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ALTERNATIVES FOR ELIMINATING PREVENTION IN THE 1980's Jonathan Fielding, M.D., M.P.H. Professor, Schools of Medicine and Public Health Co-Director, Center for Health Enhancement Education and Research University of California at Los Angeles Presented to the Coalition for Health and the Environment Washington, D.C. May 14, 1981 Ti053901 O0

Oftentimes activities continue well after they have served their original purpose. Organizational inertia is a well established and far flung problem. Health and health care service programs are not immune to such inertial forces. There are undoubtedly programs in both public and private sectors which upon reassessment would have difficulty justifying their current level of resources. In Massachusetts, for example, I remember the difficulty in getting the state legislature to agree that any monies in a very fat "tuberculosis eradication" state budget item should be reallocated to deal with smoking, generally considered the greatest public health problem in all states • The advent of new executive branch leadership is a propitious time to review whether longstanding approaches and programs are helping to meet shared objectives of reduced burden of preventable disease and improved health. It is also a propitious moment to reassess the relative roles that the public and private sectors should assume in advancing towards these goals. In public health, preventive medicine, environmental and occupational health, considerable progress has been made in reducing the need for some types of preventive services. At least in some areas the initial problem of devising a workable strategy, getting it put into place and proving its effectiveness is behind us, leaving monitoring and surveillance as important continuing responsibilities. To that degree we have reduced the need for some prevention programs. Further progress may lead to concensus that some prevention programs can be safely eliminated. But there is another way to eliminate prevention and that is simply to eliminate programs or to substitute unproven for proven approaches and see what happens. This approach runs the risk of eliminating prevention at the expense of more preventable morbidity and mortality. Unfortunately most T!05390101

-2- programs take years to build to an acceptable level of efficiency and competence so that pursuing the second alternative also increases the lag time between recognition of an error in approach and remediation. That the first approach, mounting prevention programs with specific objectives, can bear fruit and hasten the time when efforts can be reduced without adverse health effects can be substantiated by a rapid review of some prevention efforts of the past decade. Dental caries appear to have substantially diminished due primarily to fluoridation of more and more community water supplies but perhaps also as a result of education in plaque removal techniques strongly supported by practicing dentists and the availability of fluoride toothpastes. Cervical cancer incidence and mortality have declined sharply, at least in part due to the widespread use of the Pap smear. Smallpox has been eliminated through a ccmbined broad scale immunization and case finding approach. Measles, rubella and mumps, all of which can lead to serious complications, seem to be following the same path towards extinction in the United States and using similar techniques. Widespread testing of newborns for metabolic and hormonal disorders such as PKU and hypothyroidism has reduced the toll of these infrequent but devastating diseases. Safety caps for medicines have decreased the incidence of childhood poisoning by prescription drugs and over-the- counter analgesics. About one quarter of drivers regularly wear the seat belts that law requires be in every new car, reducing the carnage from auto accidents. Personal health practices have been altered at a rapid rate, mostly in the direction of improved health and largely because of sustained efforts by con- cerned individuals and organizations. The prevalence of smoking since the first Surgeon Genera|'s report on the health effects of smoking has declined T105390102

from over 45 percent of the adult population 15 years ago to less than one- third currently. The wholesale switch to low tar, low nicotine cigarettes and battle between tobacco companies to develop a cigarette with less and less of these ingredients is a stellar example of product modification in an attempt to respond to growing public fears about deleterious effects. Eating habits have also changed. Due in large part to public education efforts aimed at helping people reduce serum cholesterol, polyunsaturated vegetable fat consumption has grown at the expense of saturated animal fats. Skim milk sales are up and egg sales are down. Lmv salt, low fat, low cholesterol cookbooks abound. Endurance exercise has become an accepted part of life for many more millions of adults than at any time in this century. We are making substantial progress in controlling hypertension. A combination of efforts by private organizations, the government and the medical and nursing professions has led to a sharp increment in the percentage of hypertensives who are adequately controlled. These changes in personal health practices and professional health monitoring are the major contributors to a decline in age specific rates of cardiovascular disease deaths of over 25 percent in the last 13 years. Some progress may also be claimed for the worksite, In many sectors the incidence of industrial accidents has been reduced. OSHA and TOSCA requirements have ameliorated some dangerous situations and required a data collection system that will provide hitherto unavailable information on the gross health effects of exposure to a variety of substances and potentially harmful work environments. Employee assistance programs that provide counselling, support and appropriate referral for workers whose alcohol consumption, drug taking or other mental health problem starts to interfere with tb~ir work performance have been extremely effective in preventing progression of the problem and job loss. T105390103

-4- While teenage pregnancy remains a serious problem, its incidence appears to be on a downward trend. A combination of improved nutrition through WIC and other programs, increased use of routine prenatal care and expertise in caring for small and/or ill neonates have been among the contributors to a sustained decline in perinatal mortality. This list is not exhaustive but meant only to be illustrative of the variety of areas in which progress has been made in the past decade in reducing the deleterious impacts of preventable diseases. It is a fact of life best kno~m to politicians that problems and personalities which lose prominence in the media are soon forgotten. The same process has removed from concern many problems whose reduction or elimination represent triumphs in disease prevention, We have eliminated smallpox worldwide and polio is an extremely rare disease in many parts of the globe. We have come very close to eliminating instances of gross contamination in processed foods, at least in the more developed countries. In these same countries we have eliminated the market sales of unpasteurized milk. Devastating health problems from many infectious diseases which were among the major killers at the beginning of this century have all but slipped from consciousness of most Americans. We have almost eliminated the need for some active preventive efforts by passively building health precautions into the development of products. This is not to say that if vigilance is relaxed dire consequences won't ensue. Immunization levels against common diseases in children have periodi- cally dropped at least in part due to complacency. Epidemics resulted. Lapses in well established procedures, frequently as the result of inadequate training of personnel, have given us epidemics of food poisoning, adverse health effects of contaminated water, sma|Ipox in laboratory workers and T105390104

-5- unsafe buildings among other consequences. Yet viewing our country's current health problems versus those of 100 years ago gives us faith that improved longevity and further reductions in morbidity and disability are within sight if we continue aggressive prevention campaigns. Unfortunately there is still too much progress to be made for problems where primary or secondary prevention is known to be efficacious. For example, despite clear-cut improvements in detection and control, hypertension remains uncontrolled in about one-half those it affects. In 1977, 183,000 Americans died of stroke and many more were permanently disabled. Uncontrolled hypertension was the most important contributor. Despite an infant mortality rate of about 13 per 1,000 live births, the lowest in our history, in 1978 the infant mortality rate for black babies in the United States was 92 percent higher than for white babies. Over 150,000 new cases of pelvic inflammatory disease are diagnosed every year and sterility resulting from this disease affects over 50,000 women annually. It is estimated that the dollar costs for sexually transmitted disease are over $1 billion annually. About 31 million adults have lost all of their upper or lower teeth and 19 million have lost all their teeth from caries and periodental disease. About 320,000 deaths annually result from smoking, which also has adverse effects on the fetus. The costs of our alcohol problems have been estimated at $13 billion and 45 percent of all motor vehicle fatalities involve drivers with blood alcohol of .10 percent or higher, a level which is associated with reduced judgment, reckless behavior and inadequate coordination. Among the young both suicide and homicide have increased. Over 5,000 young adults ages 15-24 ended their own lives in 1978. In 1978 there were 6,900 deaths due to falls and roughly equal numbers due to drowning and to burn injuries. Gunshot deaths numbered 31,000 in 1977 of which only 2,000 were "accidental ." Over T105390105

-6- 13,000 substances currently in commercial use have been identified as potentially toxic to workers but definitive information is available on a very small percentage of these. In 1977 over 80,000 workers experienced injuries which were permanently disabling. Few would argue that these current mortality and morbidity statistics represent an irreducible minimum or that approaches are not available to deal with most of the problems in a cost effective manner. But there is considerable argument over who should have the responsibility for making progress against these nemeses. Further disagreement has developed over the appropriate level and sources of monies necessary to address these problems. If well thought out answers do not emerge from these debates it is possible that the nation will go down the second road to the elimination of prevention--the road of abandonment of effort and lack of resources commensurate with the problems. President Reagan has been very plain in stating that he wants to see government, especially the Federal government, play a smaller role and to rely more heavily on the private sector to lead the advance towards shared national goals. Most Americans support this direction and in health policy as other areas it may be unfair to prejudge the results of the policy shifts. However, to maintain silence while awaiting adverse effects that history tells us are inevitable may be more unfair and irresponsible. Assessing the impact of the new Administration's policies on the health of the American people is very complicated simply because there are so many determinants of health. Therefore the budgetary proposals and promised policy shifts need to be analyzed for all programs that may impact on health directly or indirectly. Questions arising from such scrutiny include: Will the rate of suicide, a major cause of death in young people, be affected by TI05390106

-7- what probably will be at least a short term decrease in employment opportunities for minority youth due to a reduction in Federally subsidized jobs? Will reduced employment opportunities and fewer dollars for income assistance lead to more violence with associated deaths? What will be the impact on both physical and mental health if therapeutic abortion is no longer a legal option for a pregnant woman? What will be the impact on overall health if EPA and OSHA requirements are generally relaxed or if automobile companies are not required to install passive restraint systems? What will be the impact on the outcome of pregnancy to low income mothers if WIC and other food stamp programs are greatly reduced? The precise answers to these and similar questions are difficult to predict but past experiences suggest that some adverse health effects are possible, if not probable. What is certain is that changes in the non-health portion of the budget and passage of some legislative initiatives proposed and/or strongly supported by the Administration could have important health effects, as important or more important than effects that might ensue from reductions in spending for health services programs. Healthy People, the first Surgeon General's Report on Health Promotion and Disease Prevention, released in 1979, stated broad national goals for the improvement of the health of Americans during the five major life stages. These goals were expressed in terms of decline in overall death rates and in days of disability by 1990. A conference was convened to develop objectives around these overall goals in 15 priority areas: high blood pressure control; family planning; pregnancy and infant health; immunization; sexually transmitted diseases; toxic agent control; fluoridation and dental health; surveillance and control of infectious diseases; smoking and health; misuse of alcohol and drugs; physical fitness and exercise; and control of stress and TI05390107

-8- violent behavior. For each of these 15 categories, a number of strategies were listed to help achieve the objectives. In general, they fall into several categories: ° education and- informational programs ° specific services to individuals and groups ° technological improvements ° legislation and regulatory efforts o development of economic incentives In every case, a combination of public and private initiatives were recommended as necessary to achieve the objectives enumerated. Perusing these strategies makes clear that government can't and shouldn't try to do it all. However, there are roles which government alone can play such as leadership in helping set national priorities. The Federal government has in recent years displayed considerable initiative in both setting the agenda and specifying the strategies for making progress to reduce the burden of preventable disease and to improve health status. Evidences of this initiative have included the creation of the position of Deputy Assistant Secretary for Health for Prevention and creation of the legally mandated Office of Health Information, Health Promotion, Physical Fitness and Sports Medicine, recruitment of knowledgeable and widely respected individuals to lead Federal prevention efforts, and better coordination of efforts of various agencies, bureaus, offices, administrations and centers involved in such efforts within HHS and between HHS and other important Federal agencies such as the Departments of Agriculture and Education. Secretary Schweiker, at his confirmation hearings on January 6, 1981, affirmed his support for a preventive emphasis to Department activities in stating, "I'd like to be remembered as putting preventive health care and TI05390108

-9- preventive medicine at the top of the list of priorities." To date it appears that the Secretary has tried, in the face of strong OMB opposition, to support continuation of many existing prevention initiatives. Still to be seen is whether the health leadership within HHS will evince a strong interest in and support for preventive efforts and argue strenuously for continuation of a strong Federal role in those areas where there is no adequate substitute. A related question is the degree to which HHS feels committed to assure that available funds are channeled into the priority areas outlined in Healthy People and Promoting Health/Preventing Disease: Objectives for the Nation. On this score some concern can be voiced. The Secretary's budget statement reflects the President's promise to decrease the role of Federal government, and to restore the state and local governments to full and effective partner- ship in the Federal system. The tradeoff offered states and localities is acceptance of fewer aggregate dollars in return for virtually complete freedom in how these dollars can be spent. On the face, it is difficult to argue that decisions regarding priorities should not be made closer to the problems than Washington, D.C. In many cases, state and local governments have been made to spend money on what they and probably objective observers would concur are not the highest priority problems. Categorical funding can never adequately take account of geographic variation in program need. Categorical appropriations also tend to build constituencies which make it hard to reallocate the funds as priorities change. However, the other side of the coin is the risk that decisions at the state and local level will be less rational, and based more on political concerns than demonstrated need. For example, in Massachusetts, when I was Commissioner of Public Health, family planning monies went directly from the Federal government to family planning service agencies at the county and local level. Had these monies T!05390109