Many traditional core public health roles--water safety, food safety, safe sewage treatment, air quality, and control of infectious and sexually transmitted diseases--have been eroded by strained budgets and public apathy. More recently public health has taken a significant role in public education, but often without adequate resources. Improving the health of Americans requires that public health roles be buttressed and invigorated in any health system reform package (Schauffler, 1993; an executive summary of this analysis of the inclusion of health promotion and disease prevention in health reform is found in Appendix E). THE THREE PILLARS OF PREVENTION We recommend investment in three tactics: motivation to change personal habits and utilize preventive services; community health programming; and health-supporting social and economic policy. Let's ask whether all of these are necessary in defining health policy for Americans. The major causes of death among U.S. residents are tobacco, diet and activity patterns, alcohol, microbial agents, toxic agents, firearms, sexual behavior, motor vehicles and illicit use of drugs (McGinnis and Foege, 1993; Appendix D outlines the actual causes of death in the United States, and potential contributions to reduction). Although many of the behaviors associated with these factors are difficult to change, reducing the toll of these would make a strong impact on the health of the public. While the health-care system, current or reformed, can contribute to this goal, greater contributions must come from elsewhere. Personal behaviors such as smoking, speeding and unsafe sex must change. Community programs must make neighborhoods safer, identify and remove toxic exposures, improve educational opportunities and reduce hopelessness. Social and economic policy must provide disincentives for tobacco use, reduce access to handguns and assault weapons, facilitate job creation, better educate the public about optimal nutrition, and continue to refine motor vehicle safety requirements. MEETING THE PUBLIC HEALTH STANDARD How can the Committee judge whether sufficient prevention of the right types is incorporated into the disparate health system reform proposals before you? Incorporation of effective preventive approaches should transcend system architecture. We therefore recommend that you measure each proposal against a prevention standard. The standard has eight key components: 1. Individual/clinical preventive services in the core benefit set determined by an ongoing scientifically objective process 2. Community prevention activities of proven efficacy and efficiency 3. Social and economic policy changes that make unique contributions to health improvement 4. 5. 6. 7. 8. A revitalized public health presence with strong linkages to personal health services, and a leadership role in developing effective community interventions and recommending health policy changes Data collection, analysis and reporting that show changes in population health and identify what system components and tactics work and which do not. Research on how to create even more efficient and effective prevention services, programs and policies Increased numbers of primary-care providers with training in personal/clinical preventive services and community-based services Public awareness interventions which contribute to an improved understanding of the value of prevention in promoting good health and longevity. CONCLUSION In conclusion, we urge that Committee deliberations be guided by the answer to one question: What are the greatest opportunities to improve the health of the American people, overall and for specific vulnerable populations? Prevention works. Its central role in rethinking health goals and ways to achieve them is therefore not only a moral imperative but a practical imperative. Thank you very much. REFERENCES Chaloupka, Frank J. Effects of Price on Alcohol-Related Problems, Alcohol, Health & Research World, 17(1):46-53, 1993. Loose, C., and Thomas, P. Spread of Violence Poisons Well-Being of Childhood, Washington, DC: The Washington Post, January 2, 1994: pp.1,19. McGinnis, J. Michael, and Foege, William H. Actual Causes of Death in the United States, Journal of the American Medical Association, 270(18):2207-2212, 1993. National Alcohol Tax Coalition, Saving Lives and Raising Revenue: The Case for Higher Alcohol Taxes; Raising the Excise Tax on Beer: Myths and Facts, Washington, DC, 1993. Russell, C. Koop Seeks Taxes on Cigarettes, Guns, Washington, DC: Health, The Washington Post, February 1, 1994: p.5. Schauffler, H.H. Health Promotion and Disease Prevention in Health Care Reform. Contract Report to The California Wellness Foundation, Berkeley, CA: University of California at Berkeley School of Public Health. 1993. Silten, Robert M., and Levin, Lowell S. Self Care Evaluation, In: Lazes, Peter M., ed. The Handbook of Health Education, Germantown, MD: Aspen Systems Corporation, 1979: pp. 201-221. Thomas, P. Illicit Drug Use Rises Among U.S. Teenagers, Washington, DC: The Washington Post, February 1, 1994: pp.1,10. U.S. Department of Health and Human Services. 1992 National Survey of Worksite Health Promotion Activities, Washington, DC: Office of Disease Prevention and Health Promotion, 1992. A. B. C. D. E. APPENDICES Members of PARTNERSHIP FOR PREVENTION Prevention is Basic to Health Reform, A Position Paper from an Expert Panel, Table: Components of Prevention Table: Actual Causes of Death in the United States and Potential Contribution to Schauffler, H.H. Health Promotion and Disease Prevention in Health Care |