PREVENTIVE
MEDICINE
19, 105-l 13 (1990)
From Preventive Policy to Preventive Practice’ RICHARD D. REMINGTON, PH.D. Department of Preventive Medicine, University of Zowa, Iowa City, IA 52242 Characteristics of the relationship of preventive policy to preventive practice are reviewed. The relatively low emphasis on prevention compared with treatment programs is discussed and the particular problem of the “anonymity” of prevention is defined. F’revention programs suffer in part because of the lack of identity of the specific individuals benefited. Examples from the cardiovascular diseases are used to illustrate the general points. The contrast between community- and patient-oriented prevention is important. Adequate levels of disease prevention and health promotion will never be attained one case at a time. Interactions among individuals are determinants of environmental behavioral factors relevant to health. The policy forming process is intrinsically interactive in nature. The Institute of Medicine’s 1988 study of the future of public health is reviewed with respect to its emphasis on professional participation in the health policy process. prevention is an essentially multidisciplinary area requiring the participation of many professions and disciplines. This property of prevention will be enhanced in the future. Ten principles which can be useful in translating preventive policy into preventive practice are presented. 6 W!lO Academic Press, Inc.
There is an old joke that may be relevant to the theme of this lecture. Please don’t stop me if you have heard it before. I want to hear it again, for old times sake, although I am well aware that even nostalgia isn’t what it used to be. Actually, this story first came to my attention in the writings of Huff (l), and I have modified it only slightly. It seems that a travelling salesman was driving through the southwestern part of the United States. It was nearing midday, and he began to become interested in a meal. He noticed a roadside sign, which said “Joe’s Diner, three miles ahead, rabbit sandwiches, 75 cents.” He thought to himself, “I haven’t had a good rabbit sandwich for a long time. I think I’ll stop.” He pulled into the diner, which proved to be empty except for one person, evidently Joe himself, bent over the counter reading the morning paper and finishing a cup of coffee. In fact, Joe looked rather pleasantly startled to have a customer, and said “Yes sir, can I help you?” The salesman said “I saw your sign back a few miles. Is it true that you have rabbit sandwiches?” “ Yes, sir, and they are still 75 cents. Would you like one?” “Yes, bring me a rabbit sandwich and a cup of coffee, please.” In due course, the sandwich appeared and he took a generous mouthful, washing it down with a swig of coffee. Joe said, “What do you think of it?” The salesman said, “It’s very good, but I’m curious about one thing: how do you manage to serve rabbit sandwiches here ? This is dry, desert country, and I wouldn’t have thought there was an edible rabbit within miles of the place.” Joe said, “Well, you’re obviously a travelling man, so I’ll tell you a secret. That’s not ’ presented at the 2nd International Conference on preventive Cardiology and the 29th Annual Meeting of the AHA Council on Epidemiology, June 18-22, 1989, Washington DC. 105 0091-7435190$3.00 Copyright 0 1990 by Academic Press, Inc. Au rights of reproduction in any form reserved.
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pure rabbit meat. ” “What’s that you say,” said the salesman “not pure rabbit meat? ” “Yes,” said Joe. “Well, what is it?” said the salesman. “Actually, it’s part horse meat. ” “Part horse meat?” “ Well, actually it’s a little more than part horse meat.” “ A little more than part horse meat?” “Yes, well it’s actually fifty-fifty horse meat and rabbit meat.” “Fifty-fifty?” “Yes, fifty-fifty, one horse to one rabbit.” Now, in the bad old days, I used to inflict that story on fellows enrolled in our international seminar, “Ten Days of Cardiovascular Epidemiology,” but the permanent faculty had it even worse. For example, I’ll bet Jerry and Rose Stamler have heard it at least a dozen times. So those of you who have only heard it once before can surely expect little sympathy from them. I used the story as an example of how percentages can be misapplied. It occurred to me, however, that horses and rabbits have some relevance to my assigned topic today, “From Preventive Policy to Preventive Practice.” I suspect that, in a number of situations, we might be told that there is a major policy emphasis on prevention-that prevention is on a par with treatment, that our policy is fifty-fifty prevention and treatment, when in fact prevention is the rabbit to treatment’s horse. How can we turn that rabbit into a horse? Should we? Is the comparison even more out of balance? How about a flea and an elephant? It would be presumptuous of me to begin this lecture by leading you to believe that there are easy answers to the problem of bringing sound practice out of sound policy. There are no answers, no formulas, only suggestions, examples, and experiences. Yet, those experiences and some new information about public health in the United States may be helpful. In this country the Institute of Medicine or IOM is one of the component units under the umbrella formed by the National Academy of Sciences. About 3 years ago, with funding from the Kellogg Foundation and the U.S. Public Health Service, the IOM decided to embark upon an ambitious study of the current state of public health in this country and asked me to chair the study committee. Our report, entitled “The Future of Public Health,” was published last October (2). While not all of that report is relevant to the subject of this lecture, I believe some of it is. After a 2-year period of data collection involving the review of masses of published information, week-long site visits to communities in six states, structured interviews with over 350 individuals, four public hearings in various locations around the country, and consideration of a number of commissioned papers and reports, we concluded that the system of public health services in this country is in disarray, and that in particular, we are not in a good position to implement recent findings from prevention research. On the other hand, the Committee recognized the difficulties of operating a modem public health system by saying, “An impossible responsibility has been placed on America’s public health agencies: to serve as stewards of the basic health needs of entire populations, but at the same time avert impending disasters and provide personal health care to those rejected by the rest of the health system. The wonder is not that the U.S. public health system has problems, but that so much has been done so well, and with so little” (2).
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It is risky to claim that the results of this study are broadly applicable to conditions in other countries, but I have a feeling that much of what we found may be at the root of our almost universal problems in translating preventive knowledge into preventive practice. The IOM report suggests that three fundamental core functions reflecting the governmental responsibility for health should be in place in order to accomplish the mission of disease prevention and health promotion. I believe these functions are important in any setting, in any country, region, or locality, and I would like to share them with you. They are assessment, policy development, and assurance. The assessment function is fundamental: “Every public health agency (should) regularly and systematically collect, assemble, analyze, and make available information on the health of the community, including statistics on health status, community health needs, and epidemiologic and other studies of health problems. . . . This basic function of public health cannot be delegated” (2). This guarantees that public health practice will rest on a foundation of data and information that is current, reliable, and directly applicable to the health of the population served. But disease prevention cannot exist on data alone. Data must be responsive to sound public policy. Policy is established in a political context involving discussion, compromise, testing, and refinement, as well as factual information and scientific knowledge. Too often, the Committee found that public health officials deprecated the political process, seeing it as the enemy of public health and disease prevention rather than the vehicle through which public programs are implemented. Too often, on the other hand, we found public officials unwilling to be guided in their political judgments by scientific and technical information. This gap between political and scientific reality is one of the most formidable barriers to the development of sound and effective prevention policy. In describing the second core function of public health and prevention agencies, the report says: “Every public health agency (should) exercise its responsibility to serve the public interest in the development of comprehensive public health policies by promoting use of the scientific knowledge base in decision-making about public health and by leading in developing public health policy. Agencies must take a strategic approach, developed on the basis of a positive appreciation for the . . . political process” (2). In developing its concept of the assurance function, the third core activity, the committee recognized that a major problem and opportunity lie in the full utilization of resources for the delivery of personal health services primarily found within the private sector. Most personal health care in this country is delivered by individuals operating in the private sector, and that situation is unlikely to change at any early date. Coupled with a payment structure that relies heavily on private insurance, this means that individuals without access to private care or to health insurance must receive care from the public sector or do without. This concept of the public sector, specifically public health, as the provider of last resort has become very important in the operation of many public health departments. In fact, a number of agencies visited by the Committee deliver massive amounts of personal health services, often to make ends meet, since these services, unlike most preventive and environmental health services, usually
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generate reimbursement to the agency providing them. This creates a dilemma for such agencies. If the health department did not provide the services, people needing those services would not receive them. Yet the department may be unable to provide adequate preventive, educational, or environmental health services because so much of its effort consists of providing one-to-one medical care. The Committee recognized the present intractability of this problem and advanced the concept of assurance as a response. “Public health agencies (should) assure their constituents that services necessary to achieve agreed upon goals are provided, either by encouraging actions by other entities (private or public sector), by requiring such action through regulation, or by providing services directly” (2). Describing the hazards of the direct provision of services, the Committee said, “The responsibility for providing medical care to individuals-precisely because it is so compelling-has drained vital resources and attention away from disease prevention and health promotion efforts that benefit the entire community. These latter efforts encounter great difficulty in competing for policy attention with personal health services. The U.S. failure to find a societywide answer to the question of financial access to needed care has seriously strained the public health system” (2). That strain on the public health system of course translates directly into a strain on the health promotion, disease prevention system, including the prevention of cardiovascular disease. In addition, the AIDS crisis is further diverting resources and attention from all other disease control efforts. One local health officer perhaps described the situation best of all, “When you put together preventive and curative, the latter gets the money, because no one has the guts to say I’m going to emphasize prevention. Sickness care takes precedence” (2). Now, the IOM study clearly has a number of features that are exclusively or at least primarily applicable to the United States. For example, the emphasis on the critical role of the fifty states and their individual governments would not apply to countries with a different political structure. There are many points, however, at which this study can offer insights into the general problems of prevention policy and practice in other countries. For example, the relative emphasis on treatment over prevention and the predominance of policies, structures, and practices to provide sickness instead of wellness care seem to be virtually universal. Part of this problem is intrinsic to prevention itself. Let me illustrate: In January 1989, the U.S. Surgeon General, Dr. Koop, released a report entitled Reducing the Health Consequences of Smoking: 25 Years of&ogress (3). That report suggests that from 1964 to 1985, decisions to avoid or quit smoking had saved roughly three-fourths of a million lives in this country. But just who are those people whose lives were saved? Not everyone who quit or failed to start smoking would have died of tobacco-related causes. There is no way to point to a specific person and say beyond doubt, “Your life was saved as a result of this decision.” This intrinsic feature of prevention is something I have called elsewhere the anonymity of prevention (4). That is, when a physician treats a patient with a particular disease and cures that patient, there is no doubt about the identity of the
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patient involved. The results are clear and definite. Those of us who labor at the community prevention level, however, do so without the benefits of grateful patients of known identity whose lives have been saved. The anonymity associated with prevention applies quite broadly. Some years ago, the World Health Organization announced the worldwide eradication of smallpox. No one doubts that many thousands of lives have been saved as a result of this-the ultimate preventive intervention. But whose lives have been saved? Can you name just one of them? You can’t and neither can I. But with a little effort we could probably identify by name every single patient in the world whose heart has been replaced by a donor organ. More than that, if we added together the column inches of newspaper coverage devoted to smallpox eradication and to cardiac replacement therapy, is there any doubt which condition would have attracted the greater press and public attention? Yet, look at the comparison between the number of lives saved. Smallpox is the winner, probably by several orders of magnitude. But we are often told that we should not look merely at mortality, but should consider quality of life. Here again, smallpox prevention is the clear and overwhelming winner. But we could use instead of smallpox improved control of high blood pressure. Dr. Claude Lenfant, Director of the National Heart Lung and Blood Institute, has recently said that since the advent of the National High Blood Pressure Education Program (NHBPEP) in the early 1970s “sales of food grade salt have decreased by 36%; visits to physicians for hypertension have quadrupled; control rates for hypertension in the U.S. have increased fourfold; and age-adjusted stroke mortality rates have declined by 53%” (5). Again, just who are those people who would have died from stroke without the benefits of the NHBPEP? There are thousands of them, but you can’t name one and neither can I. So it is with prevention. Not a glamorous business compared with case by case treatment of disease.A hard slogging, tough business, but surely one with its own very definite rewards-after all, what could be more fulfilling than the certain knowledge that, even though we can’t identify even one of them, thousands and thousands of lives have been saved and the quality of those lives enhanced by the prevention of cardiovascular disease. This business of translating preventive policy into preventive practice, then, must take into account the fact that intrinsic differences between prevention and treatment, such as the anonymity of prevention, will require policy maintenance efforts on a continuous basis. Policies consistent with preventive efforts must not only be established; they must be monitored and revised as necessary. There is another difficulty that attends modern community level prevention methods-that is, the need to involve a broad team of experts in developing and implementing prevention programs. Physicians alone cannot do the task. While this need is also beginning to be recognized in treatment programs, I would argue that it is fundamental to the field of prevention. Often, for example, we are seeking to involve people in changesin lifestyle, and with the development of new information now and in the future, behavioral scientists, health educators, experts in public information and communication wiIl become indispensable. This will place special demands on physicians and admin-
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istrators not particularly adept at recognizing the limitations of their own expertise. This is not to say that physicians will not or should not play a central, or perhaps the central role. It merely notes that, in addition to the professions and disciplines already listed, the prevention effort now and in the future may require nutritionists, statisticians, engineers, ethicists, and many others. A taste for multidisciplinary work and for assembling and managing a team will be a requisite for leadership of future preventive efforts. You will note that up to this point I have been emphasizing community level prevention and have given no attention to clinical preventive medicine. This is not because I believe that field to be unimportant. It is clear that if we could instill in every practicing physician the prevention ethic, thereby producing a standard of practice that ceased to regard episodes of illness as the only patient problems worth taking seriously, we would be far ahead. And I believe that in recent years we have made great gains in doing just that. Furthermore, the clinical encounter is an opportunity to take advantage of the patient’s focus on health issues at a time when motivation and the consequent possibilities for positive changes in behavior may be at relatively high levels. But one point must be emphasized. We will never reach public health or community level prevention one case at a time. The reasons go beyond the fact that some people, in any time period however long, never become cases. Prevention and the attendant need to change lifestyle, food marketing practices, legislation, and organizational structures cannot be embedded within a purely clinical framework. The health of a community is not composed of the individual health of each of its members. In the case of cardiovascular disease prevention as with the rest of public health, interactions among members of the community are also critically important. Of course, in the case of the infectious diseases it is obvious that contagion and exposure are central concerns. But in the case of the noninfectious diseases as well, interactions are central. Families share diets in common. Work units are subject to comparable emotional and physical stresses, including levels of job-related physical activity. Peer pressure plays an important role in decisions to start smoking, to name but a few obvious examples. Interactions, after all, are precisely what generate public policy in health and every other sector of society: education, social services, police and fire protection, roads and other public works, agriculture, economics and trade, the environment, national defense. Politics is, fundamentally, a form of interaction, and it is an important basis for formation and alteration of public policy and thus of practice-preventive and every other form of community practice. No, you can’t get to health promotion, you can’t get to disease prevention, you can’t get to public health one case at a time. Before discussing a series of specific steps to enhance the process of moving from policy to practice, let me introduce a caveat. Policy and practice are probably not as different as we often believe. If, for example, a policy is never implemented, then for practical purposes, it ceases to be policy. If practice includes elements not included in formal policy documents, and if these continue over a sufficient period of time, then these elements of practice have, in effect, become
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policy. Of course, we are really talking here about the difference between defucto and de jure policy, but for most practical-minded people like all of us, interested primarily in tangible, measurable health outcomes, de jure policy, while of passible importance as a statement of intent, is of less practical impact. Then how can communities, whether nations, regions, districts, states, cities, or other aggregates of population, move from preventive policy to preventive practice. The short answer is “I haven’t the foggiest idea.” But that answer seems unlikely to satisfy the organizers of this conference. Even if I said “No-one has the foggiest idea,” that would probably not satisfy them either. Strictly speaking, neither answer would be correct. In fact, I and others do have the foggiest idea. What we don’t have is a specific set of formulas, an algorithm if you will, Yet, I think some useful principles to guide the policy to practice transfer can be set down on the basis of recent experience and even some data such as that collected by the IOM study on the future of public health. There are ten points or principles which I believe are important: 1. Do everything possible to ensure that the mechanism for policy formation is flexible,
and subject to change.
Now, this can be a tall order to till. Without it, however, policy cannot keep abreast of new developments in the rapidly changing field of cardiovascular disease prevention. If this feature does not presently characterize policy development in your environment, considerable effort may need to be devoted to introducing it and in turn considerable patience may be needed. 2. Be sure science is a part of the policy process.
In the course of the IOM study, one of our most important observations was the frequency with which public offtcials, politicians if you will, and public health officials regarded each other with something approaching contempt. No one, least of all the general public, benefits from this situation. Prevention policy must respond to scientific information and thus must provide access to the policy process by those possessing such information. On the other hand, scientists must recognize that the political process includes pressures and stimuli from sectors other than the scientific community. 3. Build a practice
component into the policy process.
If policy is to be practical and if it is to make a difference to the health of the community, it must have the capacity for application. Lofty goals are not unimportant, but if we wish to have a direct impact on the health of the community, realities of the medical care system and limitations on practice and practitioners must be recognized. Pie in the sky can be a particularly dangerous form of air pollution. 4. Be prepared to take an active not a passive approach to the community.
Not only is it necessary that science and practice be a part of the policy process, it is also important that health practitioners and others with an interest in prevention seek to establish an active, interventionist view of community health. A health department or for that matter a prevention practitioner who simply puts up a sign or a shingle announcing his or her availability will not have the necessary impact. Our focus at the community level must, after all, include those who are healthy, perhaps mainly those who are healthy. Our goal is to keep them that way.
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The rules of the game are therefore quite different. We must find ways to take preventive services, including individual care, education, and environmental modification to the community and its members. We must, in short, be active rather than passive. 5. Build a consensus in the community. In the IOM study, we were very impressed with the situation in the city of Toronto in Canada. This is a community which by careful plan and design, as well as by tireless efforts on the part of many people, built a communitywide base for public health programs in general and for prevention in particular. I suspect that there was less theory, less structure, less formula in their successful effort than simply a willingness to work with community leaders, to build coalitions, to help impart a sense of ownership, a public stake in the health of the community. I am sure that the favorable results that so impressed our committee did not occur overnight. 6. Establish coalitions, a sense of ownership. In fact, this principle is so important that it bears listing as a separate point. Those with the largest stake in prevention are those whose lives and health will be directly affected. It seems ironic that sometimes we behave as if the health professionals are center stage and have the largest stake in these issues. Such an attitude cannot enhance the implementation of modern prevention strategies. 7. Provide information flow back to policymakers and the community itself. Prevention programs are not static, and if they are to succeed they must provide for continuing community involvement. That involvement will require a regular flow of information about program progress. Otherwise, other programs will displace prevention for the attention of policy makers. 8. Be light on your feet. Be prepared for the unexpected. Communities dance to many tunes and health is not necessarily the theme song. Flexibility on the part of those who seek to maintain prevention programs is essential. Take Murphy’s law seriously-if something can go wrong, it will. In fact, I think we must even take account of the malignant form of Murphy’s law, which says-even if something can’t possibly go wrong, it will. That sounds pessimistic, but we mean to be in business for a long time, and that means that we had better keep our senses sharp. The initial establishment of a prevention program, in other words, is only the beginning. 9. Study success, not failure. Communities vary a great deal, and your experience with your own community will be an improvement over theory nearly every time. The best guide to what will work in your community in the future is what has worked in the past. Thus, the admonition, study success, be empirical. If theory says that something should have worked for you, but it didn’t, the chances are that the problem is with the theory, not with you. 10. Make evaluation a part of preventive practice. If, as I believe, your own experience will quickly become the best guide to what will work in your community, then you need a systematic method for studying that experience, for codifying it. In short, you need to include as an integral part of your Prevention program a system for its evaluation, in terms of process, but
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above all in terms of outcome. We are surely more interested in what did work than in what should have worked. Well, looking back over these remarks, I often seem to have been more pessimistic than I intended. I also note that I have taken some hard shots at prevention theory. Yet, research in prevention is clearly one of our most important ultimate weapons against heart disease. We must learn far more than we now know, but we must also learn how to apply better what we do know. Alas, there can be no rest for the busy investigator or the busy practitioner of prevention. In fact, contrary to the pessimism I have occasionally expressed in this lecture, I am really very hopeful about the future of preventive practice. We have learned a great deal and we have many fine accomplishments, of which we can be justiIiably proud. The fact that we can come together like this in a worldwide forum is in itself a good sign. I believe the next decade will see even greater progress than the last in stemming the worldwide epidemic of cardiovascular disease through successful application of soundly conceived, scientifically based prevention programs. REFERENCES 1. Huff, D., How IO Lie with Statistics. New York: W. W. Norton and Company, Inc., 1954. 2. lnstitute of Medicine. The Future of Public Health. Washington, D.C.: National Academy Press, 1988. 3. United States Public Health Service. Reducing the Health Consequences of Smoking: 25 Years of Progress. Washington, D.C.: U.S. Government Printing Office, 1989. 4. Remington, R. D. “The Anonymity of Prevention,” Idaho Health, Idaho Public Health Association, 7(2):3, May, 1984. 5. World Hypertension League Newsletter Number 3: Geneva. March, 1989.
MEDICINE
19, 105-l 13 (1990)
From Preventive Policy to Preventive Practice’ RICHARD D. REMINGTON, PH.D. Department of Preventive Medicine, University of Zowa, Iowa City, IA 52242 Characteristics of the relationship of preventive policy to preventive practice are reviewed. The relatively low emphasis on prevention compared with treatment programs is discussed and the particular problem of the “anonymity” of prevention is defined. F’revention programs suffer in part because of the lack of identity of the specific individuals benefited. Examples from the cardiovascular diseases are used to illustrate the general points. The contrast between community- and patient-oriented prevention is important. Adequate levels of disease prevention and health promotion will never be attained one case at a time. Interactions among individuals are determinants of environmental behavioral factors relevant to health. The policy forming process is intrinsically interactive in nature. The Institute of Medicine’s 1988 study of the future of public health is reviewed with respect to its emphasis on professional participation in the health policy process. prevention is an essentially multidisciplinary area requiring the participation of many professions and disciplines. This property of prevention will be enhanced in the future. Ten principles which can be useful in translating preventive policy into preventive practice are presented. 6 W!lO Academic Press, Inc.
There is an old joke that may be relevant to the theme of this lecture. Please don’t stop me if you have heard it before. I want to hear it again, for old times sake, although I am well aware that even nostalgia isn’t what it used to be. Actually, this story first came to my attention in the writings of Huff (l), and I have modified it only slightly. It seems that a travelling salesman was driving through the southwestern part of the United States. It was nearing midday, and he began to become interested in a meal. He noticed a roadside sign, which said “Joe’s Diner, three miles ahead, rabbit sandwiches, 75 cents.” He thought to himself, “I haven’t had a good rabbit sandwich for a long time. I think I’ll stop.” He pulled into the diner, which proved to be empty except for one person, evidently Joe himself, bent over the counter reading the morning paper and finishing a cup of coffee. In fact, Joe looked rather pleasantly startled to have a customer, and said “Yes sir, can I help you?” The salesman said “I saw your sign back a few miles. Is it true that you have rabbit sandwiches?” “ Yes, sir, and they are still 75 cents. Would you like one?” “Yes, bring me a rabbit sandwich and a cup of coffee, please.” In due course, the sandwich appeared and he took a generous mouthful, washing it down with a swig of coffee. Joe said, “What do you think of it?” The salesman said, “It’s very good, but I’m curious about one thing: how do you manage to serve rabbit sandwiches here ? This is dry, desert country, and I wouldn’t have thought there was an edible rabbit within miles of the place.” Joe said, “Well, you’re obviously a travelling man, so I’ll tell you a secret. That’s not ’ presented at the 2nd International Conference on preventive Cardiology and the 29th Annual Meeting of the AHA Council on Epidemiology, June 18-22, 1989, Washington DC. 105 0091-7435190$3.00 Copyright 0 1990 by Academic Press, Inc. Au rights of reproduction in any form reserved.
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pure rabbit meat. ” “What’s that you say,” said the salesman “not pure rabbit meat? ” “Yes,” said Joe. “Well, what is it?” said the salesman. “Actually, it’s part horse meat. ” “Part horse meat?” “ Well, actually it’s a little more than part horse meat.” “ A little more than part horse meat?” “Yes, well it’s actually fifty-fifty horse meat and rabbit meat.” “Fifty-fifty?” “Yes, fifty-fifty, one horse to one rabbit.” Now, in the bad old days, I used to inflict that story on fellows enrolled in our international seminar, “Ten Days of Cardiovascular Epidemiology,” but the permanent faculty had it even worse. For example, I’ll bet Jerry and Rose Stamler have heard it at least a dozen times. So those of you who have only heard it once before can surely expect little sympathy from them. I used the story as an example of how percentages can be misapplied. It occurred to me, however, that horses and rabbits have some relevance to my assigned topic today, “From Preventive Policy to Preventive Practice.” I suspect that, in a number of situations, we might be told that there is a major policy emphasis on prevention-that prevention is on a par with treatment, that our policy is fifty-fifty prevention and treatment, when in fact prevention is the rabbit to treatment’s horse. How can we turn that rabbit into a horse? Should we? Is the comparison even more out of balance? How about a flea and an elephant? It would be presumptuous of me to begin this lecture by leading you to believe that there are easy answers to the problem of bringing sound practice out of sound policy. There are no answers, no formulas, only suggestions, examples, and experiences. Yet, those experiences and some new information about public health in the United States may be helpful. In this country the Institute of Medicine or IOM is one of the component units under the umbrella formed by the National Academy of Sciences. About 3 years ago, with funding from the Kellogg Foundation and the U.S. Public Health Service, the IOM decided to embark upon an ambitious study of the current state of public health in this country and asked me to chair the study committee. Our report, entitled “The Future of Public Health,” was published last October (2). While not all of that report is relevant to the subject of this lecture, I believe some of it is. After a 2-year period of data collection involving the review of masses of published information, week-long site visits to communities in six states, structured interviews with over 350 individuals, four public hearings in various locations around the country, and consideration of a number of commissioned papers and reports, we concluded that the system of public health services in this country is in disarray, and that in particular, we are not in a good position to implement recent findings from prevention research. On the other hand, the Committee recognized the difficulties of operating a modem public health system by saying, “An impossible responsibility has been placed on America’s public health agencies: to serve as stewards of the basic health needs of entire populations, but at the same time avert impending disasters and provide personal health care to those rejected by the rest of the health system. The wonder is not that the U.S. public health system has problems, but that so much has been done so well, and with so little” (2).
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It is risky to claim that the results of this study are broadly applicable to conditions in other countries, but I have a feeling that much of what we found may be at the root of our almost universal problems in translating preventive knowledge into preventive practice. The IOM report suggests that three fundamental core functions reflecting the governmental responsibility for health should be in place in order to accomplish the mission of disease prevention and health promotion. I believe these functions are important in any setting, in any country, region, or locality, and I would like to share them with you. They are assessment, policy development, and assurance. The assessment function is fundamental: “Every public health agency (should) regularly and systematically collect, assemble, analyze, and make available information on the health of the community, including statistics on health status, community health needs, and epidemiologic and other studies of health problems. . . . This basic function of public health cannot be delegated” (2). This guarantees that public health practice will rest on a foundation of data and information that is current, reliable, and directly applicable to the health of the population served. But disease prevention cannot exist on data alone. Data must be responsive to sound public policy. Policy is established in a political context involving discussion, compromise, testing, and refinement, as well as factual information and scientific knowledge. Too often, the Committee found that public health officials deprecated the political process, seeing it as the enemy of public health and disease prevention rather than the vehicle through which public programs are implemented. Too often, on the other hand, we found public officials unwilling to be guided in their political judgments by scientific and technical information. This gap between political and scientific reality is one of the most formidable barriers to the development of sound and effective prevention policy. In describing the second core function of public health and prevention agencies, the report says: “Every public health agency (should) exercise its responsibility to serve the public interest in the development of comprehensive public health policies by promoting use of the scientific knowledge base in decision-making about public health and by leading in developing public health policy. Agencies must take a strategic approach, developed on the basis of a positive appreciation for the . . . political process” (2). In developing its concept of the assurance function, the third core activity, the committee recognized that a major problem and opportunity lie in the full utilization of resources for the delivery of personal health services primarily found within the private sector. Most personal health care in this country is delivered by individuals operating in the private sector, and that situation is unlikely to change at any early date. Coupled with a payment structure that relies heavily on private insurance, this means that individuals without access to private care or to health insurance must receive care from the public sector or do without. This concept of the public sector, specifically public health, as the provider of last resort has become very important in the operation of many public health departments. In fact, a number of agencies visited by the Committee deliver massive amounts of personal health services, often to make ends meet, since these services, unlike most preventive and environmental health services, usually
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generate reimbursement to the agency providing them. This creates a dilemma for such agencies. If the health department did not provide the services, people needing those services would not receive them. Yet the department may be unable to provide adequate preventive, educational, or environmental health services because so much of its effort consists of providing one-to-one medical care. The Committee recognized the present intractability of this problem and advanced the concept of assurance as a response. “Public health agencies (should) assure their constituents that services necessary to achieve agreed upon goals are provided, either by encouraging actions by other entities (private or public sector), by requiring such action through regulation, or by providing services directly” (2). Describing the hazards of the direct provision of services, the Committee said, “The responsibility for providing medical care to individuals-precisely because it is so compelling-has drained vital resources and attention away from disease prevention and health promotion efforts that benefit the entire community. These latter efforts encounter great difficulty in competing for policy attention with personal health services. The U.S. failure to find a societywide answer to the question of financial access to needed care has seriously strained the public health system” (2). That strain on the public health system of course translates directly into a strain on the health promotion, disease prevention system, including the prevention of cardiovascular disease. In addition, the AIDS crisis is further diverting resources and attention from all other disease control efforts. One local health officer perhaps described the situation best of all, “When you put together preventive and curative, the latter gets the money, because no one has the guts to say I’m going to emphasize prevention. Sickness care takes precedence” (2). Now, the IOM study clearly has a number of features that are exclusively or at least primarily applicable to the United States. For example, the emphasis on the critical role of the fifty states and their individual governments would not apply to countries with a different political structure. There are many points, however, at which this study can offer insights into the general problems of prevention policy and practice in other countries. For example, the relative emphasis on treatment over prevention and the predominance of policies, structures, and practices to provide sickness instead of wellness care seem to be virtually universal. Part of this problem is intrinsic to prevention itself. Let me illustrate: In January 1989, the U.S. Surgeon General, Dr. Koop, released a report entitled Reducing the Health Consequences of Smoking: 25 Years of&ogress (3). That report suggests that from 1964 to 1985, decisions to avoid or quit smoking had saved roughly three-fourths of a million lives in this country. But just who are those people whose lives were saved? Not everyone who quit or failed to start smoking would have died of tobacco-related causes. There is no way to point to a specific person and say beyond doubt, “Your life was saved as a result of this decision.” This intrinsic feature of prevention is something I have called elsewhere the anonymity of prevention (4). That is, when a physician treats a patient with a particular disease and cures that patient, there is no doubt about the identity of the
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patient involved. The results are clear and definite. Those of us who labor at the community prevention level, however, do so without the benefits of grateful patients of known identity whose lives have been saved. The anonymity associated with prevention applies quite broadly. Some years ago, the World Health Organization announced the worldwide eradication of smallpox. No one doubts that many thousands of lives have been saved as a result of this-the ultimate preventive intervention. But whose lives have been saved? Can you name just one of them? You can’t and neither can I. But with a little effort we could probably identify by name every single patient in the world whose heart has been replaced by a donor organ. More than that, if we added together the column inches of newspaper coverage devoted to smallpox eradication and to cardiac replacement therapy, is there any doubt which condition would have attracted the greater press and public attention? Yet, look at the comparison between the number of lives saved. Smallpox is the winner, probably by several orders of magnitude. But we are often told that we should not look merely at mortality, but should consider quality of life. Here again, smallpox prevention is the clear and overwhelming winner. But we could use instead of smallpox improved control of high blood pressure. Dr. Claude Lenfant, Director of the National Heart Lung and Blood Institute, has recently said that since the advent of the National High Blood Pressure Education Program (NHBPEP) in the early 1970s “sales of food grade salt have decreased by 36%; visits to physicians for hypertension have quadrupled; control rates for hypertension in the U.S. have increased fourfold; and age-adjusted stroke mortality rates have declined by 53%” (5). Again, just who are those people who would have died from stroke without the benefits of the NHBPEP? There are thousands of them, but you can’t name one and neither can I. So it is with prevention. Not a glamorous business compared with case by case treatment of disease.A hard slogging, tough business, but surely one with its own very definite rewards-after all, what could be more fulfilling than the certain knowledge that, even though we can’t identify even one of them, thousands and thousands of lives have been saved and the quality of those lives enhanced by the prevention of cardiovascular disease. This business of translating preventive policy into preventive practice, then, must take into account the fact that intrinsic differences between prevention and treatment, such as the anonymity of prevention, will require policy maintenance efforts on a continuous basis. Policies consistent with preventive efforts must not only be established; they must be monitored and revised as necessary. There is another difficulty that attends modern community level prevention methods-that is, the need to involve a broad team of experts in developing and implementing prevention programs. Physicians alone cannot do the task. While this need is also beginning to be recognized in treatment programs, I would argue that it is fundamental to the field of prevention. Often, for example, we are seeking to involve people in changesin lifestyle, and with the development of new information now and in the future, behavioral scientists, health educators, experts in public information and communication wiIl become indispensable. This will place special demands on physicians and admin-
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istrators not particularly adept at recognizing the limitations of their own expertise. This is not to say that physicians will not or should not play a central, or perhaps the central role. It merely notes that, in addition to the professions and disciplines already listed, the prevention effort now and in the future may require nutritionists, statisticians, engineers, ethicists, and many others. A taste for multidisciplinary work and for assembling and managing a team will be a requisite for leadership of future preventive efforts. You will note that up to this point I have been emphasizing community level prevention and have given no attention to clinical preventive medicine. This is not because I believe that field to be unimportant. It is clear that if we could instill in every practicing physician the prevention ethic, thereby producing a standard of practice that ceased to regard episodes of illness as the only patient problems worth taking seriously, we would be far ahead. And I believe that in recent years we have made great gains in doing just that. Furthermore, the clinical encounter is an opportunity to take advantage of the patient’s focus on health issues at a time when motivation and the consequent possibilities for positive changes in behavior may be at relatively high levels. But one point must be emphasized. We will never reach public health or community level prevention one case at a time. The reasons go beyond the fact that some people, in any time period however long, never become cases. Prevention and the attendant need to change lifestyle, food marketing practices, legislation, and organizational structures cannot be embedded within a purely clinical framework. The health of a community is not composed of the individual health of each of its members. In the case of cardiovascular disease prevention as with the rest of public health, interactions among members of the community are also critically important. Of course, in the case of the infectious diseases it is obvious that contagion and exposure are central concerns. But in the case of the noninfectious diseases as well, interactions are central. Families share diets in common. Work units are subject to comparable emotional and physical stresses, including levels of job-related physical activity. Peer pressure plays an important role in decisions to start smoking, to name but a few obvious examples. Interactions, after all, are precisely what generate public policy in health and every other sector of society: education, social services, police and fire protection, roads and other public works, agriculture, economics and trade, the environment, national defense. Politics is, fundamentally, a form of interaction, and it is an important basis for formation and alteration of public policy and thus of practice-preventive and every other form of community practice. No, you can’t get to health promotion, you can’t get to disease prevention, you can’t get to public health one case at a time. Before discussing a series of specific steps to enhance the process of moving from policy to practice, let me introduce a caveat. Policy and practice are probably not as different as we often believe. If, for example, a policy is never implemented, then for practical purposes, it ceases to be policy. If practice includes elements not included in formal policy documents, and if these continue over a sufficient period of time, then these elements of practice have, in effect, become
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policy. Of course, we are really talking here about the difference between defucto and de jure policy, but for most practical-minded people like all of us, interested primarily in tangible, measurable health outcomes, de jure policy, while of passible importance as a statement of intent, is of less practical impact. Then how can communities, whether nations, regions, districts, states, cities, or other aggregates of population, move from preventive policy to preventive practice. The short answer is “I haven’t the foggiest idea.” But that answer seems unlikely to satisfy the organizers of this conference. Even if I said “No-one has the foggiest idea,” that would probably not satisfy them either. Strictly speaking, neither answer would be correct. In fact, I and others do have the foggiest idea. What we don’t have is a specific set of formulas, an algorithm if you will, Yet, I think some useful principles to guide the policy to practice transfer can be set down on the basis of recent experience and even some data such as that collected by the IOM study on the future of public health. There are ten points or principles which I believe are important: 1. Do everything possible to ensure that the mechanism for policy formation is flexible,
and subject to change.
Now, this can be a tall order to till. Without it, however, policy cannot keep abreast of new developments in the rapidly changing field of cardiovascular disease prevention. If this feature does not presently characterize policy development in your environment, considerable effort may need to be devoted to introducing it and in turn considerable patience may be needed. 2. Be sure science is a part of the policy process.
In the course of the IOM study, one of our most important observations was the frequency with which public offtcials, politicians if you will, and public health officials regarded each other with something approaching contempt. No one, least of all the general public, benefits from this situation. Prevention policy must respond to scientific information and thus must provide access to the policy process by those possessing such information. On the other hand, scientists must recognize that the political process includes pressures and stimuli from sectors other than the scientific community. 3. Build a practice
component into the policy process.
If policy is to be practical and if it is to make a difference to the health of the community, it must have the capacity for application. Lofty goals are not unimportant, but if we wish to have a direct impact on the health of the community, realities of the medical care system and limitations on practice and practitioners must be recognized. Pie in the sky can be a particularly dangerous form of air pollution. 4. Be prepared to take an active not a passive approach to the community.
Not only is it necessary that science and practice be a part of the policy process, it is also important that health practitioners and others with an interest in prevention seek to establish an active, interventionist view of community health. A health department or for that matter a prevention practitioner who simply puts up a sign or a shingle announcing his or her availability will not have the necessary impact. Our focus at the community level must, after all, include those who are healthy, perhaps mainly those who are healthy. Our goal is to keep them that way.
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The rules of the game are therefore quite different. We must find ways to take preventive services, including individual care, education, and environmental modification to the community and its members. We must, in short, be active rather than passive. 5. Build a consensus in the community. In the IOM study, we were very impressed with the situation in the city of Toronto in Canada. This is a community which by careful plan and design, as well as by tireless efforts on the part of many people, built a communitywide base for public health programs in general and for prevention in particular. I suspect that there was less theory, less structure, less formula in their successful effort than simply a willingness to work with community leaders, to build coalitions, to help impart a sense of ownership, a public stake in the health of the community. I am sure that the favorable results that so impressed our committee did not occur overnight. 6. Establish coalitions, a sense of ownership. In fact, this principle is so important that it bears listing as a separate point. Those with the largest stake in prevention are those whose lives and health will be directly affected. It seems ironic that sometimes we behave as if the health professionals are center stage and have the largest stake in these issues. Such an attitude cannot enhance the implementation of modern prevention strategies. 7. Provide information flow back to policymakers and the community itself. Prevention programs are not static, and if they are to succeed they must provide for continuing community involvement. That involvement will require a regular flow of information about program progress. Otherwise, other programs will displace prevention for the attention of policy makers. 8. Be light on your feet. Be prepared for the unexpected. Communities dance to many tunes and health is not necessarily the theme song. Flexibility on the part of those who seek to maintain prevention programs is essential. Take Murphy’s law seriously-if something can go wrong, it will. In fact, I think we must even take account of the malignant form of Murphy’s law, which says-even if something can’t possibly go wrong, it will. That sounds pessimistic, but we mean to be in business for a long time, and that means that we had better keep our senses sharp. The initial establishment of a prevention program, in other words, is only the beginning. 9. Study success, not failure. Communities vary a great deal, and your experience with your own community will be an improvement over theory nearly every time. The best guide to what will work in your community in the future is what has worked in the past. Thus, the admonition, study success, be empirical. If theory says that something should have worked for you, but it didn’t, the chances are that the problem is with the theory, not with you. 10. Make evaluation a part of preventive practice. If, as I believe, your own experience will quickly become the best guide to what will work in your community, then you need a systematic method for studying that experience, for codifying it. In short, you need to include as an integral part of your Prevention program a system for its evaluation, in terms of process, but
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above all in terms of outcome. We are surely more interested in what did work than in what should have worked. Well, looking back over these remarks, I often seem to have been more pessimistic than I intended. I also note that I have taken some hard shots at prevention theory. Yet, research in prevention is clearly one of our most important ultimate weapons against heart disease. We must learn far more than we now know, but we must also learn how to apply better what we do know. Alas, there can be no rest for the busy investigator or the busy practitioner of prevention. In fact, contrary to the pessimism I have occasionally expressed in this lecture, I am really very hopeful about the future of preventive practice. We have learned a great deal and we have many fine accomplishments, of which we can be justiIiably proud. The fact that we can come together like this in a worldwide forum is in itself a good sign. I believe the next decade will see even greater progress than the last in stemming the worldwide epidemic of cardiovascular disease through successful application of soundly conceived, scientifically based prevention programs. REFERENCES 1. Huff, D., How IO Lie with Statistics. New York: W. W. Norton and Company, Inc., 1954. 2. lnstitute of Medicine. The Future of Public Health. Washington, D.C.: National Academy Press, 1988. 3. United States Public Health Service. Reducing the Health Consequences of Smoking: 25 Years of Progress. Washington, D.C.: U.S. Government Printing Office, 1989. 4. Remington, R. D. “The Anonymity of Prevention,” Idaho Health, Idaho Public Health Association, 7(2):3, May, 1984. 5. World Hypertension League Newsletter Number 3: Geneva. March, 1989.
