstalltiel growth toward the prevention measttres needed to meet th~ goal~ of Healthy People.

Chapter 2: Health Status Trends Progress ~n disease preven[ion musl be mea- sured in terms of lhe reductions of preventable health problems the absence of illnesses, in- juries, and deaths {hat, based on previous ex- perience, might otherwise have been expected t0 occur. This chapter of Prevention "80 displays in chart form various aspects of health-related trends, both for the population as a whole and among the five age categories established by Healthy People. These include infants (under 1 year), children (1 to 14 years), young adults (15 to 24 years), adult,, (25 to 64 years), and older adults (65 years and older). The health trends depieled in these charts highlight the major causes of disease and death for each age group. 7

Health Status Trends Overall Trends In 1978 the National age-ad~usted~death rate declined to 606 per I(~0,000 people, the lowest level ever recorded in the United States and a 66 percent reduction from the 1900 rate (Figure 1).2 This dramatic reduction demonstrates the Na- tion's success in preventing and treating acute in- fections and diseases. Influenza and pneumonia death rates, for example, fell from 210 to 15 per leO.000 population, a decline of 93 percent. On the other hand. death rates for many chronic diseases have increased. Cancer rates have risen since the turn of the century from gl to 134 per ICO,0C0; heart disease death rates have increased from 167 to 208 per 100.000. Interestingly, the rate of death from stroke declined from 134 to 45 per 100,000 population, and the death rate from accidents declined from 76 to 44 per 100,000. The decline in the age~ adjusted stroke death rate was consistent with the overall de~th rates, so that in 1978 it accounted for approximately the same proportion of deaths as in 1900. As described in Chapter 1. successful efforts to reduce the number of deaths from both heart disease and stroke have more recently effected substantial decreases in the death rate from these diseases. Note the differences in trends in age-adjusted death rates from selected causes for the period 1900 to 1978 (Figure 2). Death rates from heart disease increased between the year 1900 and about 1950, then declined at an accelerating pace. Death rates from cancer, on the other hand, increased rapidly during the first half of the century, and continued to increase, though more slowly, through 1978. Death rates from stroke have de= creased steadily since 1900. The most dramatic de- creases were for the infectious diseases such as in- fluenza and pneumonia, for which reductions of 80 percent were achieved belween 1925 and 1950. The contrast between falling influenza and pneumonia death rates on the one hand, and rising cancer death rates on the other, provides a dra- matic example of trends with complex roots. Mul- tiple factors are clearly involved: life-saving im- provements in the prevention and treatment of in- fectious diseases; changing lifestyles, both detri- mental and favorable to health; a changing environment; and, not the least important, the im- proved standard of living that has alleviated ¢on- ditions contributing to susceptibility to disease.

Overarl age.adjusted de~th rate per 100,000 for tl~e leading causes of death in 1900 comparc'<J with 1978. Numbers in parent heses indicate percentages of total age adjusted (/eat h tale Source: NCHS, "FIr~l Mortallly S~atlstics, ~978," Monthly Vitat Statistics F~e~orL VOL 29, NO ~, ~uDDle~ent ~, Se~ember ~7, 1~3,

10 S 4

Healthier Infant~ Continuing a long-term downward trend, in 1978 the rate of infant deaths reached the lowest level ever recorded in the United States--fe~er than I4 for each 1,0O0 live births. Since 1930, the overall rate for infants has fallen bv about one haft, reflecting reductions in most causes of infant deaths. Infant deaths from influenza and pneu- monia dropped dramatically from 237 to 46 for each I(]0.0GO live births between 1950 and 1978, a decllne of gl percent (Figure 3). In 197g, about 48 percent of the deaths were caused by immaturity and blrth-associated conditions. These conditions included respiratory distress syndrome, hyaline membrane disea.~e, unspecified asphyxia of the newborn, birth injury without mention of cause, and other complications of pregnancy and child- birth. This 1978 rate represents a decline in the proportion of deaths from these causes from about 62 percent of all infant deaths in 1950, and is consistent with a drop of nearly 53 percent in the overall infam mortality rate (Figure 3L The proportion of low birth weight infants-- those newborn infants weighing less than 2,500 grams (5 pounds g ounces) is an objective, easity tracked measure, probably best correlated with deaths from immaturity and other birth-associ- ated conditions. Trends in percentages of infants Figure 3. Major Causes of Infant Deaths: 1950 and '[978 Ae~ Group - L~$ ~n 1 Yw f~,nk Ce~la~n CaUSeS el mortality ~n early infancy Infant mortalffy rote per 100.¢~0 ll~ btrlhs 1 r978r 47,9 percenl ]859.6 1930 ~!~ 58.,'percen ~ : : ~ ~ : L~ 17154 Congenital anomarie~ I 18.3 percent ] 252,1 ¢nllu~ an¢l pnE~d me nia 3.~lPerCenl ,3.3 percenl 46.0 ~ 237 4 Accidents 2.7 percent 37.9 ~eent 10~1 SePtleemM Percer~tage of totar mortality rate shown In bar. 5 ~ 4 percent 32.8 [~ 1978 (Total fate 1378.4) 2 ~)ercent 5.0 ~ ~0 (Total rote 2921 B~ I I I I I I I I 0 250 500 750 1000 1250 1500 1750 (a) NOt I~tnkecl ~n f~rst 10 leading cau~e~ of d~t h~ Sou~c~ NCHS~ V/tal ~tahstfc~--~pec~al Pepor~--Natlonat Summar/es, ~gS0~ Vo~ 37~ NCH~ ~F~al Mortality Slalisl~cs~ 1978," Monthl~ Vit~f ~ta ~i~ lic~ RP~0or t, Vn~ 2g~ NO 6~ gul)~mP.nt ~ S~pl~rnber ~7~ ~8~ 11

F]gure 4. PercQntage of Infanh; of Low Birth Weight. By Race: 1950-1978 I~prce~fage 15 ~ includin~ 81ack 10 ~ White 0 I L I 1950 ~9C-~ 1970 19B0 Sources: NGHS, Factors A ssocJated with Low Birth Weight, U S, 1976, Series 21, NO. 37. April, 19B0; NCHS, "Final Natality Slati~ics, 1978." Monthly Vilal Statistics ~eporK Vol. 29. No 1, Supplemenl, A0ril 28, 1980 of low biTth weight peaked in 1965 and 1966 and have declined gradually since then (Figure 4). Al- though since I966 ~maIler proho~on~ of both white and non-while newborns have fallen in this range, large disparEties ir~ percentages of low birth weight i~lfants persist ~norlg th~ races, tlnderscor- ing the special inl~or t arlce of addr esslng Ihis prob ]em among black worfien of ¢hildbearlng age. A n~lmher c~f maternal factors ¢:onlr~bute to lOW birth weight, inch~ding lack of prenatal ~arc. Poor nLt~rJtior~, srtlok~ng, alcohol aru] dr~g use. ~g~. race. artd ~ociaI ~u~d economic backgrotlnd Conget~it a] defects were the leading single iden- tifiable cause of infant deaths in [950 and ~n 197g. This group of birth defects comprlses those caused by deveIopmet~tal Or ger~etl¢ problems rather than injuries m utero or during birth Though the In- [ant mortalitY rate for congenital anomalies fell somewhat, from 396 to 252 for each 100.030 llve births, the actual incidence of specific congenital birth defects remained relatively stable (F~gere 3) Oztly recently has it become possible to lrack the incidence of birth defect~ with the bene ~'it of a na- tio,al birth defe~ts detection and reporting system ~2

It ~s estlrnated that between 1970 and ]97~ the total number of birth defects reported for the ten mort common types showed a sinai1 decllne (Figure -~). For some birth defects, spina biffda wlthout anencepha]y, for example, there was a small decline during the 1970s; while for others, such as hypo~padlas, there was a small Jrlcrease. The fact that death rates from birth defects have fallen over this same period, while the incidence of b~rth dcfccts has not, reflects advances in neona- tology, delivery technlques, urgent care for new horns, and special surgical methods. Preverttion actlvlt[e$ d~rected toward reducing birth defects include: immuni?~don against rubella (German measles) to prevent oecurrence of the disease during early pregnancy; J]ltrauterine diagnosis and Jnterv¢l~tlon for severe defects; genedc counseling for parcms at high risk of hav- ing infants with birth defects; public education campaigns to emphasize the haT~rd$ to the fetus presented by aXcohol, drugs, and tobacco; and special attention given to Jd~ntJfieation of toxic exposures that might injure the devefeplng fetus. F~IU re 5. Trends In Reported incidence Rates of Ten Selected B(rth Oefects: 1970-1979 Rate per 100,000 bldhs 10 5 4 3 0.5 94 03 02 f 01 I i I I I I I I I 1970 1971 1972 1973 1974 1975 ~976 1977 1978 ~979 Totar for ten se;~ct~l bldh def~t~a -- Hypospadtas; Down syndrome Spina biffda without anencephaly (a) "Selected detects" arP the folrowi~g ten defects, whic~ were selected from among those tracked by the Center for t)Jsease ContrOl Bidh Defects Monitoring Program: anenCephaly. $0ina 13if ida without anenc~ph~ly, ~.ydroc~phalus wilhout s~ina ~i!id~, c!eft Palate without c!ef~ !~p, ~ota~ cleft lip, tracheo~So~hageal fi~tula, rectal atresia acid stermsis~ ~lypo~padla~, redtlctieJit d~Iormity, ~nd D(lwn ~'fldrome Ifldividual births are counted more Ihan OrtCe if more tharl on~ defect is repo~t~d, 5oL~Ice: Centers tot Disease Control, October 1978

gigure 6. Major Causes of Childhood Deaths: 1950 and 1978 Age ~mup 1.14 y~rs Rate ~r 1~,~ ~ula~n ~#nk Accidents 27.6 Caner ~t 4,4 i Congenial anomalies ~8.2 ~rce~t 3.55.4 Healthier Children From 1950 to 1978 the death rate for children aged I to 14 fell from ~6 to 43 per 1~.~ popula- tion, a reduction of more than 50 percent, The change in rates for particular causes of death has varied widdy in both magnitude and direetlon ~ince 1951) (Figure 6). ACcidents, still the single largest cause of death among children 1 1o 14, declined 29 percent -- frona 28 to 20 per lO0,O00--between 1950 and 1978. Motor vch/de acc~denls accounted for =bout half the accidental deaths in this age group in 1978; although there weee fewer such deaths from 1973 to 1975, 5ollowJ.6 the gasoline shortage and adop- tion of the 55-mile-per-hour speed limit, more re- cent trends for this cause have not been favorable {Figure 7). Homfelde 4 3.7 ~r~e~t 1.6 ~t 0.6 Inlluenza and Dneumoni~t 25 ~3"3 percent 8.71 4 I I I 0 5 1u Pe¢centage of to~l mortalffy rate ShOWn ~n b~r. ~--~ 19"/8 (Total rate 42 9) ~195~ (TOtat rate 87.7) ~ 20 ~5 30 Sources: ~HS, Vifat Sftt[l~tfcs Sf~eC~[ tTeporfs~Nall~oaf ~tlrnmariea, tgSO, VOf 377 ~HS, "Ftna[ MoHafiW 6{atistics, ~978," Mo,lthly V/tel 6taff~tJcs ~eport. V~l ~ No. 6, Supplement 2, ~ptem~r 17,19~. 14