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AMERICAN HEALTH FOUNDATION PROPOSED CENTER FOR PUBLIC HEALTH ACTION The American Health Foundation was founded for the purpose of advancing the cause of preventive medicine. Its main activi- ties are directed towards health education, health research, and health care, and its attention is focused on today's major medical problems. The new research laboratories constituting the American Health Foundation Health Research Center were opened recently at 2 East End Avenue, New York City, permitting research in five broad areas: epidemiology, environmental toxicology, biology, carcinogenesis', and nutrition. A Health Care Surveillance Center offering fully automated health surveillance testing in a modern nultiphasic health screening clinic is in the final stages of planning. This proposal concerns our:efforts to create a third Center to integrate and stimulate the efforts of the Health Research and Health Care Centers. Preventive medicine is one of those arts more often "pr.eachedtt and "practised" by the medical profession and fre- quently ignored by the-general public. Aware of this basic short- coming in our health care delivery system, we decided to name this new activity of the American Health Foundation, the Center for Public Health Action. Its purpose is to activate and dissem- inate existing preventive medical knowledge among the medical profession, the teachers and promoters of health care, and the -general public: . . • .

-2- ( The planned Center will have two divisions: one to deal with the purely educational and motivational aspects of pre- ventive medicine: the other to deal with the practice of health care. It must be mentioned at this-point that while working closely with the Center for Health Surveillance and its clinic, the Division for Health Care will be primarily concerned with procedures, improving follow-up techniques and the proper develop- ment and utilization of research data obtained from the clinic. It•is-not the function of this division to practice medicine, but to improve the delivery of health care systems. There is an obvious interrelation between the two divisions of the Center for Public Health Action as well as with the activities of the Foundation as a whole. Division for Health Education and Motivation This division will be headed by an action-oriented_ _ individual with a Ph.D.. in psychology whose mandate will be to utilize the most effective approaches to health education and, - where necessary,.to innovate new methods after appropriate motivational studies have been completed and those already extant, The Division for Health Education and Motivation will be aided in its program by a volunteer committee on motivation, already in existance. This.group is made up of experts in the motivation field and is headed by Mr. T. J. Ross, Vice President of American Airlines (Exhibit A). Initial planning efforts have !'" . . . . . . . already led to a poster campaign and a series of TV commercials,

both of which are presently being completed by the J. Walter Thompson Company, who volunteered their services. This committee will also be able to call upon other•advertising agencies,and film makers have offered their expertise and assistance in this area. The studies into health motivation will-necessarily have to borrow techniques from proven market research studies. At . the same time, it is realized that the marketing studies under- taken by industrial companies frequently bear little relation ~ -to whether there is any -need for the product, but rather to sell one.product over another. In health education, on the other hand, the need for good health maintenance practices has been - given no sense of urgency by the majority of the public, or, for that matter, by the health professions themselves. This is :true despite'the national increase in mortality from-a-variety of chronic diseases and despite much evidence that preventive measures can be effective if undertaken in time. -S.tudies into health motivation have to consider several _ subgroups, each one having its peculiar resistance points. In this _case_, we will have to make special studies of such_ groups - as physicians,.allied health professionals, government officials and legislators, industry, and the many facets of the general public. . :zt is obvious that much attention must be given to the type of incentive that best motivates each of the various groups. Economic reward may well be the key incentive. During a recent meeting with the Employee Benefits Committee of the National

Association of Manufacturers, it was apparent that the spiral- ling cost of the health care benefits that industry pays for is causing increasing concern to management and labor alike. It was asked "How can preventive medicine help to reduce these costs?" When society recognizes the necessity for action in the health field on the basis.of economy as well as altruism, preventive medicine will become a more powerful force than at present. For this reason we have created a committee on public health action under the chairmanship of Mr. Eric Javits (Exhibit B). Consisting of lawyers; personnel directors,.physicians, allied __ health professionals, and members of the insurance industry, --this committee has been brought together to try and-make a` start on suggesting and activating health care programs on both a local and national:level. - Another approach being taken by the fimerican Health Founda- -tion is concerned with the modification of federal regulations and laws leading to significant changes in our environment which__ would be a truly effective way of reducing certain health :haaards. In recent years, we have_been involved.in_.testifying . before .the Committees of * the Senate and the FTC on tar and nicotine practices. The Federal Trade Commission's publication of tar and nicotine determinations has not only probably been instrumental in effecting a reduction of the levels in American cigarettes currently on the market, but has certainly contributed to. the tobacco industry's recent decision to include information

r -5- on tar and nicotine on all packaging, a move not even feasible to the industry a few years ago, but apparently one which is now acceptable'. A lowering of the tar and nicotine levels will lead to a gradual reduction of lung cancer among smokers of cigarettes (Exhibit C) and will hopefully also affect many other diseases associated with cigarette smoking. The whole panorama of food and nutrition is another prob- lem area iri which we are involved. The Public Information Sub- committee of our Food and Nutrition Committee (Exhibit D) is currently preparing a White Paper on "The.Role of Diet in Arteriosclerosis." . Depending on the extent that cholesterol and saturated.fats affect arteriosclerosis as determined in this position paper, the American Health Foundation will put forward its recommendations for changes in labelling practices and advertis3ng codes and laws through another Subcommittee on Government Action. We have representatives of both the Food and Drug Administration and the Federal Trade Commission. This in turn relates to a third subcommittee involved with the food industry. A fourth subgroup is concerned with the problems of mass feeding. The scope of.all these volunteer' working groups indicates the catalytic role being*played by the American Health Foundation in one of the more unusual health problems of our times: the apparent over nutrition of a large number'of Americans. "While nutritional advice on an individual basis is one approach not to be ignored, it is clear that if the overall make-up of the food in the U.S. marketplace was more carefully

-6- regulated, all citizens will benefit. Historically, preventive medicine has been most effective when the environ- ment or a specific situation has been changed rather than by attempting to change the individual and his daily habits. In terms of educational activities, the following will give an idea of our current and future program: Medical profession: Traditionally; the physician has resisted preventive medicine for economic-as well as academic or merely personal reasons. The latter will always be a problem to some extent since the task of preventing an unspecified disease in the distant future will never capture the imagination or satisfy the physician like dramatic surgery or the easing of --a-•patient's pain,and the benefits-of preventive medicine are always.long-term. We shall attempt to improve the physicians economic acceptance by encouraging badly needed changes in the health insurance field and to improve his professional involvement by providing local and national symposia on preventive medicine. In this connection, we plan to publish a new journal _ called PREVENTIVE MEDICINE, during 1971 (Exhibit E). It is of interest to note that until now, there has been no scientific publication by this name in the United States. The journal has assembled distinguished advisory and editorial boards of physicians from around the world who are leaders in their respective fields. The emphasis of the first issue will be on preventiorn of coronary diseases and in line with the general policies mentioned above, will be directed to the general practitioner.

The journal will be published by Academic Press on behalf of the American Health Foundation, Allied Health Professionals: It is apparent that we do not have sufficient physicians in this country to adequately meet the growing demands of the population. To maintain and improve the health standards of a wel7. population, 1 therefore, we need to expand the pool and train more allied health professionals to be involved in the delivery system. We include in this area of health education; teachers from kindergarten to college, public health officials, nutritionists, home economists and neighborhood community groups. We- plan to hold symposia for such groups around the country. --The Public: In addition to- posters and TV spots to alert-the - public to- the importance and benefits of preventive medicine, we shall extend the distribution of the AHF newsletter (Exhibit F) which brings preventive medical information to the educated layman.* Lectures will be given to influential groups and as an example, in March, 1971,. the Young Presidents' Organization annual meeting will be addressed by Dr. Wynder on two occasions on the subject of preventive medicine in terms of its medical and economic significance to industry. Obviously.with the proper motivation an audience like this could be counted on to have a major impact on industry's attitude towards health care. As we have stressed repeatedly, preventive medicine is a.job for all society and all society can help. This.philosophy is borne out by the heavy reliance we place on lay members of

our various committees. Obviously, to lead and to coordinate the activities we need a strong professional staff (Exhibit G). To reiterate, the emphasis of this staff is more on the practical application of existing knowledge than on the pure theoretical aspects of the problem. .Division of Health Care The purpose of this division is to work in conjunction with the patient-oriented center for Health Surveillance, towards establishing a practical mass surveillance system. The division will be headed by an experienced and motivated physician. A --cornmittee to advise this division has been set up under the chairmanship of Dr. Ernest M. Dixon of the Celanese Corporation (Exhibit H) . : The American Health Foundation plans a Center for Health Surveillance where effective health check-ups can be carried .out'at moderate cost. The.screening should take one hour with all test results available for review by the end of the session. This project,is being undertaken in cooperation with an industrial consortium unde r the direction of Mr. Stevens deClerque. We are in the final stages of negotiations whereby the AHF will set up a joint demonstration clinic with the consortium. After --demonstrating the practicability of this clinic, the industrial group will relinquish the entire operation to the AHF within one year-and will begin a number of similar operations across the United States'on their own. There would be a central data bank ,

comprising information from every clinic in operation and thus vast research potential available to the AHF. The con- sortium will provide funds for the physical aspects of the demon- stration clinic. The AHF will be responsible for all research and health components of the clinic with the exception of audio and visual health education aids which will be provided through Time and Life Corporation. In conjunction with these developments, the AHF will in the meantime set up its own Pilot "mini-clinic" to identify the high risk coronary and stroke patient. Here we will determine such factors as the patient's age, number of cigarettes smoked, weight, blood pressure and cholesterol and triglyceride values. It will be fully automated, and will be able to provide an estimate of a person's risk of developing a heart attack in the next 12 years. We estimate that the cost of-this coronary risk analysis unit will not•exceed $10 per person. Following the identification-of a high risk individual, we need to proceed to reduce the risk. Five of the-major risk factors are: Tobacco usage' Over nutrition (obesity,'hypercholesteremia) Hypertension Physical inactivity Drug abuse (including alcQholism) To begin with, there will be three follow-up clinics.to be staffed by this division: Tobacco Withdrawal Clinic Nutrition Clinic Physical Fitness Clinic

-10- t Until the Health Surveillance Center clinic is established the activities of the division will be carried out entirely . within our present facilities. The follow-up clinic concerned with tobacco withdrawal will hold group sessions, known to be a most successful method to get people to stop sraoking,-and also make this service available to employee groups in participating industrial concerns. Similar approaches will be utilized by the staff of the Nutrition Clinic._ When a strictly medical problem, such as hypertension, is revealed during the screening procedure, the patient will be passed over to a physician and the division will follow-up the case to make sure that appropriate medical treatment has been -given. Careful follow-up is one of the essential facets of the - work of the Health Care Division. For the time being, the Division for Health Care will not become involved in the area of drug abuse, with the possible exception of alcoholism; partly because there are a good number of other agencies involved in this area and partly because of ' the complexity of the problem. When the Center for Public Health Action is on its feet, the decision on a clinic for drug abuse will be considered again. Summary: ` We have attempted to show how the Center for Public Health Action can and will attack modern problems of. preventive medicine by a coordinated approach involving both health education and health care. While not neglecting basic research, we shall con- centrate on the practical application of existing knowledge. We,