Public health — the collective act of prevention

The ethical questions surrounding public health and obesity policies that seek to intervene into the medical and lifestyle choices of individuals for the collective good of society, has sparked considerable discussion. These policies are universally based on the belief that most chronic diseases can be prevented by certain “healthy” eating and lifestyles. As many people are discovering, when the science and evidence behind the most popular initiatives are critically examined, they suddenly don’t appear to be about what’s best for everyone at all.

An article in this week’s issue of the Journal of the American Medical Association hasn’t received widespread media attention — or any at all — but deserves to. It highlights that the revived field of “public health ethics” is larger than most might imagine.

In a commentary, Dr. Steven H. Woolf, M.D., MPH, of the departments of Family Medicine, Epidemiology, and Community Health at the Virginia Commonwealth University in Richmond, made the case for public preventive health policies, describing what it will require to make Americans change their behaviors. He claimed that 75% of all health care costs are the result of “modifiable risk factors,” citing the obesity epidemic as illustrative:

Targeting risk factors such as obesity can influence disease rates and costs on a scale that few biomedical advances can match... Four health behaviors (smoking, diet, physical inactivity, and alcohol use) account for 38% of all US deaths.

His focus was not on proven preventive health measures, such as vaccines that have “all but eradicated infectious diseases,” but preventive measures specifically for lifestyle diseases that he said will cost businesses and society in higher medical expenditures and lost productivity. “Behavior change occurs where people live — at home, work, and school,” he wrote, and necessitates changes in the environment to encourage physical activity and promote low-calorie low-fat foods, smaller portions, nonsmoking and less alcohol. A community-wide program that he said proves the rule is the Arkansas initiative. He added his contention that the effectiveness of behavioral strategies is related to their intensity:

Intensive counseling, which can produce lasting results, occurs outside the clinic at wellness classes, by dietitians, via quit lines and Websites, and by programs offered by health plans, employers, and public health departments. These services can provide the skilled support and continuity that behavior change requires.

Ideally, he envisions “transforming communities”:

Society would engage all of its facets — not just medicine and public health — in the collective act of preventing disease. A community with the resolve to abate unhealthy behaviors might engage its citizens and all sectors (eg, employers, schools, retailers, developers) in a concerted and coordinated effort to provide what people need to change lifestyles. With a coordinated strategy across sectors, citizens would encounter the same message and assistance options in diverse venues. For example, nutritional advice from physicians and the media might reappear at supermarkets, restaurants, school cafeterias, and fast-food outlets. Such coordination requires planning, infrastructure, and resources; these require community resolve...

History teaches that citizens and leaders make sweeping changes when they sense a mutual threat. Lifestyles change and schisms give way to accommodation when national security feels threatened (eg, wartime, climate change). Finding the economy and public health in decline may be what rouses the public to get serious about prevention. Self-interest (living longer and healthier) and common interest (economic stability) may inspire the personal sacrifice of getting healthy and the collective sacrifice (by the private sector and the state) of mobilizing the resources to make it happen.

In other words, the duty of citizenry is a collective act of healthism. We already know where this philosophy has led humanity in the past.

This article’s importance goes beyond any need to address the numerous factual errors that have already been extensively covered, such as the myths of: lifestyle medicine; that chronic diseases of aging, such as cancer, heart disease and diabetes can be prevented by eating certain ways or having certain lifestyles; that certain lifestyles will extend life; the “costs of obesity;” obesity is a measure of health and due to calorie-in-versus-out or eating “bad” foods; etc.

But what, if anything, might be influencing the increasing advancement of such proposals?

According to the financial disclosure statement of the author: “none reported.” But, remembering that some of the most significant influences don’t have to be disclosed leads us to look deeper. Dr. Woolf has an impressive background. He is with the Dept. of Family Medicine at Virginia Commonwealth University which administers the Ambulatory Care Outcomes Research Network (ACORN). He is also with Partnership for Prevention and served on its National Commission on Prevention Priorities from 2003-2006.

Partnership for Prevention [click on image to enlarge] is a nonprofit dedicated to increasing the adoption of preventive health practices and public policies and legislation. Its initiatives include promoting the government’s Healthy People 2000 goals and workplace preventive health and wellness programs. The goals of its Leading by Example initiative, for examples, states it’s for “CEOs to influence the healthcare system by emphasizing prevention rather than treatment.” Its member organizations include stakeholders in screenings and preventive health, from Abbott Laboratories to Wyeth Pharmaceuticals [see below*]. The Partnership is funded by contributions from Robert Wood Johnson Foundations (RWJF) and GlaxoSmithKline.

Its literature, including the Guide for Smart Prevention Investments, is replete with well-worn claims of obesity and of lifestyle diseases that can be prevented with diet and physical activity and “maintenance of a healthy weight.” It advocates:

Obesity is a national epidemic. And overeating and sedentary lifestyles are major contributing factors. Yet, untapped opportunities abound to counter the many social and environmental conditions that promote unhealthy weight gain.

• Physical education offers children time and training to be active, but Illinois is the only state that requires daily physical education for grades K-12.

• People of all ages walk more when they feel safe, have nearby recreational facilities, and can use paths connecting homes with schools, worksites, and stores.

• 5-A-Day programs can encourage people to eat five or more servings of fruits and vegetables each day. With more partners and resources, every community could have a 5-A-Day program.

Not surprisingly, one of its key policy initiatives is obesity and childhood obesity. Its Childhood Obesity: Taking Action page currently highlights that Washington Post series, adding: “Partnership for Prevention has developed numerous resources to help policy makers, health professionals, and others address this epidemic.” The Partnership also wrote the priorities for America’s health, which ranked the preventive services recommended by the U.S. Preventive Services Task Force, and was a project funded by the CDC, RWJF and WellPoint Foundation.

RWJF issues ongoing grants to the Partnership to continue its work, such as (ID #029975) for insurance coverage of preventive services by private employers; raise awareness of preventive services and how to “help employers make informed decisions about preventive benefits and services;” (ID# 031920) to encourage business participation in the Healthy People 2010 objectives; (ID# 038156) building partnerships for workplace wellness programs; and (ID# 039745) insurance coverage for preventive services by employer-sponsored health plans.

In 2005, ACORN, with Dr. Woolf as principal investigator, was awarded a $300,000 grant from RWJF and the Agency for Healthcare Research and Quality (AHRQ) under the Prescription for Health Initiative, to study the use of electronic health records to rapidly identify patients with ‘unhealthy behaviors’ and quickly report them for intensive counseling. “Unhealthy behaviors identified were being overweight, smoking and risky drinking.” ACORN was one of 10 primary care centers with Prescription for Health to share this $3 million grant to develop “strategies for changing Americans’ unhealthy behaviors.”

This project built on ACORN’s earlier RWJF-funded project to develop a tool for helping patients live healthier lives, its MyHealthyLiving website. This website was included among the interventions offered those patients identified in need of interventions. It’s worth taking a minute to look at this website created by ACORN “to help patients pursue healthy behaviors.” The results of this project were published in the March 2006 issue of Annals of Family Medicine. During the 9-month study, even with intensive promotion at the practices and by clinicians, they were only able to get 4% of the patients in their practice to visit the website and only 29% (273) of those completed their study questionnaire. At one month, behavior change “approached statistical significance in... physical activity and readiness to change dietary fat intake, but no significant differences persisted at 4 months.” In other words, it was a dud.

Much of this earlier $125,000 grant was devoted to creating the website, according to the paper. The website is fairly typical of those made available through employer wellness programs and is little more than a series of links to other websites with cursory mainstream consumer information on diet (ten best super foods to eat, 20 worst foods, BMI calculator, food guide pyramid, an online diet site...), exercise, and smoking/drinking cessation. Sort of lame stuff. But don’t write it off. The real value isn’t for patients but for stakeholders: in its health assessments. As the paper reported:

94% of patients who visited our Website were willing to answer online questions about health history. Systems that share such information with clinicians could obviate the need to sacrifice time during appointments for this task. Patients’ answers can be used to update medical records, populate electronic health records, and prompt clinicians about health habits and clinical services needing attention.

Prescription for Health is a five-year initiative funded by RWJF along with the AHRQ. Its goals are to transform primary care to promote ‘healthy’ behaviors, targeting the “four leading health risk behaviors” which it says are ‘unhealthy’ diet, lack of physical activity, and use of tobacco and alcohol. According to its website, these lifestyle behaviors are “the leading cause of disease, disability and premature death, and impose a significant yet preventable burden on our healthcare system.”

The forewarned cataclysm of these beliefs is that the populace is increasingly being reinforced to look at those who are fat or who get cancer, heart disease, diabetes, or become disabled — conditions most related to aging, genes, social status or the luck of the draw (not lifestyle) — as being to blame for their conditions and for burdening the rest of society.

These disclosures, which weren’t provided readers in the Journal of the American Medical Association, bring an entire different clarity to that commentary and the new face of public health.

© 2008 Sandy Szwarc

* Partnership for Prevention member organizations

Abbott Laboratories
AcademyHealth
Alabama Department of Health
American Academy of Physician Assistants
American Cancer Society
American College of Medical Quality
American College of Preventive Medicine
American Diabetes Association
American Heart Association
American Legacy Foundation
American Medical Association
American Physical Therapy Association
American Public Health Association
America's Health Insurance Plans
Arizona Department of Health Services
Association of State and Territorial Health Officials
Association for Prevention Teaching and Research
Bayer Healthcare
Benefits Administrative Systems, LLC
Center for the Advancement of Health
Delta Dental of Minnesota
Directors of Health Promotion and Education
Dow Chemical Company
Eye Care America
Georgia Department of Human Resources
Harris County Public Health and Environmental Services
Health Partners, Inc.
Health Research and Educational Trust
Illinois Department of Public Health
Indiana State Department of Health
InfecDetect, LLC
Intermountain Healthcare Community Health Partnerships
International Health Racquet and Sportsclub Assn.
International Truck and Engine
LifeSigns
Los Angeles County Dept. of Health Services
Lumenos
March of Dimes
Massachusetts Department of Health
Merck & Co., Inc.
Michigan Department of Community Health
Nashville Public Health Department
National Association of County and City Health Officials
National Health Council
National Institute for Health Care Management
National Quality Forum
Nevada Health Department
New Jersey Health Department
North Carolina Dept. of Health & Human Services
Oral Health America
Oregon Adult Immunization Coalition
Oregon Department of Health
Pennsylvania Department of Health
Pfizer Inc.
Pitney Bowes
PreventBlindess America
Research!America
Rhode Island Department of Health
Sanofi Pasteur
Self Care Institute
Society for Women's Health Research
South Nevada Health District
St. Louis County Department of Health
Tarrant County Public Health
Tennessee Department of Health
Texas Department of Health
The Advertising Council
UnitedHealth Foundation
University of North Carolina at Chapel Hill
U.S. Preventive Medicine
Utah Department of Health
Vision Council of America
Washington State Department of Health
WellPoint
West Virginia Health and Human Resources
Wisconsin Division of Public Health
Wyeth Pharmaceuticals