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Lessons from the Past
P E R S P E C T IV E
Lessons from the past Julius B. Richmond, MS, MD
O n e c o n s ta n t c h a r a c t e r is t ic o f th e A m e ric a n h ea lth care sy stem is its d yn am ism , its ev er-ch a n g in g n atu re, at o n ce resp o n siv e to th e n eed s o f th e citiz e n ry it serves, yet w illin g and d em o n strab ly able to g ive d i re ctio n and le ad ersh ip to ou r n atio n al qu est for better h ea lth . If th e reco rd o f ou r s o c ie ty ’s a cco m p lish m e n ts in h ealth is rem arkable— and , ce rta in ly , th at is the ca se— th e im p lica tio n s o f th o se a ch iev e m en ts for the y ears ahead are clea rly en co u rag in g . S in c e th e tu rn of th e p re sen t cen tu ry , w e have m u ted th e th reat o f th e in fe c tio u s d iseases and m ade s ig n ific a n t p rog ress ag ain st m any o f th e ch ro n ic c o n d itio n s and a fflic tio n s that so o ccu p y our atten tio n today. As a resu lt, w e A m erican s are h e a lth ie r today th an ever before. W e are liv in g lo n g er; life e x p e cta n cy h as risen to an a ll-tim e h ig h o f m o re th an 73 years for a c h ild b o rn today— up alm o st th ree years in th e last d ecad e, alo n e. O ur in fan t m o rtality rate has dropped to few er than 13 deaths for every 1 ,0 0 0 live b irth s— th e lo w est rate in our h isto ry. S ig n ific a n t ad v an ces have b een m ade in th e p re v en tio n and treatm en t o f h eart d isease and stroke. S in c e 1 9 6 8 , heart d isease m o rtality has fa lle n 2 3 % : d eath s from stroke h ave d e clin ed 3 8 % . E ven w ith c a n cer, th e d eath rate is co n tin u in g to d e c lin e am on g p erso n s y ou n ger th an 4 5 and n ow is b eg in n in g to d e crease am ong th o se b etw een th e ages o f 45 and 4 9 , as w ell. In th e fie ld o f oral h ea lth , th e sig n s are no le ss e n co u rag in g . E d en tu lo u sn ess is on th e d e c lin e : v isits to d en tists for p rev en tiv e serv ices are up. E ach year, the n u m b e r o f fa m ilie s se rv e d b y flu o r id a te d w a te r su p p lies in crea ses, and th e rate o f tooth d ecay is b e g in n in g to d eclin e. W ith a ll th is good n ew s, th ere rem ain som e serio u s 766 ■ JADA, Vol. 101, November 1980
p ro b lem s th at d eserve our a tten tio n , som e u n fo rtu n ate tren d s th at are ce rta in to ta x our a b ilitie s and our reso u rces in th e years ahead . A s a n atio n , w e h ave not y et b een a b le to co m e to g rips w ith th e ra p id ly e s c a la t ing co sts o f h ea lth care. N or h ave w e su cce ed e d in rem ov in g a ll th e fin a n c ia l b a rriers to ca re— barriers th at loom p a rticu la rly large, it m u st b e n o ted , in th e field o f d en tistry w h ere the gap in u se o f d en tal se r v ice s b etw een th e h av es an d th e h av e-n o ts o f our so ciety has d im in ish e d little d urin g th e p ast 15 years. It is estim ated that, still, m ore th an 6 0 ,0 0 0 p erm a n en t teeth are ex tracted every day, a great m any m ore are fille d , and h un d red s o f p eo p le b eco m e co m p letely ed en tu lo u s. In d eed , by age 6 4 , one o f ev ery th ree A m e rica n s has lo st a ll o f h is or h er n atu ral teeth .
O verall progress W e ca n b e proud o f th e o v erall prog ress th at w e h ave m ad e in re d u cin g in fa n t m o rtality , b u t w e m u st n ot lo se sig h t o f th e fact th at w e co n tin u e to ran k b eh in d at le a st ten oth er in d u stria liz ed n a tio n s in th is im p o r tan t in d ica to r o f h ea lth status and th at our prog ress has b een u n ev en . O n ly 5 9 % o f b la ck w o m en , c o m pared w ith 77 % o f w h ite w o m en , b eg in p ren atal care d urin g th e first th ree m o n th s o f p reg n an cy . A nd b irth rates for b la ck teen ag ers rem a in m ore th an th ree tim es as h ig h as th o se for w h ite teen ag ers. It is h a rd ly su r p risin g , th e n , th at ev en th o u g h th e b la ck in fa n t m o r ta lity has b een ro u g h ly h alv ed s in c e 1 9 5 0 , it is still n early tw ice as h ig h , tod ay, as th e rate for w h ite in fants. W e m ig h t ask o u rselv es if w e are co n cen tra tin g on savin g very you ng liv es o n ly to lo se th em , in later y ears, to o th e r, la rg e ly p re v e n ta b le illn e s s e s and traum as. B e tw een 1 9 7 6 and 1 9 7 7 , m o rta lity d eclin ed in every seg m en t o f th e A m erica n p o p u la tio n bu t one. A m on g teen ag ers, th e d eath rate a ctu a lly in crea sed , w ith m o to r v e h ic le a c c id e n ts and su icid e s h ead in g the list o f cau ses. T o ca lcu la te th e m an y p ro d u ctiv e years o f ad u lt life that w ere n ee d le ssly lo st in th is on e year, a lo n e , is to a p p ro ach th e ess e n ce o f A m e ric a ’s gro w in g p re o ccu pation w ith d isea se p rev en tio n and h ea lth p ro m o tion . T h e re is no su b stitu te for p rev en tin g h ealth pro b lem s b efo re th ey o ccu r. W e learn ed h o w to p re v en t th e in fe c tio u s d iseases th at took su ch a terrib le
P E R SP E C T IV E
to ll in liv es in d e ed , w e co n fro n t us L ate la s t
for so m any y ears. W e can do th e sam e— can do no le ss— w ith th e co n d itio n s th at today. su m m er, m y o ffic e re le a s e d a re p o rt, H ea lth y P e o p le : T h e Su rgeon G e n e r a l’s R ep o rt on H ealth P ro m o tio n a n d D isea se P rev en tio n , th at e x pressed th e op p o rtu n ity and th e c h a lle n g e in u n m is tak ab le term s. If w e are to im prove th e h e a lth o f our p eo p le in th e years ahead , th e report p re d icted , w e w ill h ave to reord er ou r cu rren t p rio ritie s in h ea lth care, to pu t g reater em p h asis on th e p re v en tio n o f d is ease and th e p ro m o tio n o f h ealth . M o st serio u s illn e sse s, th e report m akes clea r, are related to sev eral risk factors. So m e risk facto rs, su ch as cig a rette sm o k in g , poor dietary h ab its, and sev ere em o tio n a l d istress, h av e b een im p lica ted in sev eral illn e sse s. “ It is th e c o n tro lla b ility o f m any r is k s ,” th e rep ort c o n c lu d e s, “ and often the sig n ific a n c e o f c o n tro llin g ev en a few , th at lie at th e heart o f d isease p rev en tio n and h ea lth p ro m o tio n .” A c co rd in g ly , th e rep ort fo cu ses on m ajo r h ea lth p ro b lem s an d th e ir asso ciated risks at each o f th e five p rin cip a l stag es o f life— in fan cy , a d o le sce n c e , you n g a d u lth o o d , ad u lth o o d , and o ld er ad u lth o o d . T h e r e port th en p resen ts a qu an tified goal, to be ach iev e d by 1 9 9 0 , for ea ch stage. In term s o f m akin g life safer for b a b ies, th e rep o rt ca lls for at le ast a 3 5 % re d u ctio n in in fa n t m o rtality , to a rate of few er th an n in e d eath s per 1 ,0 0 0 liv e b irth s. T o im p rove th e h ea lth o f ad u lts, th e rep ort m a in ta in s th at w e shou ld be ab le to red u ce d eath s am on g p eo p le 25 to 64 years o f age by at least 2 5 % , to a rate of few er than 4 0 0 per 1 0 0 ,0 0 0 .
G oals defined T h e se g oals, o n ly tw o o f w h ic h I h ave m e n tio n e d , are b a sed on re ce n t U .S . m o rtality tren d s, on rates alread y a ch iev ed by o th er co u n tries w ith reso u rces s im ila r to our ow n an d , in th e w ords o f th e report, on “ th e very g reat lik e lih o o d th a t a reaso n ab le, affo rd able effort ca n m ake th e goals a c h ie v a b le .” T h e rep o rt did n o t
stop th ere, how ever; it also stip u la ted 15 p rio rity a c tio n areas, grouped in th ree broad ca teg o rie s, th at w e th o u g h t w ou ld be c r itic a l to th e a ch ie v e m e n t of the fiv e m ajor goals. T h u s, H ea lth y P e o p le re co m m en d s co n tin u e d em p h a sis on th e p rev en tiv e h ea lth serv ic e s th at are u su ally d eliv ered to in d iv id u a ls by h ea lth ca re p rovid ers. C h ie f am o n g th e se are fa m ily p la n n in g se r v ic e s , p reg n an cy and in fa n t care, im m u n iz a tio n , sex u a lly tra n sm issib le d isease se rv ic e s, and co n tro l o f high blood p ressure. A t th e sam e tim e, w e m u st pay in creased atten tio n to th e kin d s o f h e a lth p ro tectio n m e a su re s th a t g o v e rn m e n ts, in d u s tr y , a n d o th e r co m m u n ity a g en cies ca n take. O f im p o rta n ce, h ere, are flu o rid a tio n o f co m m u n ity w ater s u p p lie s, to x ic ag en t co n tro l, o cc u p a tio n a l safety an d h e a lth , a c c i d en tal in ju ry co n tro l, and in fe c tio u s ag en t co n tro l. T h e th ird category, h e a lth p ro m o tio n efforts, is co m p rised o f fiv e im p o rta n t a ctio n s th a t in d iv id u a ls and co m m u n itie s ca n take to p ro m o te h e a lth y life sty les. N one, in m y v iew , is m ore im p o rta n t than sm okin g cessa tio n . C lose b eh in d it co m e re d u cin g the m isu se of a lco h o l an d dru gs, im p ro v ed n u tritio n , e x e rcise, and fitn e ss and stress co n tro l. W e m u st im p rov e ou r p erfo rm a n ce in th e se 15 c r it ic a l areas if our p re v en tio n prog ram s are to su cce ed . P r e v e n tio n an d h e a l t h p r o m o tio n a re th e c o r n ersto n es of our n atio n al h ea lth strateg y for c o n tin u in g to ad v an ce th e h e a lth o f th e A m e ric a n peop le. T h is is the m essage of th e Su rgeo n G e n e ra l’s R eport. It is h ard ly a n ew m essag e; in d e ed , o n e m ig h t ca ll it a le sso n from th e past. B u t w h a t m akes it so co m p e llin g tod ay is th at w e are re d isco v e rin g it at a tim e w h en .we h ave th e a b ility and th e k n o w led g e to m ake it w ork. A n d w e are en u n cia tin g it and sp read in g it at a tim e w h en th e A m erica n p e o p le seem p rep ared to a cc e p t it and m ake it a re a lity in th e ir liv es. T o h elp g u id e ou r co u rse and m easu re ou r p rogress, w e are d ev elo p in g m ore d eta iled n a tio n a l p rev en tio n o b je c tiv e s for 1 9 9 0 . T h e s e w ill e s ta b lis h s p e c ific targets for risk re d u ctio n and im p rov ed h e a lth status.
It is important to k eep in m ind that prevention is desirable not only because it m ay save m oney in the long run or extend the length of life but also because it can improve the quality of living. This is especially true in dentistry fo r the young and old alike.
R ich m o n d : L E S S O N S F R O M T H E P A S T .
767
PERSPECTIVE
T h e y w ill d eal w ith oral h e a lth issu e s alo n g w ith th e fu ll ran g e o f o th er h e a lth m atters e n co m p a ssed by th e 15 p rio rity a ctio n areas for p rev en tio n . It is im p o rta n t to keep in m in d th a t p re v en tio n is d esira b le n o t o n ly b ec a u se it m ay save m o n ey in th e lo n g ru n or ex ten d th e le n g th o f life , b u t also b eca u se it ca n im p ro v e th e q u ality o f liv in g . T h is is e sp e c ia lly tru e in d en tistry for th e y ou n g and o ld alik e. C er ta in ly , e x p e rie n cin g to o th a ch es and e x te n siv e re sto ra tio n s d u rin g ch ild h o o d or d estru ctiv e p e rio d o n ta l d ise a se d u rin g th e ad u lt y ears d etracts from th e q u a l ity o f life . It is th e u su al pattern for th e q u a lity o f life in la ter y ears to b e co m p ro m ise d by th e lo ss o f a ll n atu ral teeth , w h ic h a d v ersely affe cts ap p e a ra n ce , m a s tic a tio n an d p ro p er n u tritio n . E fforts to av o id th is s itu a tio n an d im p ro v e th is im p o rtan t a sp e ct o f life for fu tu re g en era tio n s can be m ost effectiv e b y co n c e n tra t ing on d en tal d ise a se p re v en tio n an d o ral h e a lth p re s erv atio n from ch ild h o o d th ro u g h o u t life.
Conclusions
in g . If o n ce th e re w as ro o m for co n je c tu re a b o u t th e lin k s b e tw e e n e n v iro n m en ta l co n d itio n s, b eh a v io r p attern s, an d th e d ev e lo p m e n t an d p ro g ressio n of d isease, th o se days are g o n e: th e re la tio n sh ip s are b e co m in g cle a re r ev ery day. A m e ric a n s are m o re c o n sc io u s o f th e se issu e s th a n ever b efo re, an d th e ir aw aren ess h a s b ro u g h t w ith it n ew an d co n stru c tiv e w ays o f lo o k in g at “ good h e a lth ” an d its co m p o n e n ts: it h as m ad e u s co g n iz a n t o f th e step s th at e a c h o f us ca n an d sh o u ld take to p ro tect ou r ow n h e a lth an d the h e a lth o f our fa m ilie s and co m m u n itie s. T o th e e x te n t th at w e tak e th o se step s, n o w an d in th e years im m ed ia tely ah ead , w e w ill e lim in a te u n n ecessa ry d eath an d d isa b ility in th is co u n try an d e n h a n ce th e q u a lity o f life for g en era tio n s to co m e . T h at, in m y v iew , is an e x c itin g an d en co u ra g in g p ro sp ect.
Dr. R ich m o n d is a ssista n t secretary fo r h ea lth , D ep artm en t o f H ealth and H um an R eso u rces, W a sh in g to n , DC 2 0 2 0 1 , and su rgeon g en era l, P u b lic H ealth S erv ice. A d d ress re q u e sts fo r Teprints to th e author. E ssay s o f o p in io n on cu rren t issu es in d en tistry are p u b lish e d in th is s e c
T h e sh ap e o f h e a lth care in th is co u n try is ch a n g in g to d ay in w ays th a t ca n only b e v iew ed as en c o u ra g
768 ■ JADA, Vol. 101, November 1980
tio n o f T h e Jo u rn a l. T h e o p in io n s ex p ressed or im p lied are s tric tly th o se o f th e a u th o rs an d do n o t n e c e ssa rily re fle c t th e o p in io n or o ffic ia l p o lic ie s or p o sitio n o f th e A m e rica n D en tal A sso cia tio n .
Lessons from the past Julius B. Richmond, MS, MD
O n e c o n s ta n t c h a r a c t e r is t ic o f th e A m e ric a n h ea lth care sy stem is its d yn am ism , its ev er-ch a n g in g n atu re, at o n ce resp o n siv e to th e n eed s o f th e citiz e n ry it serves, yet w illin g and d em o n strab ly able to g ive d i re ctio n and le ad ersh ip to ou r n atio n al qu est for better h ea lth . If th e reco rd o f ou r s o c ie ty ’s a cco m p lish m e n ts in h ealth is rem arkable— and , ce rta in ly , th at is the ca se— th e im p lica tio n s o f th o se a ch iev e m en ts for the y ears ahead are clea rly en co u rag in g . S in c e th e tu rn of th e p re sen t cen tu ry , w e have m u ted th e th reat o f th e in fe c tio u s d iseases and m ade s ig n ific a n t p rog ress ag ain st m any o f th e ch ro n ic c o n d itio n s and a fflic tio n s that so o ccu p y our atten tio n today. As a resu lt, w e A m erican s are h e a lth ie r today th an ever before. W e are liv in g lo n g er; life e x p e cta n cy h as risen to an a ll-tim e h ig h o f m o re th an 73 years for a c h ild b o rn today— up alm o st th ree years in th e last d ecad e, alo n e. O ur in fan t m o rtality rate has dropped to few er than 13 deaths for every 1 ,0 0 0 live b irth s— th e lo w est rate in our h isto ry. S ig n ific a n t ad v an ces have b een m ade in th e p re v en tio n and treatm en t o f h eart d isease and stroke. S in c e 1 9 6 8 , heart d isease m o rtality has fa lle n 2 3 % : d eath s from stroke h ave d e clin ed 3 8 % . E ven w ith c a n cer, th e d eath rate is co n tin u in g to d e c lin e am on g p erso n s y ou n ger th an 4 5 and n ow is b eg in n in g to d e crease am ong th o se b etw een th e ages o f 45 and 4 9 , as w ell. In th e fie ld o f oral h ea lth , th e sig n s are no le ss e n co u rag in g . E d en tu lo u sn ess is on th e d e c lin e : v isits to d en tists for p rev en tiv e serv ices are up. E ach year, the n u m b e r o f fa m ilie s se rv e d b y flu o r id a te d w a te r su p p lies in crea ses, and th e rate o f tooth d ecay is b e g in n in g to d eclin e. W ith a ll th is good n ew s, th ere rem ain som e serio u s 766 ■ JADA, Vol. 101, November 1980
p ro b lem s th at d eserve our a tten tio n , som e u n fo rtu n ate tren d s th at are ce rta in to ta x our a b ilitie s and our reso u rces in th e years ahead . A s a n atio n , w e h ave not y et b een a b le to co m e to g rips w ith th e ra p id ly e s c a la t ing co sts o f h ea lth care. N or h ave w e su cce ed e d in rem ov in g a ll th e fin a n c ia l b a rriers to ca re— barriers th at loom p a rticu la rly large, it m u st b e n o ted , in th e field o f d en tistry w h ere the gap in u se o f d en tal se r v ice s b etw een th e h av es an d th e h av e-n o ts o f our so ciety has d im in ish e d little d urin g th e p ast 15 years. It is estim ated that, still, m ore th an 6 0 ,0 0 0 p erm a n en t teeth are ex tracted every day, a great m any m ore are fille d , and h un d red s o f p eo p le b eco m e co m p letely ed en tu lo u s. In d eed , by age 6 4 , one o f ev ery th ree A m e rica n s has lo st a ll o f h is or h er n atu ral teeth .
O verall progress W e ca n b e proud o f th e o v erall prog ress th at w e h ave m ad e in re d u cin g in fa n t m o rtality , b u t w e m u st n ot lo se sig h t o f th e fact th at w e co n tin u e to ran k b eh in d at le a st ten oth er in d u stria liz ed n a tio n s in th is im p o r tan t in d ica to r o f h ea lth status and th at our prog ress has b een u n ev en . O n ly 5 9 % o f b la ck w o m en , c o m pared w ith 77 % o f w h ite w o m en , b eg in p ren atal care d urin g th e first th ree m o n th s o f p reg n an cy . A nd b irth rates for b la ck teen ag ers rem a in m ore th an th ree tim es as h ig h as th o se for w h ite teen ag ers. It is h a rd ly su r p risin g , th e n , th at ev en th o u g h th e b la ck in fa n t m o r ta lity has b een ro u g h ly h alv ed s in c e 1 9 5 0 , it is still n early tw ice as h ig h , tod ay, as th e rate for w h ite in fants. W e m ig h t ask o u rselv es if w e are co n cen tra tin g on savin g very you ng liv es o n ly to lo se th em , in later y ears, to o th e r, la rg e ly p re v e n ta b le illn e s s e s and traum as. B e tw een 1 9 7 6 and 1 9 7 7 , m o rta lity d eclin ed in every seg m en t o f th e A m erica n p o p u la tio n bu t one. A m on g teen ag ers, th e d eath rate a ctu a lly in crea sed , w ith m o to r v e h ic le a c c id e n ts and su icid e s h ead in g the list o f cau ses. T o ca lcu la te th e m an y p ro d u ctiv e years o f ad u lt life that w ere n ee d le ssly lo st in th is on e year, a lo n e , is to a p p ro ach th e ess e n ce o f A m e ric a ’s gro w in g p re o ccu pation w ith d isea se p rev en tio n and h ea lth p ro m o tion . T h e re is no su b stitu te for p rev en tin g h ealth pro b lem s b efo re th ey o ccu r. W e learn ed h o w to p re v en t th e in fe c tio u s d iseases th at took su ch a terrib le
P E R SP E C T IV E
to ll in liv es in d e ed , w e co n fro n t us L ate la s t
for so m any y ears. W e can do th e sam e— can do no le ss— w ith th e co n d itio n s th at today. su m m er, m y o ffic e re le a s e d a re p o rt, H ea lth y P e o p le : T h e Su rgeon G e n e r a l’s R ep o rt on H ealth P ro m o tio n a n d D isea se P rev en tio n , th at e x pressed th e op p o rtu n ity and th e c h a lle n g e in u n m is tak ab le term s. If w e are to im prove th e h e a lth o f our p eo p le in th e years ahead , th e report p re d icted , w e w ill h ave to reord er ou r cu rren t p rio ritie s in h ea lth care, to pu t g reater em p h asis on th e p re v en tio n o f d is ease and th e p ro m o tio n o f h ealth . M o st serio u s illn e sse s, th e report m akes clea r, are related to sev eral risk factors. So m e risk facto rs, su ch as cig a rette sm o k in g , poor dietary h ab its, and sev ere em o tio n a l d istress, h av e b een im p lica ted in sev eral illn e sse s. “ It is th e c o n tro lla b ility o f m any r is k s ,” th e rep ort c o n c lu d e s, “ and often the sig n ific a n c e o f c o n tro llin g ev en a few , th at lie at th e heart o f d isease p rev en tio n and h ea lth p ro m o tio n .” A c co rd in g ly , th e rep ort fo cu ses on m ajo r h ea lth p ro b lem s an d th e ir asso ciated risks at each o f th e five p rin cip a l stag es o f life— in fan cy , a d o le sce n c e , you n g a d u lth o o d , ad u lth o o d , and o ld er ad u lth o o d . T h e r e port th en p resen ts a qu an tified goal, to be ach iev e d by 1 9 9 0 , for ea ch stage. In term s o f m akin g life safer for b a b ies, th e rep o rt ca lls for at le ast a 3 5 % re d u ctio n in in fa n t m o rtality , to a rate of few er th an n in e d eath s per 1 ,0 0 0 liv e b irth s. T o im p rove th e h ea lth o f ad u lts, th e rep ort m a in ta in s th at w e shou ld be ab le to red u ce d eath s am on g p eo p le 25 to 64 years o f age by at least 2 5 % , to a rate of few er than 4 0 0 per 1 0 0 ,0 0 0 .
G oals defined T h e se g oals, o n ly tw o o f w h ic h I h ave m e n tio n e d , are b a sed on re ce n t U .S . m o rtality tren d s, on rates alread y a ch iev ed by o th er co u n tries w ith reso u rces s im ila r to our ow n an d , in th e w ords o f th e report, on “ th e very g reat lik e lih o o d th a t a reaso n ab le, affo rd able effort ca n m ake th e goals a c h ie v a b le .” T h e rep o rt did n o t
stop th ere, how ever; it also stip u la ted 15 p rio rity a c tio n areas, grouped in th ree broad ca teg o rie s, th at w e th o u g h t w ou ld be c r itic a l to th e a ch ie v e m e n t of the fiv e m ajor goals. T h u s, H ea lth y P e o p le re co m m en d s co n tin u e d em p h a sis on th e p rev en tiv e h ea lth serv ic e s th at are u su ally d eliv ered to in d iv id u a ls by h ea lth ca re p rovid ers. C h ie f am o n g th e se are fa m ily p la n n in g se r v ic e s , p reg n an cy and in fa n t care, im m u n iz a tio n , sex u a lly tra n sm issib le d isease se rv ic e s, and co n tro l o f high blood p ressure. A t th e sam e tim e, w e m u st pay in creased atten tio n to th e kin d s o f h e a lth p ro tectio n m e a su re s th a t g o v e rn m e n ts, in d u s tr y , a n d o th e r co m m u n ity a g en cies ca n take. O f im p o rta n ce, h ere, are flu o rid a tio n o f co m m u n ity w ater s u p p lie s, to x ic ag en t co n tro l, o cc u p a tio n a l safety an d h e a lth , a c c i d en tal in ju ry co n tro l, and in fe c tio u s ag en t co n tro l. T h e th ird category, h e a lth p ro m o tio n efforts, is co m p rised o f fiv e im p o rta n t a ctio n s th a t in d iv id u a ls and co m m u n itie s ca n take to p ro m o te h e a lth y life sty les. N one, in m y v iew , is m ore im p o rta n t than sm okin g cessa tio n . C lose b eh in d it co m e re d u cin g the m isu se of a lco h o l an d dru gs, im p ro v ed n u tritio n , e x e rcise, and fitn e ss and stress co n tro l. W e m u st im p rov e ou r p erfo rm a n ce in th e se 15 c r it ic a l areas if our p re v en tio n prog ram s are to su cce ed . P r e v e n tio n an d h e a l t h p r o m o tio n a re th e c o r n ersto n es of our n atio n al h ea lth strateg y for c o n tin u in g to ad v an ce th e h e a lth o f th e A m e ric a n peop le. T h is is the m essage of th e Su rgeo n G e n e ra l’s R eport. It is h ard ly a n ew m essag e; in d e ed , o n e m ig h t ca ll it a le sso n from th e past. B u t w h a t m akes it so co m p e llin g tod ay is th at w e are re d isco v e rin g it at a tim e w h en .we h ave th e a b ility and th e k n o w led g e to m ake it w ork. A n d w e are en u n cia tin g it and sp read in g it at a tim e w h en th e A m erica n p e o p le seem p rep ared to a cc e p t it and m ake it a re a lity in th e ir liv es. T o h elp g u id e ou r co u rse and m easu re ou r p rogress, w e are d ev elo p in g m ore d eta iled n a tio n a l p rev en tio n o b je c tiv e s for 1 9 9 0 . T h e s e w ill e s ta b lis h s p e c ific targets for risk re d u ctio n and im p rov ed h e a lth status.
It is important to k eep in m ind that prevention is desirable not only because it m ay save m oney in the long run or extend the length of life but also because it can improve the quality of living. This is especially true in dentistry fo r the young and old alike.
R ich m o n d : L E S S O N S F R O M T H E P A S T .
767
PERSPECTIVE
T h e y w ill d eal w ith oral h e a lth issu e s alo n g w ith th e fu ll ran g e o f o th er h e a lth m atters e n co m p a ssed by th e 15 p rio rity a ctio n areas for p rev en tio n . It is im p o rta n t to keep in m in d th a t p re v en tio n is d esira b le n o t o n ly b ec a u se it m ay save m o n ey in th e lo n g ru n or ex ten d th e le n g th o f life , b u t also b eca u se it ca n im p ro v e th e q u ality o f liv in g . T h is is e sp e c ia lly tru e in d en tistry for th e y ou n g and o ld alik e. C er ta in ly , e x p e rie n cin g to o th a ch es and e x te n siv e re sto ra tio n s d u rin g ch ild h o o d or d estru ctiv e p e rio d o n ta l d ise a se d u rin g th e ad u lt y ears d etracts from th e q u a l ity o f life . It is th e u su al pattern for th e q u a lity o f life in la ter y ears to b e co m p ro m ise d by th e lo ss o f a ll n atu ral teeth , w h ic h a d v ersely affe cts ap p e a ra n ce , m a s tic a tio n an d p ro p er n u tritio n . E fforts to av o id th is s itu a tio n an d im p ro v e th is im p o rtan t a sp e ct o f life for fu tu re g en era tio n s can be m ost effectiv e b y co n c e n tra t ing on d en tal d ise a se p re v en tio n an d o ral h e a lth p re s erv atio n from ch ild h o o d th ro u g h o u t life.
Conclusions
in g . If o n ce th e re w as ro o m for co n je c tu re a b o u t th e lin k s b e tw e e n e n v iro n m en ta l co n d itio n s, b eh a v io r p attern s, an d th e d ev e lo p m e n t an d p ro g ressio n of d isease, th o se days are g o n e: th e re la tio n sh ip s are b e co m in g cle a re r ev ery day. A m e ric a n s are m o re c o n sc io u s o f th e se issu e s th a n ever b efo re, an d th e ir aw aren ess h a s b ro u g h t w ith it n ew an d co n stru c tiv e w ays o f lo o k in g at “ good h e a lth ” an d its co m p o n e n ts: it h as m ad e u s co g n iz a n t o f th e step s th at e a c h o f us ca n an d sh o u ld take to p ro tect ou r ow n h e a lth an d the h e a lth o f our fa m ilie s and co m m u n itie s. T o th e e x te n t th at w e tak e th o se step s, n o w an d in th e years im m ed ia tely ah ead , w e w ill e lim in a te u n n ecessa ry d eath an d d isa b ility in th is co u n try an d e n h a n ce th e q u a lity o f life for g en era tio n s to co m e . T h at, in m y v iew , is an e x c itin g an d en co u ra g in g p ro sp ect.
Dr. R ich m o n d is a ssista n t secretary fo r h ea lth , D ep artm en t o f H ealth and H um an R eso u rces, W a sh in g to n , DC 2 0 2 0 1 , and su rgeon g en era l, P u b lic H ealth S erv ice. A d d ress re q u e sts fo r Teprints to th e author. E ssay s o f o p in io n on cu rren t issu es in d en tistry are p u b lish e d in th is s e c
T h e sh ap e o f h e a lth care in th is co u n try is ch a n g in g to d ay in w ays th a t ca n only b e v iew ed as en c o u ra g
768 ■ JADA, Vol. 101, November 1980
tio n o f T h e Jo u rn a l. T h e o p in io n s ex p ressed or im p lied are s tric tly th o se o f th e a u th o rs an d do n o t n e c e ssa rily re fle c t th e o p in io n or o ffic ia l p o lic ie s or p o sitio n o f th e A m e rica n D en tal A sso cia tio n .