Commentary Health Promotion-Some Notions in Search of a Constituency JONATHAN E. FIELDING, MD, MPH As medicine qua science has become better defined, health promotion-given much prominence in classical civilization under the reigning religious and social tenets of society-has decreased in importance and become fractionated as the "preventive" part of specific medical regimens: * Exercise is prescribed as a part of the medical regimen to recover from myocardial infarction; * Cessation of smoking is recommended as part of the therapy for chronic lung disease; * Weight reduction is advised as one medical response to incipient diabetes, hypertension, and heart failure. Medicine today is, in general, oriented to illness and technological remedies. Health care professionals are, in the main, in the business of minimizing effects of illness. The payment system supports this set of priorities. How many insurance policies pay for visits to no-smoking clinics, nutritional counseling, or physical fitness classes? Our strong beliefs in traditional medical institutions and medical technology have been eroded by the very small improvement in curative medicine during the past quarter century despite the growing financial burden that saw health care costs multiply tenfold. It appears that increased technological investment brings diminishing returns. As a result we have difficulty knowing where to turn in our search for a disease free status. Turning inward to ourselves, our lifestyles, social values and the social system which sustains us are rejected as paltry and pedestrian substitutes for impressive edifices, computer printouts, and medical jargon that add the desired mysticism to the patient-health professional relationship. The problem is not one of the orientation and expectations of patients, but rather of the training and orientation of practitioners of medicine. Over 130 years ago, Dr. Address reprint requests to Dr. Jonathan E. Fielding, Commissioner, Department of Public Health, Commonwealth of Massachusetts, 600 Washington Street, Boston, MA 02111. This paper, submitted to the Journal January 31, 1977, was revised and accepted for publication June 9, 1977. 1 082

Edward Jarvis expressed the problem of physician education this way: "Our education has made our calling exclusively a curative and not a conservative one, and the business of our responsible lives has confined us to it. Our thoughts are devoted to, our interests concerned in, and our employments are connected solely with, sickness, debility or injury,-with diminution of life in some of its forms. But with health, with fullness of unalloyed, unimpaired life, we, professionally, have nothing to do."' The problems of disease-specific orientation of health professional training are paralleled by the structure and legislatively-assigned functions of federal and state health agencies. In addition, neither the current organization of the patient's record nor the way public moneys are distributed force priority attention on the maintenance of health. The answer is not to eschew what medical technology has brought us. The most zealous advocate of holistic medicine wants modern, well-equipped hospitals and well-trained up-to-date physicians, dentists, nurses, and other health professionals when illness occurs. However, if we feel the need to integrate health promotion into our individual lives and mission as health professionals, we must program ourselves, our agencies, our public institutions, and our elected representatives. The need for a basic reorientation is hardly a new concept. Lemuel Shattuck and his co-authors of the 1850 Report of the Sanitary Commission of Massachusetts, stated: "We believe that the conditions of perfect health, either public or personal, are seldom or never attained, though attainable;-that the average length of human life may be very much extended, and its physical power greatly augmented; that in every year, within this Commonwealth, thousands of lives are lost which might have been saved;-that tens of thousands of cases of sickness occur, which might have been prevented;-that a vast amount of unnecessarily impaired health, and physical debility exists among those not actually confined by sickness;-that these preventable evils require an enormous expenditure and loss of money, and impose upon the people unnumbered and immeasurable calamities, pecuniary, social, physical, mental, and moral, which might be avoided;-that means exist, within our reach, for their AJPH November 1977, Vol. 67, No. 11

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mitigation or removal;-and that measures for prevention will effect infinitely more, than remedies for the cure of disease. "2

While there is no available road map for this long journey, following are some concrete notions and specific directions which evolved from a recent reevaluation of priorities within the Massachusetts Department of Public Health. 1. Compile and disseminate information demonstrating the favorable ratio of benefits to costs for health promotion programs. While cost/benefit studies are available for some primary and secondary preventive efforts such as immunization, neonatal screening, and flouridation, much less effort has gone into making the economic argument for investment in other significant issues, such as gun control, improved nutrition, and product safety. In still other areas of prevention, cost/benefit data may be available nationally but need to be broken out to demonstrate their impact on individual states and municipalities. It is not enough to advise our citizens and elected representatives that attention to the effects of life-style and our man-made environment on health are just causes. We must, supported by adequate data, convince others that health promotion can effectively reduce the incidence and costs of illness and death during the most productive years of life. Even some areas which to date have not been associated with proven cost-effectiveness programs can justify investment based on the magnitude of the problem. For example, automobile accidents cost the Commonwealth of Massachusetts $200 million last year.3 Studies of other countries have shown us that use of seat belts could reduce this figure substantially. Even without proof that marketing programs with increased seat belt use as an objective will be successful, the stakes probably justify the investment if the programs include careful evaluation. Thus, the Massachusetts Department of Public Health (MDPH), in cooperation with a local hospital, has set up a controlled trial to confirm restraints in cars increases use and if so, for how long. "A Program for Prevention"* developed by MDPH outlines those areas of prevention where cost/benefit or cost/ effectiveness have been demonstrated. 2. Develop methods to have insurance premiums reflect self-imposed health risks. Actuarial information confirms that non-smokers should pay lower health and life insurance rates, as should individuals who wear seat belts or maintain cardiovascular fitness through regular intensive exercise. Recently introduced legislation in Massachusetts would require higher health insurance premiums for smokers than for non-smokers, and higher car insurance for drinkers than non-drinkers, with the premiums based on acturial risk assessment. While such legislation would bring both greater equity and financial incentives for healthful behavior, the chances for passage are slim because of the administrative difficulty in identifying and categorizing smokers and drinkers, both initially and as personal habits change. A possible *Available from Massachusetts State Bookstore, Room 116, State House, Boston, Massachusetts at a cost of 350 to cover postage. 87 pp. The paper outlines MDPH's goals over the next three years in the area of health prevention. Specific programs which will be developed to impact on life-style habits through either individual or government action are also discussed. AJPH November 1977, Vol. 67, No. 11

approach to ensuring more honest self-declaration of alcohol use might be to have automatic cancellation or reduction in benefit clauses in the policy if a self-declared non-drinker was found to have an elevated alcohol level at the time of an accident. Likewise the coverage under a car insurance policy might be automatically reduced if the insured was not wearing a seat belt at the time of an accident. An encouraging sign that administrative problems in identifying risks are not insurmountable is health insurance policies, such as that of The State Mutual Life Insurance Company of America which announced in April 1976 that it was offering discounts of up to 8 per cent on premiums of all non-smokers because non-cigarette smokers are better insurance risks and should receive more favorable premium rates.* Ironically national health insurance is likely to be very egalitarian and reverse any progress made in this direction. 3. Develop economic incentives for health care institutions to invest in health promotion. With the possible exception of HMOs, no institutional providers have the proper economic incentives to reduce utilization. As hospitals-faced with increasing pressures for efficient operation-close some underutilized services, perhaps they could continue to be reimbursed for a portion of the costs eliminated, with the provision that they use such money to develop innovative health promotion programs.. Priority for such programs could be established through a community planning process involving the appropriate Health Systems Agency. 4. Encourage the involvement of civic groups and local boards of health in community-based approaches to lifestyle issues. Chambers of Commerce, Rotary and Kiwanis Clubs, church groups, and others can become interested in sponsoring alone or co-sponsoring with local hospitals or health agencies community-wide health promotion programs. The key to gaining their interest is to make a strong case for demonstrable benefits of their efforts and to provide at least a small amount of funding to complement their own resources. These groups can legitimatize promotion programs in their community and reach many more residents than can a health care facility with a similar program. The Massachusetts Department of Public Health (MDPH) has co-sponsored demonstration projects with four community groups, ranging from smoking cessation clinics to weekly swimming meets for elderly citizens. 5. Adopt a taxation policy that provides disincentives for use of harmful products and provides funds to promote their non-use. A bill recently filed in the Massachusetts legislature would dedicate a portion of alcohol tax revenues for alcohol detoxification, halfway houses, and outpatient alcoholism programs. Another bill would use some cigarette tax receipts for development of prevention programs. Such legislation has a chance of passage only if there is a strong constituency willing to focus most of its resources on securing passage. In Massachusetts, because there is a strong and coordinated alcoholism program lobby, the alcoholism bill has some chance of passing. By contrast, weaker and poorly coordinated anti-smoking forces are unlikely to secure passage of *A "Program for Prevention." See prior footnote. 1 083

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pending legislation that would tax cigarettes differentially based on their tar and nicotine content. Ultimately, however, taxing cigarettes based on their relative impacts on health, just as taxing cars based on their emergency consumption, may gain public support as a "fair" measure. Because of the greater strength of the tobacco lobby in Congress than in non-southern state legislatures, state passage is more likely than federal action in the next few years. Necessary prerequisites to passage in Massachusetts are not only coalescence of health interests behind such a bill but strong assurances that the tax restructuring will not reduce the revenue figure that state budget balancers now rely upon from the cigarette tax. 6. Institute as a part of primary medical practice a clear explanation to patients of the risks associated with their lifestyle. Practitioners could elaborate the potential health problems that can be eliminated through changing behavior, quantifying for each behavior the increased risk of: 1) dying; 2) becoming seriously ill; and 3) loss of income due to each of these behaviors. One way of assuring that the patient retains this information is to incorporate it as part of an individual health record that each patient keeps. Providing this essential information can imbue patients with a greater sense of responsibility for staying healthy and quantify benefits for reducing avoidable risk factors. State health departments can help by compiling information on relative risks and distributing it to all primary care practitioners. 7. Develop and utilize school health education curricula that permit students, from an early age, to understand the significance of their individual role in keeping healthy. The previously cited 1850 Massachusetts report recommended, "Every child should be taught, early in life, that to preserve his own life and his own health . .. is one of the most important and constantly abiding duties."4 While this suggestion is hard to oppose because it makes intuitive sense, the ability of school health education to affect life-styles is questionable. Knowledge of healthful practices does not ipso facto lead to their adoption. This dissociation of knowledge and behavior stems in large part from the counterexamples to healthy behavior often provided by parents, sibs, peers, and media role models as well as teachers themselves. Removal of bad role models based on the other suggestions on this list could lead to student life-styles more in line with what is taught in health education courses. At a minimum, educators and health professionals should join to ensure a strong health education curriculum that starts in kindergarten and a minimum of observable counterexamples among teachers and other school personnel. 8. Make health promotion a high priority in the plans of the Health Systems Agencies and State Health Planning and Development Agencies. Public Law 93-641 spells out prevention of illness as a major priority for these mandated agencies. Agency plans can bring visibility to the areas where more health promotion efforts are needed and provide encouragement for hospitals, health professionals, and interested groups to develop programs designed to maintain health. In addition, making prevention an explicit priority at the local level would be a signal to local legislators that their constituency expects their support of both consumer-orient1084

ed health promoting legislation and enhanced public expenditures for innovative programs. 9. Develop partnerships with the media in the promotion of healthful activities. While consumer behavior has been well studied by marketing experts we know more about how to sell a particular brand of soap or breakfast cereal than how to change ingrained patterns of behavior. Nonetheless, a good marketing program utilizing radio and television can be helpful in making the public develop strong negative feelings about unhealthy behavior. For example, a concerted public service campaign by all radio and television stations to depict smoking as unsophisticated, dirty, polluting, and unsexy could be instrumental in reversing the current trend toward more teenage girls smoking. However, to be successful in countering the massive advertising of tobacco companies to make cigarette smoking a desirable social attribute, an antismoking program of comparable dimensions is necessary.

Such cooperation in the public interest can be useful ammunition for radio and television stations when they periodically come before the Federal Communications Commission (FCC) to justify renewal of their licenses. More difficulty in getting media support is likely when health interests clash with commercial interests. A public service advertising campaign to lower cholesterol by reducing consumption of eggs, whole milk, and red meat could lead to reduced advertising revenues from the meat and diary industries. The Massachusetts Broadcasters Association has tentatively accepted an MDPH proposal to cooperate on a yearlong program with the goal of decreasing the number of smokers in the state by at least ten per cent. In addition, the MDPH entered into a cooperative venture with a major Boston television station to motivate people to look at their own habits in the areas of alcohol abuse, smoking, obesity, and lack of cardiovascular fitness. In both cases independent evaluations of effectiveness in changing behavior are being performed. 10. Focus on a limited agenda of measurable objective. Too few resources are chasing too many problems amenable to preventive efforts. While many voluntary agencies combine in a unified campaign for collection of donations through the United Way, there is much less movement toward pooling program resources to ensure maximum impact. The result is both frustration and reinforcement of the public perception that prevention programs are infrequently effective. However, again using smoking as a prototype problem, if the American Cancer Society, the American Heart Association, the American Lung Association, and the appropriate state and federal government agencies pooled existing talents and resources toward concrete five-year objectives such as: 1) decreasing the percentage of adult smokers by 20 per cent; 2) decreasing by 30 per cent the average amount of tar smoked by adult smokers; and 3) reversing the current trend toward a higher percentage of teenage girls smoking, the objectives could probably be met. Quantifiable and highly visible successes in two or three such programs could lead to greater public support for health promotion as well as increased public funds for similar programs. MDPH is funding a number of primary prevention demonstration projects by community groups to help us define those target areas where measurable AJPH November 1977, Vol. 67, No. 11

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objectives can be met over a three- to five-year period. Each project is only initiated after careful evaluation methodology has been established. 11. Develop and disseminate lists of health promoting resources for every town, city, and county. When educational and motivational techniques are successful in convincing individuals to take some action, there must be readily available ways of linking good intentions with outside help. For example, it is useless to convince an overweight person that he or she should get help in reducing if he or she can't find a self-help group or a Weight Watchers' program and/or an interested physician nearby. Lists of places to exercise, nosrnoking clinics, garages that can properly install effective child restraints, and agencies that can help with a drinking problem are all necessary. Such lists might be distributed free with (or as part of) local phone books, as inserts to newspapers, through service stations, supermarkets, or other simple methods of reaching most people. In Massachusetts a resource book focusing on smoking, nutrition, alcohol, and exercise has been developed by the Department of Public Health and the Medical Foundation, a non-profit agency interested in health promotion. It was distributed through vol-

untary agencies, local boards of health, and a combined newspaper and television campaign. In addition, Blue Cross and Blue Shield of Massachusetts has recently published a Directory of Mutual Help Organizations in Massachusetts which presents alphabetically, within categories, the name, address, phone number, and a brief description of various support and mutual help groups around the state. In order for these strategies to work, we need to build a consensus for change that includes the use of legislative and financial leverage. Ultimately success requires the reallocation of dollars within health budgets and investment in developing better technology for health promotion efforts.

REFERENCES 1. Jarvis, E. In Communications, Massachusetts Medical Society, Vol. VIII, p. 1. 2. Shattuck, L. Report of the Sanitary Commission of Massachusetts, 1850, p. 10. Dutton & Wentworth, State Printers, Boston, MA. 3. Fielding, J.E. and Walsh, D.C. Comprehensive Health Care and Motor Vehicles. N Eng. J. Med. 294:841-843, 1976. 4. Ibid. p. 178.

ERRATUM In the article entitled "Hypertension: Effects of Social Class and Racial Admixture," by Julian E. Keil, et al., Am. J. Public Health 67:634-639, 1977, the captions for Figures 2 and 3 were transposed.

They should read as follows: FIGURE 2-Incidence Rate of Hypertension among Black Males by Social Class and Skin Color, Charleston County, South Carolina. FIGURE 3-Frequency Distribution of Socioeconomic Status among Black Males, Charleston County, South Carolina Heart Study.

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Health promotion--some notions in search of a constituency.

Commentary Health Promotion-Some Notions in Search of a Constituency JONATHAN E. FIELDING, MD, MPH As medicine qua science has become better defined,...
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