Prevention – Got Change?
There’s considerable agreement and common ground among those of us involved in combating health disparities, broadly defined. That agreement includes the modest portion of health status that can be addressed by appropriate medical care. But that’s about as far as most go—identifying what needs to be done outside of the clinical encounter, but stopping short of how to get that done. Unfortunately, that’s a chronic problem with disparities research and practice. The overwhelming majority of the resources are dedicated to observational studies further defining the problem and its parameters, populations affected, interactions between such sociodemographic factors as race/ethnicity, gender, region of residence, and income. Rather than intervention studies testing solutions, or even qualitative investigations to guide the development of innovative and pragmatic solutions to test.
An important step toward getting health care reform done this time is the specificity of the approaches to accomplish it and engaging stakeholders from various perspectives in grappling with the nitty gritty details to arrive at something we can all live with. So let’s begin with identifying some levers to spur the physical, socio-cultural, organizational and economic environmental changes necessary to reshape the societal landscape to promote health and well-being.
Let’s start with the existing infrastructure. It’s going to be difficult enough to loose the resources to provide universal health care coverage. The only way to create sustainable change is to build the necessary changes into the systems we have. Second, we must align our public health objectives with those of a variety of organizations and agencies across many sectors and content areas. Leaders seek to operate in the best interests of their own organizations, and are strongly incentivized to do so, whether in the public sector by elected and appointed officials, or in the private sector by owners and shareholders.
Strengthening linkages between public health agencies, community-based organizations and academic institutions is particularly necessary in that each entity embodies complementary and synergistic roles and missions in the practice of public health. Public health agencies have consistent funding streams (however inadequate) and mandates for improving the health of entire geographically-defined populations. Community-based organizations exist to represent the preferences and respond to the needs of their targeted populations; they may mediate between the needs of individuals in a specific locale and institutional bureaucracies charged with addressing those needs at a societal level to achieve certain outcomes. Colleges and universities are repositories of scientific expertise, are measured by research grant and publication productivity, and have a central focus on educational activities. With the increasing attention to, resources available for, and validation of “academic public health practice” and “community-based participatory research,” the applied research and training opportunities presented by collaborative community health improvement projects could fuel further investment by universities, federal agencies and foundations.
To facilitate practice-based solutions, it may also be important simply to do a better job of capturing intervention effects. Better instruments are being developed to assess organizational support, social network interactions and economic influences. However, independent evaluation efforts can be quite costly and challenging. A part of the solution may rest in government investment in expanded surveillance to provide risk behavior and disease prevalence estimates for smaller geographic areas (e.g., ZIP codes or census tracts). External sources of evaluation data, capturing secular trends and presumably intervention effects, would decrease the burden of research participation on community-based organizations and local health departments, allowing them to focus on the service missions that motivate their involvement.
For example, if our research demonstrates the beneficial influences of healthy eating and physical activity on student concentration and attentiveness, cognitive processing, discipline, and academic performance, school systems are much more likely to “carry our water.” However, if we focus solely on health, they may agree that it’s important, but how much can they add to their already crowded plates? How many unfunded mandates are already in the queue? Here in California, we can monitor the success of policy and programmatic interventions through existing data collected by the state education department, foundations, universities and the feds, e.g., the FitnessGRAM, the California Health Interview Survey and the California Healthy Kids Survey.
If a central premise of improving health and addressing health disparities is building upon existing community infrastructure, organizational settings will be integral to service delivery. These settings (e.g., government agencies, clinics, social services agencies, civic associations, professional networks, religious institutions, sports organizations, youth groups, schools, child care centers and pre-schools) are key starting points in moving the needle on health in underserved communities. Let the dialogue begin!
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Here is dialogue of what I would do if in charge of health in California:
1. End the cultural taboo against insisting on personal lifestyle change, by entering every person’s lifestyle habits score in their medical record, and urgently adressing poor scores. (see the website, freehealthreform.com ).
2. Create Health Action Zones (HAZ) in economic problem areas, and blanket them with federal, state, and foundation grant money, to set up demonstration projects to reduce chronic disease. Both indirect strategies, like social determinates of health, and direct strategies, like treating lifestyle habits as disease causes to be urgently addressed, would be used.
Since the HAZ areas are in health crisis, emergency powers would exempt providers from the entrenched constraints enforced by legal and cultural interests.
a. medical interests: tell people the truth, that their health plan of the existing model – Symptom Diagnosis – is structurly incapable of keeping anyone healthy.
b. marketing interests: Tell people the truth, that eating red meat, white flour or rice, and riding in cars is causing chronic disease.
c. educational interests: the professors, and the M.D.’s they train, are ignoring clear data on the causes of 85% of all health problems, and costs, and just let people suffer 20 years of full-body damage, waiting for symptoms to emerge, and then using this as reason to make efforts at lifestyle change.
d. law enforcement interests: the barbaric and inefective putting people in cages for non-violent offenses. With a little thought, they could do contributory work, instead.
These HAZ zones would soon demonstrate that people are naturally healthy if the proper genes are expressed, and the improper ones turned off.
These oppressed populations would welcome these urgent efforts, and would not complain about unbiased straight (truthful) information. They do not have the option to switch providers if asked to make extra efforts, as more wealthy people would do.
What do you think?
donald wilhelm, III