Putting Prevention First...and Foremost Prevention has won first place, as evidenced by the 2-day Steps to a HealthierUS national summit held on April 15-16 in Baltimore, Maryland. Every aspect of the summit reflected how to win with prevention, from the morning warm-ups, to the healthy meals, to the information-packed plenary sessions and breakouts. Throughout the summit, participants experienced the benefits of prevention. At the morning sessions, the nearly 1,000 participants were jump-started by Reggie Freeman, a certified fitness instructor. “We’re going to start moving—come on, come on, come on.” The exercise periods were fitting because the Steps initiative is about urging Americans to move more—and more often. Steps is also about eating healthier, so, of course, the food was nutritious. When Michael S. Steele, Lieutenant Governor of Maryland, introduced Secretary Thompson, he said, “This is the healthiest lunch I’ve had in years. This is what today is about—health and prevention.” Participants got substance in economic and epidemiologic terms, proof of the benefits of collaboration, and the tools for practicing prevention at home. (Visit www.healthierus.gov/steps/index.html#summit for the program and webcast information.) They laughed together, honored each other, and agreed to lead the way to a healthier United States.
Collaboration at the Federal Level Collaboration was a theme running through the entire summit, beginning with the presence of the heads of the U.S. Departments of Health and Human Services (HHS), Education (ED), and Agriculture (USDA), plus the U.S. Surgeon General. Public and private efforts were showcased. The luncheon speaker, HHS Secretary Tommy G. Thompson, rallied prevention fans and urged them to carry the message to every community in America. “A child who is not feeling good is not going to be a child who can learn well,” reported Secretary of Education Rod Paige, Ph.D. “Our first responsibility is to make sure that a child is safe in school and that a child is well and can concentrate on his or her lessons.” He said, “Our goal of ensuring that every child has a quality education depends a lot on what happens here today and on what we do about children’s health.” USDA Secretary Ann Veneman, J.D., M.A., highlighted collaborative efforts by the three departments and talked about her firsthand experience with preventive screenings, one of the four pillars of the Steps initiative. She has undergone treatment for breast cancer, which was detected at a very early stage during a routine screening last year. Ms. Veneman used examples of USDA programs to talk about the other pillars—making healthy choices, being physically active, and eating a nutritious diet. The U.S. Forest Service, for example, offers physical fitness opportunities as part of its recreational programs. She described the action-based memorandum of understanding between the three departments to support USDA’s team nutrition initiative to improve children’s lifelong eating and physical activity habits. Through a pilot project, USDA is providing fruit and vegetable snacks in schools. “We all have a responsibility to promote healthy choices and nutrition,” she said. Surgeon General Richard H. Carmona, M.D., M.P.H., FACS, delivered the opening welcome and closing remarks at the summit. In his opening remarks, he thanked participants “for being here and making this commitment to lead this legacy of change, because it’s so important to the health, safety, and welfare of our citizens.” Stressing that public health is all about prevention, he said, “Health providers across the public health system have the capacity to contribute to dramatic reductions in the health, economic, and social burdens of preventable disease.” In his closing remarks, Dr. Carmona talked about prevention in terms of reaching the many people who are not experiencing the quality of life that they can experience. He said, “People need to understand that [good health] is within their control—every single day in everything they do to make themselves healthy, to keep themselves well.” He charged participants “to be more vocal in spreading the word about prevention in your communities.” In turn, “The mantra coming from the Office of the Surgeon General will be prevention first.”
Why Invest in Prevention?—Health and Economic Perspectives Kicking off the first plenary session were James S. Marks, M.D., M.P.H., Director of the National Center for Chronic Disease Prevention and Health Promotion of the Centers for Disease Control and Prevention (CDC), and Ron Z. Goetzel, Ph.D., Director of the Cornell University Institute for Health and Productivity Studies and vice president of consulting and applied research at MEDSTAT. Like the presenters following them during the next 2 days, they focused on the facts of prevention. Dr. Marks observed that “70 percent of all the deaths in this country are caused by chronic disease,” which represents “a similar proportion of total healthcare costs.” He said that two-thirds of the differences in deaths of people younger than 75 years could be attributed to “modifiable risk factors.” “Protecting health must rank above repairing health problems,” he said. Dr. Goetzel then provided the private sector’s perspective on the value of investing in the health and well-being of the population. “Healthy people consume fewer resources in the form of benefit payments for medical care. They are absent from work less often. Their quality of life is improved. An employer, health plan, or government that invests in the health and well-being of the population and the communities is socially responsible, which in the long run will benefit the employer, health plan, or government and all—in both monetary and nonmonetary ways.” He said that well-designed and well-implemented programs can save more money than they cost, thus producing a “positive ROI, or return on investment.” Dr. Goetzel drew attention to the costs of poor health, including lost or reduced productivity, and the need to address modifiable health risk factors. “Can you change the risk profile of the population?” he asked the audience. Answering, “Yes, but it’s not easy to do,” he proceeded to highlight successful programs. “Research suggests that people who adopt good health habits, even later in life, after age 65, can forestall disability, improve their health, and use fewer healthcare resources,” he said. Putting Prevention First: Program Examples The next general session featured speakers from the fields of business, education, public health, and medicine, beginning with Joel R. Bender, M.D., Ph.D., corporate medical director for the General Motors Corporation. He described the company as the largest nongovernment health payer, with more than 1.2 million people covered in the United States. Explaining the reason for the company’s interest in prevention, he said, “Cash outflow for health care alone at General Motors is $4.5 billion a year and is going up about 9 percent each year.” Dr. Bender talked about the company’s 89 U.S. clinics, its staff of 550 health professionals, and its special health and wellness programs, such as Life Steps and Motown in Motion. The Detroit program is designed to reduce sedentary lifestyles by at least 10 percent in the next 3 years. General Motors’ community efforts are tied to improving quality of outcomes, increasing collaboration, and driving toward best practices. “Improving the health status of a community makes a big difference,” Dr. Bender said, mentioning improvements in the bottom line as well as in the quality of life for employees, their families, and the firm’s many retirees. Michael E. Ward, Ed.D., superintendent of the North Carolina Department of Public Instruction, recalled his experiences as a runner and called advancing the cause of healthy, active Americans “a marathon, not a sprint.” He referred to the health crisis with children and the challenges faced by schools as problem-solvers. “Health and physical activity are positively related to academic performance,” he said. Noting that North Carolina’s schools and public health departments share “the goal of eliminating health disparities among children,” he called for advocacy for children at all levels of government. “Today, while we are here [at this summit], 2,714 people will learn that they have diabetes,” said David P. Hoffman, M.S., Director of the Bureau of Chronic Disease Services in the New York State Department of Health. He cited staggering statistics, such as the $13,000 average annual cost of health care for people with diabetes, compared with $2,500 for those without diabetes. “We know that preventing complications saves lives as well as dollars,” he said. He attributed improvements in the number of eye and foot exams and other measures of diabetes care to community coalitions, university-based consortium projects, and other public-private programs. The fourth panelist, Francine R. Kaufman, M.D., president of the American Diabetes Association, offered compelling anecdotes and statistics, such as the $132 billion annual cost of diabetes. “‘I’m just so scared because the word die is in diabetes,’” she quoted the sister of a recently diagnosed 9-year-old patient. She talked about the growing problem of obesity in children and the increase in type 2 diabetes, stating, “We are very concerned about the next generation of young Americans.” Dr. Kaufman, a pediatric endocrinologist, predicted that no magic bullet or pill will be available any time soon. She said, “We need to invigorate the American population to make lifestyle changes.” Healthcare Challenges and Solutions Elizabeth M. Duke, Ph.D., Administrator of the Health Resources and Services Administration, who served as moderator, opened the afternoon session by highlighting her Agency’s healthcare collaborations to address chronic illness. These efforts are expected “to close the gap between the population at large and minorities.” Gerard F. Anderson, Ph.D., Director of the Center for Hospital Finance and Management of Johns Hopkins Medical Institutions, talked about people with multiple chronic conditions. “One-third of children with a chronic disease have two or more chronic conditions,” he said, adding that the proportion increases to two-thirds for people older than age 65. “Designing programs just around a single condition, especially for older people, does not make sense,” he declared. Dr. Anderson said that prevention packages must be designed to get the attention of the 125 million Americans who already have a chronic condition to prevent them from getting the second, the third, and the fourth chronic condition. He recommended “good care coordination” among doctors, home health agencies, and others to avoid unnecessary hospitalization, duplicate testing, and drug interactions. Tracing the history of the disease management approach to medicine and research on the human genome, Ralph Snyderman, M.D., chancellor for health affairs at Duke University and president and CEO of the Duke University Health System, called for the knowledge base to be used for prevention. He described the ability “to predict risk or to understand risk and to predict disease before it occurs” as “a very different way of thinking about the practice of medicine.” Dr. Snyderman asked participants if they have a 5-year plan for their health and suggested a futuristic approach to health care. “With the good risk-assessment tools that are being developed, we need to provide a risk-assessment personalized health plan and then assign people according to their risk. We then can make available to them the best ways of becoming educated about their own health and learning and getting motivated toward wellness.” The fourth panel member, Robert G. Harmon, M.D., M.P.H., FACPM, president of the American College of Preventive Medicine and vice president and national medical director of Optum/United Health Group, described his day job as overseeing the care of 23 million people. His summit remarks, however, focused on health plans in general and efforts to incorporate prevention. He cited data from the American Association of Health Plans as measures of progress, including data showing that 86 percent of plans offer exercise counseling, 70 percent offer substance abuse prevention and treatment, 68 percent offer cervical cancer screening, and 62 percent offer well-child exams. In closing, he said, “Let’s not stop at the clinic door. Let’s get out into the community and reach everyone repeatedly with these [prevention] messages.” Technology Tools for Prevention In opening the “Technology Tools for Prevention” session, Carolyn Clancy, M.D., Director of the Agency for HealthCare Research and Quality, talked about how information technology can help improve the quality of health care. As examples she cited decision-support systems to overcome poor judgment, e-mail to reinforce important communications to patients, Web sites to enable consumers to inform themselves, and personal digital assistants (PDAs) to perform a variety of tasks. She described the Agency’s use of PDAs for distributing updates from the U.S. Preventive Services Task Force and encouraged participants to sign up. “We know that information technology can improve the quality and safety of health care,” she said. As many speakers did throughout the meeting, she used a sports analogy: “Potential is what you have when you haven’t done it yet.” She predicted that “the medical revolution of our children’s lifetimes will be the application of information technology to health care. I have every expectation that prevention will be one of the first frontiers where we begin to get this right.” “Clinicians have enormously powerful tools to treat disease,” began Victor J. Strecher, Ph.D., professor of health behavior and health education at the University of Michigan School of Public Health. “Unfortunately,” he said, “our number one tool in the public health field continues to be the pamphlet.” “Knowledge does not predict behavior very well,” he continued, adding that getting people to change behavior “is difficult.” “Powerful public health behavior change tools” are needed, and they must be “low cost, effective, and [have] a long reach,” he said. Dr. Strecher cited the “tremendous advantages” of the Web but said that “just shoveling pamphlets online does the same thing that handing out pamphlets does—it enhances knowledge, which is good, but it does not change behavior.” He discussed tailored online experiences, both user-navigated and expert systems, and described a tailored computerized weight management program from Kaiser Permanente that is showing strong results. He suggested that national programs would provide data for evaluation purposes. Technology is changing the face of prevention at the U.S. Department of Veterans Affairs (VA), according to Frances Murphy, M.D., M.P.H., Deputy Under Secretary for Health. The agency uses electronic health records and clinical reminders and will soon launch a nationwide program of coordinated community care services. Technology will be the tool that allows the VA “to manage patients on a continuous basis.” Enrollment, monitoring, scheduling, and educational services will be integrated. According to Dr. Murphy, pilot programs have worked to the extreme satisfaction of both patients and providers. Dr. Murphy told participants that the VA is the “largest integrated healthcare system in the country,” with a full continuum of care and about 1,300 sites, 183,000 healthcare employees, and an annual treatment population of 4.5 million veterans. Forty-five percent of the patient population is older than age 65. Most have incomes below $25,000, and about one-third have no other source of health insurance or health care. She described the VA’s progress in prevention as “incredible” and highlighted the differences that programs have made in the lives of veterans. For example, the vaccination program alone has saved about 4,000 lives. Dr. Murphy’s closing remarks provided an appropriate conclusion for the panel and the summit as well. “We can no longer practice 20th-century medicine. We need to come into the 21st century. Health care must adopt technology that will help us address our patients’ needs and help save lives. We must become more patient centered, and the healthcare system must be more accessible and accountable. All of this can be accomplished in part by using technology as a tool. It is not the sole answer. The hearts and hands of providers are still important, but we need to give them technology so that they can do their jobs.” To view this webcast and download presentations from this summit, visit
www.healthierus.gov/steps Get Ready, Get Set, Go As befits the name of the new Steps to a HealthierUS initiative, action steps are being taken at an accelerated pace. Within a few weeks of the Putting Prevention First summit in April (see Focus), Secretary Thompson announced a $15.6 million community grant program to prevent diabetes, asthma, and obesity. The request for application (RFA) is posted on the Web at www.healthierus.gov/steps/rfa/Steps_RFA_Summary.pdf and appeared in the May 9, 2003, Federal Register (http://a257.g.akamaitech.net/7/257/2422/14mar20010800/edocket.access.gpo.gov/2003/03-10986.htm). Less than 2 weeks after the RFA announcement, Secretary Thompson kicked off a live interactive broadcast to help applicants prepare their responses. Citing a series of frightening statistics about chronic disease, Secretary Thompson said, “Now it’s time to focus on prevention. The good news is that prevention actually works.” Secretary Thompson also said that he expects the grant program “to lead the country in changing our healthcare model from one that only treats the sick to one that successfully promotes better health.” He reemphasized that the President’s fiscal year budget proposal would substantially increase the investment in the Steps initiative to a total of $125 million. The webcast is available for viewing at www.phppo.cdc.gov/phtn/webcast/RFA/default.asp. The race is on. State, tribal, and local health departments across the Nation are stepping lively to meet the July 15 application deadline for the 5-year cooperative agreement programs. Awards will be made quickly—September 22—and selection will be based on the applicant’s ability to be “up and running within weeks.” In other words, “get ready, get set, go.” Within the first 8 months, grantees must complete a 5-year community action plan that incorporates public-private partnerships and evidence-based public health strategies. The requirement for a 5-year plan shifts the focus of a typical grant from a 1-year effort to a longer term prevention approach. All programs must address obesity, asthma, diabetes, and their related lifestyle choices of poor nutrition, physical activity, tobacco use, and risky youth behavior. Most important, all grantees are expected to begin implementing programs during the first year. The Steps to a HealthierUS initiative seeks to educate Americans about the tremendous benefits of making healthier choices. As an integral part of that educational effort, a host of resources is available on Steps itself, the chronic diseases and lifestyle choices targeted by the initiative, and the successful models for action. The Steps Web site is the first place to let your fingers do the walking: www.healthierus.gov/steps. Check out the prevention portfolio, a set of three publications that outlines Secretary Thompson’s emphasis on prevention in America: The Power of Prevention, Prevention Programs In Action, and Prevention Strategies That Work. Learn about promising prevention strategies for reducing the major health burden created by diabetes, heart disease and stroke, and cancer. Find useful tools on the why, how, and what of disease prevention for policymakers and their managers, as well as fact sheets on the targeted chronic diseases and lifestyle choices. To view or print the portfolio and fact sheets, visit www.healthierus.gov/steps and click on the Publications link. Get a copy of A Public Health Action Plan to Prevent Heart Disease and Stroke to learn about new and creative approaches to solving the Nation’s largest health challenge. The plan lays out a strategy and framework for health practitioners and policymakers to prevent and treat heart disease and stroke, the Nation’s first and third leading causes of death, respectively. The plan also lists five key recommendations:
To print or order a copy of the complete plan, visit www.cdc.gov/cvh. Check out the webcast from the 2-day national prevention summit in April (www.healthierus.gov/steps /index.html#summit). (For highlights of the conference, see Focus.) Look for future issues of Prevention Report and the continuing flow of information on Steps. The summer issue will examine more closely the targeted chronic conditions and lifestyle choices and provide examples of successful programs. The fall issue will showcase the winners of the first community grants. (See Spotlight.)
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We need to take care of ourselves and our families and our communities. 
