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S IATEMENT' OF CHARLES B. ARNOLD. M.D.. 1i'.P.H. PRESIDENT OF THE' AhIERICANCOLLEGE' OF PREVENTIVE MEDICINE on S. 3115, THE DISEASE PREVENTION AND HEALTH PROMOTION ACT OF 1978' f Before the Senate Committee on H'uman Fesourc:c.s, ' Subcommittee on Health and Scientific Research June 7, ]J97'8.

have a system to gauge successes and to yive direction. Because such datai will enable generation of -chronic disease risk estimates for the entire popullation,we will be much better able to design preventive services aind' to define pot ulation groups which ~ .. , ~ ., . should receive those services. As part of the strategy, embodied in Section,203, the Secretaru of MEW should be encouraged to study the experience of Canada wi:th its first Canadian National Health Survey. Unlike the Unitedl. States National Health Survey, the Canadian model, first implemented this spring, will include smoking, nutrition, physical activity, and related health promotion activities in its standard format. In addition a brief examination will be given to a subset of this pop- ulation which includes weight, height, skin-fold thickness, total serum cholesterol, resting blood pressure, and alphysical fitness estimate derived from a, modification of the Harvard two-step process. 'If a comparable interview and screening procedure were implemented for Americans as well it would yield much valuable data in this area. CHTLDAND ADOLESCENT SMOKING As the larg,est single cause of preventable death and' illness,, cigarette smoking poses a major threat to our nation's~healthl. In recent years the statistics have shown an encouraging,downtEirn in the percentage off'the adult population that srnokes. However, increase in the percentage of our nation's youth that smokes is truly alarming. Obviously the message that is somehow g,etting, through to the adult polulation is being lost on our children and adolescents.

C At the same time it is important that we be Quided bv realism.. Although we already have at our disposal much of the knowledge which is neccesary to make a start, "prevention" has it.s limits. Until further research and! demonstrations are conducted, we must ',avoid the temptation to view prevention as a cure to all of the ills of our health care system. To do so would'be to push the =body of knowledge beyond it''s current ability to produce results. However, a great deal can be accomplished in the years ahead!bv .buildinq, slowly on the base of knowledge that already exists as well as new knowledge that will develop. While S. 3115 contains a number of provisions of interest to us, I will limit my co^iment.s to those that we vieca as the most important. Among _ these are: NATIONAL DISEASE PREVENTIOh1' DATA PROFILE -Section 2'J3' is one of the most important provisions of S. 3115, for it would enable formulation of a baseline profile of health status as it relates to preventable diseases. Only then will we have a standard of comparison against which too prograrns. judge the effectiveness of preventive Data collection of the type stipulated in this section is long over- due, and addresees what is currently a serious limitation in4F statistical knowledge about the health of'Americans. If such a data collection project had, been initiated ten years.ago, the current downturn in coronary heart disease in this country might not seem w va. Cj W' . 1-+r MDb so inexplicable. Especially now, as we propose to build an inf'rastructuree in the area of preventive. services, it is vitally important that we

4 Control of diseases caused bv cinarette'smoking will only be possible when we understand'and are therefore able to control the underlying causes of the smoking habit: The key to this under- .standing is:behavioral research. Without such research health education initiatives in this area are doomee1to modest success at best. That is why it is vital that research be undertaken as soon as possible to determine the basic causes for this upturn and to find ways to bring about a halt in its progiTession. T;here- .ffore, of the provisions of Title IV, Part D is perhaps the most important because it holds the promise of'the greatest benefit per health dollar spent in this area.. CENTERS' FOR HEALTH PROMOTION AND D'EMONSTRATION'S' OF PREV'EN T IVE S'ERVICES I view the centerpiece of a comprehensive health promotion and disease prevention program as the actual delivery of health promotion and primary prevention services to the public, as provided for in Title - I of S. 3115. Tb prepare for such progra_s, it will be necessary to expand upon the limited research which has been conducted relating to the delivery of such services. By establishing multidisciplinary centers for health promotion, this leaslation meets t his need. In the meantime, however, the authority for demonstration centers in this legislation will allow us to begin projects based upon the - . ~ valuable knowledge which has already been obtained from other ~' studies that have been conducted. 0 W C~s .. Because community involvement and identification with healthipromotion ~pr~ogramswill be:vital to~~ their succes~s,,, I recommend' that all demonstration programs have strong participation by local steering comri- ittees responsible for the surveillance o€ the programs. Further-

iC ~ . ~~~9; i . l' " ._,__. .. . . . _. _._ _- .. .. .. . _. . . . . . .. .. - . ,~.~r, Chairman, Subcommittee members, I: am Charles Arnold, Director 4.,: = of the HealthiMaintena~ze Institute at the Americlr,~ Health Foundation. and President of the American College of Preventive Medicine. I am also principal investigator of'the New York MRFIT Center, the national :~ . . _ program fundied by the NHLBI to demonstrate the preventability : of coronary heart disease. I am pleased to appear before you today to ~" eYpress the views of the College on1S. 3115, the Disease Prevention and HealthiProir,otion Act of 11978. . The testimon•z which I am aresentina todav has also been endorsed bv the Association of Teachers of Preventi.ve Medicine. We have prepared a formal statement which we would like too offer for the record; at this time I' will summarize for you the major points contained in that statement. The American College of Preventive Medicine is a medical' specialty society comprised of approximately 1'80q physicians enaacred full' time in the four oreventive medicine soecialti'es of oublic healthy, occuna- tional'medicinel aeneral oreventive medicine and aerosnace medicine. Ours is the only specialty society whose membership represents all facets of preventive medicine teaching, practice and'research. Senator Kennedy, I commend'you for taking this important first step toward the development of a comprehensive strategy for disease pre- vention. As you stated in your introductory remarks to S. 3115, it is truly astoundingithat a country with a personal health services bill' of $180 billion has no such strategy. The cost of treating preventable disease is compounded by the human suffering which it entails: in 1976 preventable cancers,, cardiovascular diseases and' diabetes alone were responsible for over three-quarters of a million deaths in this country. There is no reason for this state of affairs to continue. We alreadv have the tools and knowled've that are needed to becrin the imnlementation of a disease nreuention straterIv. S. 3115'mak'es an excellent start in that direction.

fi. This program, to be successful, must be tightly coUrlinated and "professiona= - ; T am therefore pleased that S. 3115 contains provisions which pSace the responsibility for coordination of suchia program within a specific ` , institutional state entity and'at the sar.se time provides a major role for private advertisers. Certainly iff we are to spark the interest of our audience it will be necessary for us to break with the tradition of mundane public service messages whichihave been of questionable value in terms of outcomes inihPalth status. At the same time, however, we should' not overlook the capabilities in this area that are held by many of our public institutions. The goal should'be the optimal cruality at the minimal cost, whatever the sources of production and distribution. Since the combined marketing budgets of the fait-produciingg industries. (Idairy, meat, and their processediproducts) and tobacco alone probably eXceeds $2' billion annually, the program whichis - proposed is extremely small in comparison (' $.101 annually per person, as compared' to advertising, of' $10'.0..0annually per person)i. With suc relatively limited funds, therefore,*it is important that this program be centrally ad.ministerediand coordinated at the state level. In the past, under Section 314(d) of the Public Health*Service Act, states ,have been awarded grants to provide comprehensive public health services. The states hav established!a positive record' of performance under this program, although federal appropri'ations under this section have amounted to less than 3' percent of the total public health expenditures of official state agencies. In addition, categorical grant support has beeniawarded to the states for prograr.ts, such as rodent control and immunization. Unfortunately,— while grants under Section 314(,d)

more, ini' order to narrowthe scope of such programs and to ensure comparability of' results, I woulc',' hope that initially such programs. k7ii11 be directed primarily at school childreniand younger workinR persons. Sbecifically, I would recommend that in the 5 - 3'5 aae group target populations be drawn from children in grades 1- 8 ; andl working individuals in the 18 to 35 age bracket. covering the entire population, as is called'for in Title I of S. 3115.. As the results of these demonstrations become avai lable it will be possible to begin the implementation of serrvI~ce delivery programs The health communications component of the formula grant program is a provision which •'deserves particular comm.e t. Any first-stage program FO:'2t-IULA AND PROJECT GP,MTS FOR PP.EUEntT'IVE SERVIOES ; SECTION 314 (d) , PHSA services must pursue two courses simultaneously 1)' the'development of a program of intensive personal preventive services, delivered' designed to deal comprehensively with the delivery of preventive to defined populations, and 2) a nrogram to bring health promotion and disease prevention education to~the entire public: Enough is known now about the means of preventing certain diseases 6A to mount an aggressive health ed!ucation~mass communications campaign, such as that specified in Ttile I of S. 3115.The message of' such a~ would be simple: 1)chronic disease is of agina, and 2)~ a few simDle actions for health *~romotion. Once the nublic understands the extent to which of such a mass education camoaian will be the develonment of a constituencv not an inevitable consequence ec taken each dav bv neonle can campaig;n nrevent the develonment of manv serious illnesses. A nolitical bv-orod'uct their self-interest in health is affected b,r their nersonal irnaction, .f the eventual nolitical sunnort that will be necessarv to move "Drevent'ion" ahiead on the list of our national heal th priorities will emerae.

11 that I er,aggeraae by saying that we all eagerly look forward to the promise that now lies ahead. Thank you.

grants for sch:ool-ba~sed flouridation p~rogram~s~~.~ Our fear is~ tY'iatt the entire program, if not re-invigorated at this tirae, will s1'o*vrly atrophy. Because this orovision addresses this dilemna we are strongly in favor of MAbIPO:':ER CONSIDERATIONS Finally, Mr. Chairman, I would like to touch upon an issue which is not addressed by this legislation but which is of major importance both to the success of any national prevention program as well as to the specialty of preventive medicine, that beingithe development of manpower resources. Currently there is a shortage of' rnanpoc•aer inithe health field trainedd to develop a large-scale nationwide health promotion and'disease prevention program. There are three categories of personnel which need attentionlin the development of manpower: (1)' preventive medicine specialists (2)' comrnunity diagnostic and program evaluation ('epidemiologists and statisticians), personnel (3)' allied health personnel to deliver . health promotion -and d'iseaseprevention services (e.g,.,nu~trition~ists,: substance abuse specialists, high blood pressure treatment. --technician~s)' .~ Preventive Medicine Leadership Development. Two recent national reports (Preventive PK'edicine, U.S.A., report by the Milbank Cbmmission on H!igher Edu- cation for Public Health), have identified the need, for increased! personnel in leadership positions in the field of public health. This primarily refers to attracting physicians into preventive medicine residencies,'and'increasingi faculty development resources for training programs for such residencies. Both these need immediate > -; . . - - ._.,.~;.. ._ _ ...._ _ _ _ _ .,_ . .. . , _. . ._ .;~ ...,. _.. ~~ s. ,.:~a ~:...

attention by the Federal government if we are to eventually have a successful national disease prevention and health promotion strategy. Non-physician leadership can also be developed for key parts of disease prevention services. For exarnple,, psychologists, nutritionists,, health management specialists, and others with-doctoral level training n related'fields could benefit from nost-doctoral education designed to train them for leaders:iiproles in disease prevention program~, including educational institutions. Gbntinuing mediical education -for preventive medicine is another important area which is in need of support- According to the Ar'lA Masterfile, which lists all U.S. physicians, approximately16,20'0 physicians presently designate preventive medicine as their primary specialty. Another 5,200 list preventive medicine as a secondary " specialty. Of a total of'over 11,0010 physicians currently practicing preventive medicine, onlv about 3.00'0' are Board certified in the saecialtv. This indicates that roughly 701% of'this total population have had'no formal training in preventive medicine. This is due to the fact that most practitioners enter the field in mid-career and have formal training in such areas as internal medicine, pediatrics, family practice or psychiatry. There is a strong need, therefore, .for support of non-traditional remedial education progxams for these _- ~ mid-career entrants and for continuing medical education programss for all preventive medicine practitioners. Gbmmunitv Diagnostic and!Program, Evaluative Personnel. There is ~ a C~J a grim shortage of statisticians and' epidemiologists in the United ~. States presently. Greatly increased numbers wil]l need to be available for community as well as state and regional programs. Health