PREVENTIVE MEDICINE 6, 198 -208 t 1977)

Present HEW Policies in Primary Prevention

THEODORE COOPER’

I/. S. Department of Health. Education. arld Welfnre. Washitqton, D. C. 20201

Federal preventive health policies are predicated on factors and conditions deemed likely to pertain to the health field for some time to come: cost escalation, the uncertainty that discovery will yield epochal advances in diagnosis and curative medicine, and the growing awareness of relatively unused paths toward disease and injury prevention along both medi- cal and nonmedical approaches. Four broad and interrelated elements of a preventive health strategy have been identified: health education, nutrition, child health, and the environment. To a large extent, the emphasis in each of these areas is on efforts to modify individual and institutional behavior. to increase awareness of both personal and community responsibility for the preservation and maintenance of health, and to interrupt processes and behavior that jeopardize health. Federal policy aims at supporting preventive health as the most promising approach toward significant improvement in the health of the American people.

HEW health policies, including those addressed to prevention, are continually evolving in response to a great many factors, not all of which have a firm scientific basis. As an arm of the Federal government, the health component of HEW is subject to the dictates of Congress and the decisions of the Chief Executive; both are influenced in their actions by considerations of broad social policy, by political philosophy, by the state of the Nation’s economy, and not least by events in this country and abroad that have a way of compelling unforeseen changes in health policy that may not jibe with objective scientific or medical judgments. In other words, policy discussed and written about in November may take on a different cast next summer (in more than one sense of the word “cast”). Nonetheless, some of the conditions that have helped to shape present health policy with respect to prevention are virtually certain to be operating 6 months from now, if anything, with even more force than they exert at present.

It seems highly likely, for example, that the trend toward higher health care costs will not be reversed. Rising hospital rates and physicians’ fees will continue to be reflected in higher insurance premiums and increased public spending, as well as in larger out-of-pocket health expenditures for nearly all Americans. Be- cause the overwhelming majority of these expenditures represent payment for, or prepayment in anticipation of, remedial care, as opposed to preventive services, and because the unit cost of diagnostic, therapeutic, and rehabilitative procedures is unlikely to go down, it seems only reasonable to seek to control spending by reducing the need and demand for such services through prevention. Although our knowledge of the relative cost of prevention vusus treatment is less than exhaus- tive, there would seem to be sufficient economic grounds, as well as an obvious social and humanitarian rationale, for investing in measures that might improve the health of the population by preventing illness and injury.

’ Address for reprints: Offtce of the Assistant Secretary for Health, 200 Independence Avenue, S. W., Room 709B4, Washington, D. C. 20201.

198 Copyright fa 1977 by .Acadsmic Presr. Inc. All rights of reproduction in any form reserved.

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Another factor underlying current prevention policy is our expectation of epoch- al progress in the science and technology of health care. While it would be pessimistic to rule out the hope of fundamental advances in the treatment of the major chronic diseases, experience clearly suggests that progress will continue to be incremental. We will see more effective anticancer agents or regimens to re- place those now in use, better ways of managing heart disease and stroke, surgical refinements that will improve the outcome in many disease and injury situations, and perhaps some as yet unknown approach to the treatment of a host of metabolic diseases. But to anticipate or, worse yet, to count on biomedical break- throughs on the order of aseptic surgery, immunization, antimicrobials, anaes- thesia, psychopharmacology, and other landmarks in the history of medical prog- ress would appear ill-advised. Biomedical and behavioral research must continue to receive substantial support and encouragement as a matter of national health policy, but to count on research to yield quantum advances in human health is to bank on wishful thinking.

We do not have to await some discovery or parade of discoveries to open up new paths to better health for Americans. On the contrary, a path is open already, well-marked if not well-traveled. To follow that path will require no mind-boggling discoveries, technological miracles, huge investments of resources, nor radical shifts of public or professional attitudes. In fact, to capitalize on the opportunities that preventive medicine offers in its broadest sense would require a renaissance of attitudes toward health that were once far more readily accepted and adhered to than they are now: the idea that individuals and communities have a major respon- sibility for their own health; that illness and injury usually represent a departure from the norm, the result of a failure of omission or commission; and that medicine is an art and a science concerned as much with preserving health as with restoring it. The decline in acceptance of these ideas by the general public and by many members of the profession brought about, ironically, by the spectacular advances in curative medicine, is a formidable barrier. For that reason, the policies and initiatives pursued by HEW in the area of prevention are aimed as much at a change of attitudes as at the development of new tools and knowledge. In our view, enough is known about health-compromising conditions in contem- porary society to warrant the greatly increased emphasis that we intend to place on disease and injury prevention and health promotion. More extensive and more precise knowledge must and will be sought, but there is no valid reason to delay doing what we can do now to increase awareness of health promotion, to identify and seek to minimize hazardous environmental conditions, to encourage more informed and responsible behavior, to stimulate professional interest and activity in the delivery of preventive health services, and to develop and pursue policies aimed at taking advantage of preventive health opportunities that, despite the best efforts of some individuals and groups, have yet to receive the broad attention they deserve.

At the risk of belaboring the obvious, it should be pointed out that government can have no more than a minor role in these efforts, a role of support and stimula- tion and perhaps of coordination. To generate a national commitment to disease and injury prevention and health promotion and to translate that commitment into

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action that truly improves the health of the American people will demand more enterprise, more resources, more expertise, and more intelligence than govern- ment alone can muster. Yet we clearly have a substantial role to play, and what follows is a brief outline of the prevention policies under which we intend to proceed, at least for the foreseeable future. These policies are discussed in some- what more detail in the Fomwrd Plan for Health-FY 1978-82, which was issued by the Public Health Service in August, 1976.

HEALTH EDUCATION

Most primary prevention proposals are designed to influence individuals and institutions to change to more healthful behavior. By placing our proposals to achieve more healthful practices under the heading of health education, we are extending the meaning of that term to encompass not only knowledge transmis- sion but also the range of practices designed to motivate, stimulate, and provide skills to help people live longer, free from disease and disability. We feel that this makes better theoretical sense and recognizes that the traditional approach to health education has had limited effect on individual health practices. The ultimate objective of health education must be healthful alteration in the way people or institutions act. The diabetic who begins to follow strictly a prescribed diet to avoid diabetic coma, thereby staying alive and out of the hospital, has modified his behavior in a significantly healthful way. Similarly, the inveterate smoker who successfully completes a smoking cessation clinic has modified his behavior in a way which is clearly beneficial, as has the industrial worker who adopts the habit of wearing a face respirator when exposed to toxic fumes.

The government’s function is to enable people to make sound decisions about their health, to equip them with the information and skills and other resources needed to translate these decisions into action, and to aid in the removal of legal, economic, physical, or other barriers that might prevent them from acting accord- ingly. It should be understood that as far as government actions are concerned the proposals are intended solely to provide opportunities and incentives for people to assume full responsibility for their own health.

People have a right to know about the health effects of the kinds and amounts of food they eat, of overmedication, and the benefits of not smoking, regular exer- cise, and moderate alcohol consumption. It follows that it is also a responsibility of government to alert the public to health hazards in our industrial society and to shield the worker from their effects.

To fulfill these responsibilities a health education program must be comprehen- sive, within the limits of our knowledge of the links between behavior and health. It must maintain the broad support of affected groups and ensure their active participation in program and policy design.

To be successful, health education strategies must incorporate what is now known about the psychological and social determinants of health. They should also attempt to counter or ameliorate social and economic influences on people’s lives which discouraged healthful change. The following criteria should be used to develop health education messages:

Messages must take into account the perceptions and values of specific audi-

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ences. This will require frequent and sensitive surveys and research of people’s interests, attitudes, and needs.

Messages should be designed to effect specific change in health behavior and, where necessary, provide the individual with the opportunity to acquire the techniques or skills needed to bring about and maintain that change.

The task is to make it easier for people to follow healthful practices and less desirable to choose unhealthful behavior. Even the most effective drug education message is blunted for the child growing up where drugs are easily obtained and drug users are accorded social status by their peers. Similarly, where excessive drinking is made to appear culturally acceptable, either socially or by the media, the task of health education may be overwhelming unless the- program design includes steps to counter these influences.

Since most unhealthful practices are not disease-specific, preventive health education programs should concentrate on modifying practices such as smoking or overeating that lead to disease, rather than on the disease itself. Educational programs for patients suffering from a specific disease, such as diabetes, must focus on‘that condition, of course, but even here the other dimensions of their style of living and work should be considered.

The development of methods to study and evaluate health education programs must be given higher priority. Evaluation projects should be designed to measure the effectiveness of health education activities in achieving stated goals and to assess the impact on program performance of such variables as knowledge, at- titudes, behavior change, and consumer satisfaction. Research should be con- ducted to determine the ultimate costs and resultant benefits associated with ongoing health education programs and projects. Such research should be con- ducted in specific health care settings. We need to know the extent to which health education can reduce operating costs and improve the quality of health care.

NUTRITION

The Department plans several approaches to provide educators, medical pro- fessionals, and the public with current information on the role of nutrition in the promotion of health.

1. Public School Nutrition Education Although community attitudes and priorities established by state and local

agencies determine the degree of emphasis on nutrition education, we need to work with them to determine the role of nutrition education in the schools and to increase the emphasis on nutrition education as a means of disease prevention and improving the quality of life. Strategies should be developed for reaching out-of- school youth and adult populations and motivating them to act upon sound nutri- tion information.

Model curricula and specialized techniques, such as the teaching models under development by FDA, should be designed to teach elementary and secondary school children about the role of nutrition in total health and how they can practice more healthful food purchasing and food consumption habits. Use of nutritional labeling of food in educational programs, for example, and discussion of the

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nutritional basis for selecting food components of school lunch programs can serve to reinforce desired practices with respect to diet and nutrition.

2. Nutrition Education of the Public To take full advantage of the opportunities provided by the mass media, the

Department will consider plans to alert people to current scientific information on the links between nutrition and health and to teach them how to maintain more healthful food purchasing and food consumption practices. A meeting of nutrition authorities could be called to establish the contents of the program, while a sepa- rate conference of media experts, health educators, and nutrition authorities could be convened to design specific communication strategies. At this point, the newly established, non-Federal, National Center for Health Education, for example, or a similar group could undertake the initial phases of the program’s operation, with particular emphasis on children and groups at high risk.

To help make nutritional concerns an integral component of the Nation’s health care systems, nutrition programs should be considered by the new Health Sys- tems Agencies and the State Health Planning and Development Agencies as they develop long-range plans for community resources development and allocation. As they are developed, the National Guidelines for Health Planning will formalize these considerations.

Incorporating nutritional concerns into the training of all health-related person- nel would provide a major impetus to the full integration of nutrition into the daily, direct health care provided to Americans. However, some reservations have been expressed about such training, including: the lack of consensus among authorities concerning the links between nutrient intake and disease, the generally low prior- ity and limited funding devoted to nutrition education, and possible concerns about interference with school curricula.

Studies to update information on the extent and content of nutrition instruction conveyed by health professionals to their patients should be conducted and the results should be used to help design programs to improve the nutrition knowledge of health professionals, working in conjunction with educational institutions, pro- fessional societies, and recognized nutritional experts.

Improving the health status of the American people requires a continuing pro- gram of surveys, monitoring, and surveillance of the health and nutritional status of all citizens, particularly those known to be nutritionally at risk: infants, children, expectant mothers, and the elderly. Such evaluation should be conducted on a local, as well as on a national, basis and should include the examination and identification of the extent and location of nutrition problems, including obesity and other conditions related to overeating, according to region, income, sex, race, food availability, and cultural habits. Current PHS activities include the Health and Nutrition Examination Survey of the general U. S. population, operated by the National Center for Health Statistics, and the Center for Disease Control’s ongoing program for nutritional surveillance of high risk groups. These surveys can be used to evaluate the effectiveness of local nutrition efforts and to provide data for use in nutrition education.

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CHILD HEALTH

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Genetic diseases and congenital anomalies are individually rare and even in the aggregate occur in only a small percentage of live births, but they account for approximately one-quarter of all pediatric hospital admissions, about 12% of in- fant and childhood mortality, and an enormous financial burden in terms of medi- cal care, provision of special social services, and institutionalization. Two ap- proaches will be followed to deal with these problems:

I. Amniocentesis

To make amniocentesis more generally available to pregnant women over age 35, CDC will initiate efforts to educate and train physicians, explore the psycho- social dimensions and communicate them to the medical community and the public, develop standards for the conduct of the procedure, encourage insurance companies to reimburse for amniocentesis, and support improvement of labora- tory capacities to conduct the tests. In addition, it is envisioned that simple laboratory tests will soon be able to screen for environmental mutagens leading to genetic diseases.

2. Coordination of Early Detection and Treatment Programs for Handicapped Children

While more resources for early detection and treatment programs serving dis- abled children might solve some problems, there is evidence that some of the resources already available are not being fully utilized. During the period from 1963 to 1970, about 20% of the resources for some special programs, including those for sight-saving, hearing disorders, and orthopedic problems, went unused in schools. To correct this, PHS will initiate efforts to improve coordination among health, education, and welfare institutions responsible for the special needs of disabled children and will outline steps to foster more effective state and local action on behalf of handicapped children.

Adolescent pregnancy, because of its adverse effects on the mother and her infant, is one of the most pressing health problems of young women. In 1974, 608,000 girls 19 years of age and under gave birth to infants in the United States. An additional 247,000 pregnancies among this age group were terminated by abortion. The births constituted almost 20% of all live births and more than 26% of low birth weight infants. The increased health risks to the mother and infant resulting from a teenage pregnancy are compounded by the disruption in her schooling and the likelihood of subsequent economic dependence.

The adverse effects of teenage pregnancies, including infant and maternal deaths, are multiplied when a second pregnancy occurs before a woman has reached 20 years of age. Increased parity and short birth intervals emerge as important issues because teenagers tend to sustain repeated pregnancies sepa- rated by only brief intervals.

These consequences can be reduced by aiding adolescents in their efforts to prevent pregnancy and by providing comprehensive support services to those who do become pregnant. Preventive efforts should include the following:

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Public education campaigns to increase awareness of the problem and to en- courage responsible action at the Federal, State, and local levels;

Prevention of unplanned pregnancies through increased utilization of con- traceptive services and the development of education programs;

Strengthening of comprehensive health, education, and social services provided to pregnant adolescents;

Strengthening and expansion of contraceptive and social science research and ensuring that existing data are made available to health professionals and other appropriate audiences;

Identification of high-risk groups. In spite of recent success in the control and prevention of measles,

poliomyelitis, and rubella, immunization levels among children in this country remain unacceptably low. During the past 10 years the percentage of children protected against polio has declined steadily. In 1973 two out of five children (aged 1 to 4) were not adequately protected.

As a result of efforts such as CDC’s “Immunization Action Month” (IAM) and a continuing public information campaign, this downward trend has been re- versed. However, many children remain unimmunized, two-thirds of them in families with income above the poverty line.

IAM activities in 1977 will be officially affiliated with the National Bicentennial “Every Child in 76/77” efforts and will feature increased use of volunteers to identify children who are inadequately immunized.

CDC will concentrate on immunizing preschoolers from low income families. Immunization programs will focus on Head Start, EPSDT, Day Care, and Neighborhood Health Center populations. Health departments will be encouraged to work with community-based organizations to locate and assist families with unimmunized children to have the children immunized. This outreach effort can also be used to refer children for other needed health services.

In mental health, services to children will continue to receive special attention. The number of children under age 15 in mental health institutions more than doubled between 1955 and 1973. The number of runaway youths has increased.

Young children pose a particularly difficult problem. They are unlikely to know when they should seek help. If they do, they are reluctant to seek care, especially from traditional mental health centers. They may be more willing to visit a free clinic or counterculture facility where they feel more accepted. PHS will increase its efforts to modify or expand community service programs which make available information about particularly effective ways to reach children before they be- come acutely ill, commit suicide, or run away.

Special attention will also be paid to the mother/infant relationship, especially since mounting evidence suggests that much psychosocial disability is preventable by relatively simple intervention programs. For example, such a simple factor as intimate contact allowing bonding between a mother and infant immediately after birth has been shown to correlate with improved health and psychosocial function- ing of the child years later.

PHS is initiating steps to apply such knowledge to its programs. An education program is being developed for the new mother and father at the time of birth

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regarding the capabilities and needs of the infant and the effects of their actions on the baby. In addition, information will be provided to parents and hospitals on the importance of early parent contact and interaction with the infant to encourage liberalization of hospital practices that might interfere with early development of parent-infant bonds.

Health providers have a vital role to play in reaching out to children and their parents, informing them of what services are available and how they can utilize them. Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment pro- gram is the only child health program with a specific mandate for outreach. The EPSDT program is approaching its potential of reaching 13 million children; as of June 1975,5 million children have been screened. Approximately one-half of those children were referred for diagnosis or treatment. Though the quality of programs varies state by state and county by county, there is no question that the EPSDT program has contributed to the development of innovative preventive health pro- grams. One area which will be given special attention is the expansion of health education efforts through EPSDT programs. With its mandate to inform eligible families of health services available to their children, the EPSDT program pro- vides a vehicle to reach large numbers of people and to inform them about availa- ble health services and how to use them.

ENVIRONMENTAL HEALTH

Recent evidence of the long-term, chronic effects of exposure to certain chemi- cal substances has alerted much of the public and the Congress to what those involved with environmental health recognize as a mounting threat to the health and future well-being of the country.

We must, of course, devise more effective techniques to prevent the acute effects of massive exposure to toxic chemicals, but we must also establish a system that will provide reliable data on the hazards of long-term exposure to a chemical substance. Legislation now before the Congress would establish a much needed mechanism for assessing new toxic products of industry, but to be really effective we need a Federal environmental health strategy that will encompass the various environmental agencies. The strategy should include the necessary reg- ulatory, research, and surveillance dimensions and provide a clear definition of the role of each agency. Similar efforts are needed at state and local levels to achieve greater order and to make the best use of available resources.

As the Federal agency primarily responsible for safeguarding the Nation’s health, PHS must be able to provide effective scientific guidance to other Federal agencies on the health implications of their environmental policies and decisions. It must also offer the leadership and technical assistance that state and local agencies need to resolve environmental health problems. This requires the crea- tion of a unified environmental health policy that would clarify the research and operational responsibilities of PHS agencies. It would also identify the objectives and explain the basis for agency cooperation in research, policy and regulation development, planning, and technical assistance to state and local governments.

PHS research in the prevention of environmental illness must continue to in- clude the identification and measurement of environmental factors affecting health

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and the development of techniques for measuring human response to varying levels of toxic materials. The time is ripe for a very large increase in efforts to link human ill-health directly to environmental exposures. In addition, studies are needed to determine the fundamental biochemical mechanisms involved in human adaptation to deleterious environmental exposures and methods to counteract the effect of such exposures.

The Federal government can help state and local environmental health agencies most by providing leadership in research, establishing national guidelines and standards relating to environmental health, providing technical training and guid- ance, and developing educational and information materials. The PHS should be able to tell state and local agencies where and how to obtain environmental health information, including that obtainable from other Federal agencies. Federal agen- cies should provide advisory and consulting services and should stress the desira- bility of developing programs that use the capabilities and resources of state and local agencies in accomplishing mutual environmental health goals.

More than 14,000 people are killed each year in work accidents. Occupation- related diseases have been estimated to be responsible for more than 100,000 deaths a year. The annual costs associated with work accidents alone are about $15 billion. For example, approximately $1 billion a year is being paid for just one occupational disease, black lung, which might have been prevented by appro- priate measures 30 years ago.

To increase the amount of basic information on the links between occupational exposures and disease, we must develop a more systematic, anticipatory ap- proach to the analysis of exposures, including consideration of chemical, physical, and psychological stressors and their possible interactions. With thousands of chemicals in daily use and the large number of new chemicals being developed each year, it is crucial that we make sure that no uncontrollable hazard exists before the chemical or material is introduced into the work setting.

After data has been collected and analyzed, NIOSH, OSHA, and the CDC Bureau of Health Education should develop appropriate education and training programs for target populations such as physicians, engineers, nurses, business managers, union leaders, workers at high risk (e.g., pregnant women), govern- ment occupational health personnel and inspectors, the public, and the press. These programs should be modified regularly to reflect new research findings and should include built-in evaluation mechanisms so that improvements can be made as needed.

PHS plans to initiate several programs in occupational safety and health. These programs include the following:

Research in Work Safety and Occupational Injury Prevention NIOSH will collect and analyze data on occupational safety for use in research

and as a basis for scientifically valid standards enforcedby OSHA. Initial- efforts will concentrate on solutions to fatalities, permanent disabilities, and lost work- days in 10 high-risk industries.

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Research to Protect the Health of Women in the Workplace NIOSH will expand its research programs to include studies of women, particu-

larly pregnant women, and conduct laboratory and field studies of teratogenic effects, fetal wastage, and reproductive physiology for specific high-risk occupa- tions. Information gained will be incorporated in new or revised critieria docu- ments and medical surveillance guidelines for physicians. It will also be used to educate workers, management, and the scientific community about the particular health problems of women in the workplace. Particular attention will continue to be given to the very serious equal employment opportunity implications of these criteria and guidelines. Close coordination with the EEOC will be maintained to assure the protection of women’s employment rights.

Control Technology Assessment and Detvelopment To protect workers from chemical and physical agents we must design new

industrial processes to reduce worker exposure and adapt existing technologies, thereby allowing continued operation of plants which might otherwise be forced to close. Initial efforts will include assessing available control technology for selected high-risk industrial processes such as sandblasting and cotton processing, and then recommending process redesign or development of new controls for use in plants being built.

Manpower Detyelopment Efforts will be made to designate preventive medicine, including occupational

medicine, as being in critical shortage. Loans might be extended to individuals who on completion of their training agree to serve with local and state health departments to provide consultation to industries and small business on how to improve their health and safety practices.

CONCLUSION These policies and strategies, in health education, nutrition, child health, and

the environment, represent what we consider to be the basis for a rational program in primary prevention. At a time of budgetary restraint, they have the virtue of not requiring huge additional public or private spending. Similarly, as noted earlier, a major effort at primary prevention need not await the uncertain results of funda- mental research. The knowledge with which to proceed is at hand. And certainly we are not lacking in incentive to seek more effective and more comprehensive preventive health efforts. The high and rising cost of remedial health care is surely a powerful stimulus, made even more ominous by the prospect of national health insurance, which, by any estimate, will increase the demand for health services.

The United States has operated far too long on the premise that a vast health care system can compensate for the failure of society to attend to the preservation and maintenance of health. That notion is at least partly responsible for the tripling of health care costs within the present decade and for .the more than tenfold increase of the last quarter century. Even if our economic resources were unlim- ited, which clearly they are not, medicine would be hard put to justify a mode of

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action that failed to give the fullest possible attention to fostering health as well as to aiding those whose health is in one or another way impaired.

Prevention seemingly lacks the glamour and excitement of the spectacular cure or the electrifying discovery. To be able to say, ‘Here is a health problem that did not happen because we succeeded in preventing it,’ is not often the stuff on which headlines are written and Nobel Prizes are awarded. But it is, in our thinking, the path for the future of medicine and health care. And the Federal government intends to help move the Nation along that path.