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TESTIM'ONY' OF JONATHAN E. FIELD]iN'G, M.D. COMMISSIONER C7F~PUBLIC HEALL TH. COMMONWEALTH'OF MASSACHUSETTS ~ FOR THE ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICIALS APID THE COMMONWEALTH OF M'ASSFiCHUSETTS' BEFORE THE SUBCOMMITTEE ON HEALTH & SCZENTIFIC RESEARCH COMMITTEE Ori1i HUMAN RESpURCES U. S'. SENATE June 7, 19'78

r Mr. Chairman, my name is Dr. Jonathan Fielding. I am the Coordinator of Public Health for the Commonwealth of Massachusetts. I come before youitoday to speak on behalf of the Association of State~~ and Territorial I3ealth~ Officials (ASTHO) and State of Massachusetts. My purpose for being,here today is to lend the support of our association to the Bill you have before you today 3115), The National Disease Prevention and Health Promotion Act of 19'?8'. In its focus and conceptualization this Bill embodies many of the ideas and principles which form sensible and cost- effective public health practice. As we approach the 1980's, we find ourselves in the health fieldlapproaching several limits: - we are probing the limits of the ability of curative medicine to reverse and offset the multiple effects of self-abuse, genetic susceptibility, and environmental impact on health status;. -Ve have reached, andimany would say surpassed, the willingnessf of society to pay for corrective intervention and rehabili- tation; -.gone are the days when changes in the dollar expenditures for personal health care were reflected in comparable changes in health status as morbidity and mortality; measured by indices such as - nor are we in public heaLth immune from these changes. The days have ended'when sanitary science and communicable disease: epidemiology alone held the promise of controlling and eliminating the major causes of deathand disability in this country.. It is clear that we standiat an important juncture when all . ~ of us, whether at the Federal, state, or local level.must examine

our roles and reorient our thinking to focus and concentrate our energies on prevention of disease and promotion of health. It is important to distinguish between disease prevention and health promotion since the two are often confused. Primary both of these important concepts which we feel are essential._ prevention implies the removal or neutralization olf specific factors whichicause alsingle disease or group of diseases. Health promotion. carries with it a more affirmative connotation of enhancing the ability of ind'ividualls to resist disease and to feel and be healthier. To a great extent, S. 3115 incorporates and embodies national program whose emphasis was directed entirely at primary prevention would fail to respond fully to the important mandate for dievelopment of programs which can help people enhance the. , quality of their lives. It is clear that state and local health departments have a pivotal role to play inithe further development and implementation of preventio and promotion programs. As you remarked yourself, Mr. Chairman, in referring to the work of John Snow in removing the pump handle in London in the La-st century, pFevention is the.. operating dictum and first principle around which public health -- trad!it3on of being at the forefront= of' new programs and new id'eas. Title I' and Title IV of this proposedilegislation acknowledge this important role and provide the opportunity for these agencies. to participate in new program development and impllementatio . efforts revolve. State and local health departments have a rich The Association wants to underline the importance of both the level of new funding requested andthe proposed increases in =the 314d.. appropriation. As you point out, prevention gets less than 2 percent of'the health care budget. If the increases you P

- 3'- propose seem large to sorne, they should consider that the annual increases proposed are less than $2'00' million, a small part of the $'20-30, billion that the cost of curative medicine is increasingi each year to pay for roughly the same services and programs. -cutting back staffing levels and public health programs. The increases proposed in S'. 3115 will have a major beneficial effect on stabilizingi the infrastructure of state health d'epartments-.and thus enhance our ability to dievelop and carry out the new program The increased appropriation proposed for 314d is essential because 3'14d provides the basic operating support funds for many health departments. The appropriation levels under this authority have been fixed~at $901million since 1971 and have shrunk in real dollar terms in the interim. This has led to many heal:th d'epartments initiatives outlined in this legislation. In addition, the increased dollairs,yo~u propose could assure th~econtinuity andifunding ofexisting programs aimed'at,maintenance of current levels of'disease control. ~ The idea of~ developing a health c~ommunica~~t~ions~ p~~rograml is~ a~ particularly appealingione, given the plethora of d'rab, unimaginative that this goal of attracting marketing andiadvertising experts to, ~ . ~'. pamphlets handed out in the name of health education. We believe -a range of-strategies from taxing cigarettes by tar and nicotine to counter, is in ourviewsuffic-i'ent tobegiinto: overcomethe: negative impact of the mass media on the behavior of individuals. Finally, the approach to smoking which attempts to integrate allotment,whiile small compared to the deleterious advertising needs address themselves to h-k--al-th issues is overd.ue and essentyal to effective use of the mass media. The suggested $.10, per capita z.r ~a

6_ . _ - c In conclusion, Mr. Chairman, I agree Sh you that there is ample and growing evidence that prevention and health promotionn activities work; the declining incidence of'death from coronary heart disease, theexperiencewuthimmunization and'fluoriidation of public water supplies, the decline of automobile deaths which followed the imposition of the 55-mile per hour speed limit are but a few examples. It is clear, however, that if we are to help, Americans achieve the level of health they want and'can attain, a program for prevention and promotion rnust have national scope.. Senate Bill 3115 begins to provide that kind of scope and ASTH'0 commends you and your committee for your vision and sense of'f priorities, andilooks forwardi tolcontinuingito work with you.

-4- content to prohibiting smokingion interstate carriers has to be. seen ais an important beginning to this development of a comprehen- sive approach toia problem as large and complex as that posedby While, as I have just indicated', the Association applauds and supports the basic outlines and concepts encompassed in the J legislative package, there are a few areas which we feel needifurther clarification or further refinement: 1. The planning process as outlined in Title I (S. 3115) provides an important and unique opportunity tolcomple- memt the planning process being carried out under Public Law 913'-641. Si:nce the HealthiPlanning and Development Act (Public Law 9'3-641) also incorporates health promo- tion as one of the ten priority areas and since hea]1th status indicators are the ultimate outcome measure as well, careful thought needs to be given to the relation- ship between these two processes. Could not the state healthiplan serve as the "detailed plan..."' called for in Tit]1e I, if a state desiredi this to serve for botli those purposes? 2. Clarification is needed'on the latitude that states will have in focusing or targeting their plans and program dollars.,: Clearly, given the universe $f' potential directions that one might take, it is necessary toitarget-limited'resources. Yet, while the language of'Title I appears to allow the option of targeting program dollars at leading causes of morbidity, it is unclear whether the language allows the plan which targets at several major causes of both morbidity and mortality.

-5^ but primarily in the future. It is only recently that As we all know, there are many major types of morbidity which almost never alone lead to d'eath, for example, periodontal disease and dental caries, and other majior causes of morbidity whichlare only minor contributors to mortality: for examplie, sports injjuries, bicycle andi moped' accidents, industrial accidents. It is essential that states have the flexibility within the general areas you proscribe. 3. Thequestiionof a~ccountabilityis'appropriatelyraised iin: - the language of Title I and' is linked to tlie development of program gpals and the development of an evaluation methodology. We agree that states and other recipients olf,these funds need to be held accountable to produce antiicipatediresults. However, a word of' cautionlis needed.. The development and'support of prevention and health promotion programs is a long-term investtment. The benefits which will accrue to society are not immediate,, we have begun to accumulate evidence that preventionn programs really work, becaluse it has been only beenlin recent years that we have had access to large enough oohorts over long enough periods of time to begin to see changes in health status emerge. We therefore feel that the Secretary of HEW should be given some flexibility in both determining what degree of quantification of short-term goals is realistic and what intermediate measures of program outcomes can be used as a valid proxy for the ultimate positive effects, which will take longer to, verify.