News and Updates

Health Promotion Provisions are law

Michael P. O'Donnell, PhD, MBA, MPH
Editor in Chief and President, American Journal of Health Promotion
Chairman, Executive Committee of an effort to build health promotion into the national agenda

How Can It Be True?

How can it be true that in the US we spend almost twice as much on medical care per capita as any other country (Anderson), yet rank 24^th in the world in terms of disability-adjusted life expectancy (WHO)?

How can it be true that half of premature deaths in the US are caused by lifestyle related problems (McGinnis and Foege), yet health promotion programs are not a major part of the health care system?

How can it be true that the Healthy People 2010 planning document clearly shows the necessity of health promotion programs as part of the overall strategy to improve health in the US, yet health promotion is so small a part of the $24 billion NIH budget that it is not even tracked, and health promotion procedures are typically not covered by the $400+ billion spent annually by Medicare and Medicaid?

The answer is NOT lack of persuasive evidence. A comprehensive review of the literature on worksite health promotion programs, funded by the Centers for Disease Control and Prevention and published by the American Journal of Health Promotion in 1996, found 378 studies and concluded that health promotion programs with only shoestring budgets were consistently able to produce short term improvements in a wide range of lifestyle areas—including smoking, exercise, nutrition, obesity, and stress—that are primary risk factors for cancer, diabetes, cardiovascular diseases, and other diseases.

More intensive and more expensive health promotion programs have been able to produce even greater results, e.g., reversal of heart disease, showing reduced size and severity of myocardial perfusion abnormalities measured by PET scan at rest and after dipyridamole stress, and regression of coronary artery stenosis (Gould, Ornish, et al).

Compelling evidence also shows the massive financial impact of behavioral factors that can be modified through health promotion. A study of 46,026 employees of six major employers showed that lifestyle factors account for 25% of all medical care costs (Anderson). A comprehensive literature review on the financial impact of health promotion programs found that 28 of 32 programs reduced medical care costs and 18 of 18 reduced absenteeism (Aldana). Only 18 of the studies included cost/benefit analysis, but those that did showed that the programs more than paid for themselves.

Because health promotion is a relatively new field, it must be acknowledged that the methodology of many of the above studies was not optimal: sample sizes were sometimes small, study duration was usually short, measures were sometimes not validated, and only half of the studies had experimental or quasi-experimental designs. Nevertheless, as a body of research, the methodological quality of these studies is comparable to that of the evidence supporting virtually all non-pharmacologic medical procedures practiced in major medical centers and is generally better than that of studies most businesses use to make decisions on much larger investments.

Advocacy for Health Promotion

Who advocates for health promotion? Until recently, basically no one. A recent survey showed that 65% of US Congressional respondents (Members or staff) felt that health promotion and disease prevention research and programs are a "very high" priority and 34% felt they were a "somewhat high" priority (compared to other policy areas). Eighty percent felt funding for health promotion and disease prevention research should "double" or "more than double" by 2003. Forty percent felt that "lack of political will or effective interest groups" was the biggest barrier to greater support for health promotion and disease prevention in Congress (Research!America). Their general perception is that there is not popular support for these areas because their constituents are not demanding more funding in these areas.

Members of Congress typically hear only from people who are politically well-organized and well-financed, including (but not limited to) pharmaceutical companies, medical equipment manufacturers, and advocates for specific diseases. However, these groups are not representative of the full population as illustrated by a 2001 Research!America survey that found 44% of people favored federal investment in research to PREVENT disease, 35% favored investment in research to TREAT AND CURE disease, and 20% valued research in both areas equally.

In response to these realities, a growing coalition of over 100 professional associations, universities, employers, and advocacy groups together with over 150 prominent scientists, health care professionals, and advocates is helping to speak in a unified voice to make Congress aware of the strong demand for health promotion among their constituents and to show Congress both the health and financial benefits of health promotion. The long term goal of this effort is to create a world in which health promotion is integrated into all elements of society, including schools, health care organizations, workplaces, faith communities, families, and neighborhoods.

As a first step to create awareness in Congress, we introduced resolutions in the US Senate (S Con Res 11) and House of Representatives (H Res 115) and have met with over 94 Senate and 200 House office staffs to discuss this concept. To date, 82 Members have signed on as co-sponsors. Our goal is to confirm at least 55 Senators and 250 Representatives before we call for a vote on these resolutions.

Our second step will be to introduce the Health Promotion Research Act, which would create a Center for Health Promotion within NIH and create funded linkages to CDC, AHRQ, Medicare, and other HHS agencies. The purpose of this funding is to develop the basic and applied science of health promotion and disseminate the best strategies to policy makers and practitioners. We feel this step is important to establish the legitimacy of health promotion within science and medicine and to develop effective procedures to produce lasting health behavioral changes among all strata of society.

Our third step is to figure out "What's Next?" We have started a formal review process to determine the specific issue we should advocate next. Possibilities include increasing Medicare coverage for health promotion, stimulating health promotion programs in schools, creating community designs that enhance health, and a wide range of other possibilities. Three principles will guide our selection of issues: What will make the greatest contribution to our long-term goal? What can we achieve given our resources and the political landscape? What will strengthen our collaborative effort and extend its reach?

This web site contains details on our goals, organizational structure, collaborating members, research documentation, and links to other informative sites.

The CEO's Role

What can the CEO of an academic health center do to contribute to this effort? First, I invite you to work with us to build health promotion into the national agenda by participating in any of the following ways:

1. Add your institution to the growing list of organizations endorsing this effort.
2. Serve on one of the six coordinating committees.
3. Become a member of our grassroots advocacy network.
4. Contact your US Senators and Representatives to encourage them to co-sponsor our health promotion resolutions, our forthcoming Health Promotion Research Act, and our subsequent efforts.

But even more importantly, each of you can ask the question: "How well is the commitment to health promotion integrated into the goals and the mission of my academic health center and my role as its leader? I would like to end by encouraging and challenging you to:

• Make sure that the policies and practices of your own institution reflect a commitment to health promotion.
• Ensure that health promotion and disease prevention is part of the curriculum of all of your health professions students.
• Go beyond traditional biomedical research and treatments and lobby your state and federal elected representatives to fund health promotion efforts.
• Speak out at every opportunity, both inside and outside your institution, on the importance of health promotion.

If I have a health problem that is best treated through medical care, I want to get that care in the US—probably in an academic health center—because the miraculous advances in trauma care, orthopedics, surgical procedures, immunology, to name a few, make the medical science in the US the best in the world. We want to preserve that. Our goal is to reduce the need for such care by keeping people healthy through programs that encourage exercise, eating nutritious foods, managing stress, and avoiding tobacco and other abusive substances.

Full references available. Contact skochseder@acadhlthctrs.org.