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Not in Sickness; in Health: How Health Reform could Start a <i>Real</i> Revolution

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While the nation still struggles to understand the impact and implementation of health reform, the Prevention and Public Health Fund—a barely noted part of the overall package—has the potential to transform the way we think about health. Are we bold enough to seize that opportunity?

The Prevention and Public Health Fund must focus resources and strategy not on sickness, but on health—through $15 billion dollars over the next ten years supporting prevention efforts that will help communities thrive. With the first disbursement Wednesday, the fund fell short of its promise. Instead of dedicating the money towards quality prevention, $250 million of the first funds made available went to shoring up the primary care workforce. "We need to do prevention and we need to do workforce, but we had an agreement," said a disappointed House Energy and Commerce Chair Henry Waxman. "I don't like the idea that there should be a scramble for funds when we had a pretty clear idea that we were going to use them for different purposes." Ensuring the availability of primary care providers is critical—especially in underserved communities—but every dime we put towards prevention now will decrease our need for healthcare down the road, and save money, too. We must be courageous enough to make that investment.

Our national health conversation has always focused on how we treat people after they get sick. But research has shown that medical care only attends to about 10% of the factors that contribute to illness and injury. Seventy percent of health is shaped by our environment and behaviors. Living near safe places to play and exercise; making commutes shorter and less polluting; steady employment in a job that doesn't put your health at risk; having access to healthy foods in your community; and living in a neighborhood free of pollutants, lead and other toxins—all of these can help keep you out of the doctor's office in the first place. Still 96% of our health resources—and most of the health reform bill—goes towards that tiny ten percent of medical care. Prevention, which changes behaviors and environments and builds health more effectively than any other means, has historically gotten a barely noticeable four percent of the resources.

Rather than pulling funds from the prevention side to improve our medical services, we need to build prevention into medical care. The National Institutes of Health must develop and assess not just medical treatments but community solutions through its research; the Health Resources and Services Administration must emphasize not just clinical services or even clinical prevention, but engaging and training medical practitioners to be spokespeople for community prevention. Let's prepare our doctors to fulfill their Hippocratic oath: "I will prevent disease whenever I can, for prevention is preferable to cure."

The additional $250 million for this fiscal year will be released any moment. It should begin to address that gap by allocating resources to community efforts to improve health. By using similar guidelines as the Recovery Act's Communities Putting Prevention to Work, this $250 million could bring together local public health departments, community organizations and leaders to focus on what will reduce chronic disease in their neighborhoods: strategies as diverse as breastfeeding support for new moms; zoning that encourages more opportunities to buy fresh fruit and vegetables; taxes that discourage buying cigarettes; and construction of activity-friendly bike paths, parks and roadways. Our families work hard to stay healthy—trying to eat well, exercise, reduce our stress levels—and these resources will support those efforts.

Two groups must have a large say in whether we spend the rest of the fund on sickness or on health. An Executive Order last week established the National Prevention, Health Promotion, and Public Health Council to guide our national prevention and health promotion strategy. The council includes representatives from twelve critical sectors of the federal government, including the secretaries and chairs of homeland security, transportation, agriculture labor, health and human services, and education, chaired by the Surgeon General of the United States. Having the Secretary of Homeland Security and the Secretary of Labor on a council overseen by the Surgeon General—the person responsible for our nation's health—is unprecedented. It establishes, beyond a shadow of a doubt, that health and prevention have to be critical considerations in every branch of the government.

Yes, we need more primary care providers. But what will be truly transformative is having the Secretaries of Transportation and Homeland Security talk about what it takes to get you to work safely and easily on public transportation or a bicycle. Or having the Secretaries of Agriculture and Education figure out a way to get fresh, local vegetables on your child's school lunch plate. Or allowing the Secretaries of EPA and Agriculture to talk about reducing pesticide exposure for migrant workers. It is a revolutionary recognition of what Prevention Institute's work has consistently shown: without cross-sector collaboration, without the right hand knowing what the left hand is doing, transforming our nation's health is impossible. This will maximize the impact of our prevention efforts by identifying approaches that work for multiple sectors: good solutions that solve multiple problems.

The executive order also establishes a national advisory group that will include twenty-five health professionals and practitioners, including public health and community health representatives who will make recommendations to the council on strategy and best practices. These must not be appointments based on prestige or patronage. This advisory group must bring together the nation's best thinkers from community, academic and workplace sectors, the people who can integrate the collective experience and wisdom of practitioners, community and research. They are the leaders in prevention, and we need their courage, and their innovation. We must continue to expand our prevention efforts, focusing not just on chronic disease prevention, but including broad community concerns such as violence prevention. We must particularly prioritize funding for and capacity building in low-income communities where there is a vital need for prevention work.

Over the next ten years, about $15 billion more dollars will be released through the Prevention and Public Health fund. The challenge for all involved will be to think boldly and transformatively about how it should be used. We cannot afford or accept to continue business as usual.