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Executive Summary - Word document
Introduction
The 2002 edition of The Health of
Washington State is the Department of
Health's periodic review of Washington's
well-being. It asks three general questions: How
healthy is Washington State as a place to live?
How healthy are we as a community of people
sharing that place? And, are some of us better
off than others?
These questions reflect the goals set by the
national program to improve health, Healthy
People. Begun in 1979, the Healthy People
initiatives are intended to improve the health
of the American people and to reduce disparities
in health between groups. When national goals
were set for 1990 and 2000, disparities were
defined solely in terms of race and ethnicity. Healthy
People 2010 defines disparities more broadly
to include differences by gender, socioeconomic
position, geographic location, disability
status, and sexual orientation. That broader
perspective is reflected in this edition of The
Health of Washington State, which
systematically evaluates health indicators for
disparities by age, gender, race and ethnicity,
education, income, rural or urban residence, and
county.
The State and Its People
The 2000 census reported almost 5.9 million
people living in Washington, a 21% increase
from 1990. Washington's growth rate was about
50% higher than the national average of 13%.
Like populations in most industrialized
countries, the state's population is getting
older. Between 1990 and 2000, the median age
rose from 31 to more than 35 years, about the
same as that of the US.
Washington is considerably more racially
and ethnically homogenous than the US. Based
on those who reported a single race in the
2000 census, whites made up about 82% of
Washington's population, compared to 75%
nationally. Washington has more Asians and
American Indians/Alaska Natives than the
nation, but fewer African Americans and
Hispanic or Latino/a individuals.
Social conditions are major determinants of
health. Social forces acting at a collective
level shape individual biological responses,
risk behaviors, environmental exposures, and
access to resources that promote health. In
general, people of higher socioeconomic
position (measured by income, education,
occupation, community resources, or social
factors) enjoy better health than those of
lower socioeconomic position. Two
readily-available measures of socioeconomic
position are income and education. Median
family income in Washington for 1999 was
almost $46,000 per year compared to about
$41,000 for the US. In 2000, almost 90% of
Washington's population age 25 years and older
had at least a high school education compared
to approximately 82% in the country as a
whole.
One consequence of Washington's relatively
higher levels of income and education is that,
in general, Washington's health indicators are
better than those of the US. Even when
accounting for income and education, Asians
and whites have better health as measured by
many health indicators than people of other
races. Thus, Washington's relatively large
proportion of Asian and white residents also
contributes to Washington's health indicators
being better than those in the US.
Eighty percent of the state's population
lives west of the Cascade Mountains, and more
than half live in King, Pierce, or Snohomish
counties. This three-county region is also
where health care providers and facilities are
concentrated, a pattern which means those
living in many parts of the state often have
to travel long distances to receive health
care.
Major Risk and Protective Factors
Risk factors are characteristics of
individuals, families, and communities that
make us more vulnerable to ill health.
Protective factors are characteristics that
"protect" and thus significantly
reduce the likelihood of disease, injury, or
disability. An article published in 1993 in
the Journal of the American Medical
Association (JAMA) explored the
"actual" causes of death in the
United States and concluded that half of US
deaths can be attributed to tobacco, poor diet
and lack of physical activity, alcohol abuse,
and unhealthy sexual behaviors.
Smoking in Washington remained relatively
constant throughout the 1990s at more than 20%
of adults and about 25% of high school
seniors. Both levels are above the Healthy
People 2000 target of no more than 15%.
Efforts to decrease smoking in Washington
continue to face countervailing influences
from national marketing campaigns by the
tobacco industry, and it is not clear whether
the Healthy People 2010 targets can be
reached.
The percent of adults in Washington
reporting heights and weights indicating
obesity doubled in the 1990s. By 2000, almost
20% of the state's adults were obese, and
another third were overweight. This level is
significantly above the Healthy People 2000
target that no more than 20% of adults be
overweight or obese. Modification of the
environment to encourage physical activity and
healthy food choices is effective in helping
people maintain healthy body weights and in
reducing the prevalence and impact of many
chronic diseases associated with unhealthy
diets and sedentary lifestyles.
Heavy alcohol drinking in Washington has
declined over the last decade. Per capita
alcohol consumption has also declined. These
declines are consistent with drops in
alcohol-related traffic deaths and cirrhosis
deaths to the point where both these rates are
about equal to the Healthy People 2000
targets. During the same period, the rate of
drug-related deaths more than doubled and now
is nearly twice the Healthy People 2000
target. Washington is on track to meet the Healthy
People 2010 goal for reducing
alcohol-related traffic deaths, but barring
substantial change, it seems unlikely that
Washington can achieve the Healthy People
2010 targets for cirrhosis deaths and drug
use.
Washington residents with lower incomes
report more smoking, and women with lower
incomes are more likely to be obese compared
to people in higher income groups. Adults with
lower levels of education report more smoking
and obesity and lower consumption of fruit and
vegetables than those with more education.
Additionally, African Americans and American
Indians report more obesity and American
Indians report more smoking than do people in
other racial groups.
Infectious Disease
Today, immunizations protect children
against a wide range of infectious diseases
and also protect vulnerable adults against
influenza and pneumonia. Rates of infectious
diseases such as gonorrhea, syphilis,
hepatitis A, hepatitis B, and HIV/AIDS in
Washington are lower than the Healthy
People 2000 targets and, in some cases,
have already approached the Healthy People
2010 levels. Washington also came close to
the target for adult immunization against
influenza and met the target for adult
immunization against pneumonia. However, the
state has failed to meet the Healthy People
2000 targets for childhood immunizations,
and tuberculosis rates here are significantly
higher than the national target. Additionally,
dental caries (tooth decay) is the most common
disease of childhood, and while Washington has
met or surpassed some Healthy People 2000
and 2010 targets related to oral health, the
proportion of six- to eight-year-olds with
dental caries was significantly higher than
the 2000 and 2010 targets.
Some infectious diseases are relatively
rare and case reports often do not include
information about education or income. For
these reasons, it is difficult to identify
patterns of disparities, and when racial or
ethnic disparities are observed, it is
difficult to determine whether they are
related to socioeconomic factors. Certain
diseases, such as tuberculosis, occur more
frequently among foreign-born persons, while
others - such as sexually transmitted diseases
- are concentrated among younger adults.
Chronic Disease
Many chronic diseases leave a residual
disability that can have a profound impact on
the quality of life for persons affected by
them. Chronic diseases discussed in this
report include coronary heart disease, stroke,
high blood pressure, lung cancer, colorectal
cancer, female breast cancer, invasive
cervical cancer, melanoma, asthma, diabetes,
and arthritis.
Mortality, incidence, and hospitalization
show encouraging declines in recent years for
some chronic diseases, but worrisome increases
in melanoma, diabetes, and arthritis. Although
Washington has lower rates than the US for
some chronic diseases, rates for stroke and
melanoma are higher. And, despite having
reached some Healthy People 2000
targets, Washington has not met the targets
for stroke, lung cancer, or diabetes. For each
of these chronic diseases, considerable effort
will be required to duplicate the successes
seen in coronary heart disease and cervical
cancer. For these two diseases, rates are
declining, Washington has lower rates than the
US as a whole, and the Healthy People 2000
targets have been met.
Rates of chronic disease vary widely among
counties, but for the most part, no geographic
patterns are apparent. Overall, rural areas
have higher rates for high blood pressure,
cervical cancer, diabetes, and arthritis than
do urban areas. For asthma, rates are higher
in the most rural and the most urban parts of
the state. Most chronic diseases affect older
persons more than younger ones. Cervical
cancer and asthma are notable exceptions. Men
have higher rates of most chronic diseases
than women, although arthritis and breast
cancer are exceptions. Asthma, on the other
hand, shows a peculiar pattern: rates are
higher for males at the youngest ages, but
higher for females once puberty is reached.
Injury and Violence
The risk of injury is so great that most
persons sustain a significant injury at some
time during their lives. Most injuries are not
accidents, or random, uncontrollable acts of
fate but are predictable and preventable.
Injuries are the leading cause of death in
Washington for people age 1 to 44 years. One
death out of every 14 in Washington resulted
from injury; 65% of these were classified as
unintentional and 30% were due to violence
(homicide or suicide).
Injurious and violent events discussed in
this report include motor vehicle deaths,
drowning, traumatic brain injury, falls among
older adults, suicide, homicide, youth
violence, domestic violence, and child abuse.
Washington has achieved the Healthy People
2000 targets for motor vehicle deaths,
homicide, domestic violence, and youth
violence. However, the state's suicide rate
remains higher than the national target, as
does the rate of hip fracture among older
adults. Data limitations make it difficult to
determine whether the state's child abuse rate
has met the Healthy People 2000 target.
While every person is at risk for injury,
certain types of injuries appear to affect
some groups more frequently. For example,
white, elderly females are at highest risk for
falls and fall-related injuries while young
people are at highest risk of dying from a
motor vehicle injury or homicide, and males
are more likely to die from suicide than
females. There are substantial differences in
motor vehicle death rates between counties.
Maternal and Child Health
A healthy population begins with a healthy
pregnancy. Six aspects of maternal and child
health are examined in this report: prenatal
care, adolescent pregnancy, low birth weight,
infant mortality, children with special health
needs, and unintended pregnancy. The state's
achievements in these areas are mixed. Rates
of adolescent pregnancy and infant mortality
are lower than both the Healthy People 2000
targets and the more demanding Washington
State goals. However, the state failed to meet
the national target for first-trimester
prenatal care, pregnancy intention, and low
birth weight. In addition, changes in how
services are provided now threaten our goal to
provide every child with special health needs
access to a regular health care provider and
appropriate case management.
There are substantial differences in
maternal and child health indicators by income
and education and between counties. Overall,
African-American and American Indian mothers
generally have poorer maternal-child health
outcomes than do whites. Hispanic mothers are
less likely to get first-trimester prenatal
care than non-Hispanic mothers, but Hispanic
infants do not have higher rates of low birth
weight or infant mortality.
Environmental Health
Environmental health is concerned with
chemical compounds, microbiological organisms,
and other hazards in our surroundings that can
adversely affect our health. People come into
contact with these hazards either by breathing
contaminated air, eating or drinking
contaminated food or water, or touching a
contaminated object or soil. This report
includes chapters on drinking water quality,
foodborne illness outbreaks, shellfish safety,
pesticide-related illnesses, indoor and
outdoor air quality, recreational waterborne
illnesses, and childhood lead poisoning.
Outdoor air quality has improved. The
proportion of the population living in areas
that did not meet the national outdoor air
quality standards for carbon monoxide and
ozone dropped from over 50% in 1990 to less
than 10% today. While this is better than the Healthy
People 2000 target, there are continuing
concerns about pollutants that can cause
health problems but are not regularly
monitored. There were also substantial
decreases in the number of foodborne
outbreaks, and in the number of reported
illnesses that were classified as
pesticide-related among farm workers.
Other environmental problems are either
becoming more widespread or, at least, gaining
more attention. Indoor air quality concerns
have been growing and recently have focused on
molds and bio-aerosols. Exposure to
environmental tobacco smoke (ETS) is common,
with 62% of all 6th graders reporting that
they had been in a room with someone who was
smoking in the past seven days. There has been
a steady decline in the acreage of shellfish
beds "approved" for harvesting,
reflecting a slow degradation of the marine
environment. Commercial growers are not
allowed to harvest from areas that are not
approved. However, the number of recreational
shellfish harvesting visits to beaches that
have not been evaluated has jumped more than
30% since 1997.
There are many environmental issues for
which more information is needed. For example,
while many of the state's larger public water
systems (those serving 15 or more homes)
completed much of their required water quality
testing, only about half completed the
required testing for nitrate. Over 98% of
those completing nitrate testing met the
established public health standards. Testing
information is generally not available for
smaller public water systems. Efforts are
currently underway to more adequately address
the status of these small systems. The extent
of recreational water contamination and
potential for waterborne illness is often
unknown. On-going monitoring of natural
recreational waters is limited, as are
effective programs to manage heavily used
recreational waters.
Until the 1999 Childhood Blood Lead
Prevalence Study, there were no comprehensive
data on the number of children in Washington
with elevated blood lead levels. While the
study found the overall prevalence to be lower
than the national average, Hispanic children
living in central Washington appeared to be at
higher risk.
Health Care Services
The health care Washington residents
receive is delivered, administered, and
financed by a complex and rapidly changing
system of providers, facilities, services,
health insurers, intermediaries, regulators,
and payers. With medical care expenditures
increasing at more than twice the rate of
inflation, this infrastructure is facing
significant financial stress and instability.
The cost pressure on publicly financed health
care, the source of more than half of all
medical expenditures, is even greater than in
the private sector. Recent analyses reveal
declining margins and deteriorating financial
performance for many hospitals and medical
practices.
About 14% of Washington residents were
without health insurance for some part of
1999, a level higher than the Healthy
People 2000 target but lower than the
national average. This level of uninsured has
persisted for a number of years and, barring a
substantial change, it is unlikely the state
will achieve the Healthy People 2010
target that no one lack health insurance. In
fact, the economic downturn which began in
2001, increasing medical costs, rising
insurance premiums, and state and federal
budget pressures are expected to increase the
number of the state's uninsured.
Washington and the rest of the country are
facing growing health workforce shortages in
several disciplines, including nursing,
pharmacy, radiology, dentistry, laboratory
science, and medical billing and coding.
Preserving the health care infrastructure and
maintaining and expanding access to care
involve complex trade-offs among cost,
consumer choice, quality of care, covered
services, and public expenditures.
There continue to be significant
disparities in availability of health services
between rural and urban Washington, between
the lower and higher income residents, and
among racial and ethnic groups. Of particular
concern are young adult males, American
Indians and Native Alaskans, migrant and
seasonal farm workers, recent immigrants,
people with developmental disabilities, and
those receiving publicly subsidized care.
Access to dental and mental health services
for low-income people remains a concern.
Occupational Health
Every working day more than 2.5 million
Washington residents work for one of
Washington's 160,000 employers. On average,
one Washington worker will die every three
days from an occupational injury. Every hour,
100 Washington workers suffer a recognized
occupational injury or illness. This toll of
workplace illness and injury imposes
significant costs, both direct and indirect,
to workers, employers, and society at large.
Lead has been recognized for centuries as
an occupational hazard, and a well-organized
system to track and monitor occupational lead
exposures exists in Washington through the
Adult Blood Lead Epidemiology and Surveillance
Program. Washington State is working towards
eliminating occupational lead exposure in
accordance with Healthy People 2010.
The occupational fatality rate continues to
decline in Washington. The fatality rate for
1999 achieves the Healthy People 2010
target, and given the current trend, it is
expected that the state's rate will remain
below this goal. The occurrence of
work-related musculoskeletal disorders (WMSDs)
continues to be a major concern in
occupational health, because carpal tunnel
syndrome, tenosynovitis, and low back
disorders account for more than one-quarter of
all accepted workers' compensation claims in
Washington.
Occupational exposure is thought to account
for up to 20% of new onset adult asthma. Over
250 workplace chemicals are known to cause
asthma in workers. Numerous workers with
pre-existing asthma experience aggravations
from workplace exposures. Because many people
in Washington have asthma, the frequency of
asthma exacerbations is also large.
There appear to be systematic variations in
occupational health indicator rates by gender,
age, education, income, and between counties.
Because information is not routinely collected
by race and ethnicity, it is not possible to
determine whether rates differ on that
dimension.
Conclusion
The 2002 edition of The Health of
Washington State says that, as a place and a
community of people, we are generally doing as
well or better than the nation as a whole. But
we can do better. Systematic disparities in
health indicators among people of different
races and ethnicities, living in different
counties, with different levels of income and
education, and living in urban or rural
environments can and must be reduced. Moreover,
our access to care, including services to
prevent disease, is often uncertain either
because the services are only sporadically
available or because the necessary funding
mechanisms are fragile. One challenge we face in
the 21st century is not only to help each person
in our state have accurate information to enable
them to make healthy choices but also to foster
environments that enable them to make changes to
reduce risk of disease and protect health. A
second challenge is to develop policies that
will assure every person has access to needed
health services. A third challenge is to create
a set of public policies that protect our air
and water and soil which are the foundation of a
healthy community. If we can meet these
challenges in the years ahead, Washington will
indeed be one of the healthiest places in the
nation.
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