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               Health Promotion-Some Notions in Search of a
                                               JONATHAN E. FIELDING, MD, MPH

      As medicine qua science has become better defined,                Edward Jarvis expressed the problem of physician education
 health promotion-given much prominence in classical civ-               this way:
 ilization under the reigning religious and social tenets of so-           "Our education has made our calling exclusively a curative
 ciety-has decreased in importance and become fractionated                 and not a conservative one, and the business of our respon-
 as the "preventive" part of specific medical regimens:                    sible lives has confined us to it. Our thoughts are devoted to,
                                                                           our interests concerned in, and our employments are con-
      * Exercise is prescribed as a part of the medical regimen            nected solely with, sickness, debility or injury,-with dimi-
 to recover from myocardial infarction;                                    nution of life in some of its forms. But with health, with full-
      * Cessation of smoking is recommended as part of the                 ness of unalloyed, unimpaired life, we, professionally, have
 therapy for chronic lung disease;                                         nothing to do."'
      * Weight reduction is advised as one medical response                  The problems of disease-specific orientation of health
to incipient diabetes, hypertension, and heart failure.                 professional training are paralleled by the structure and leg-
      Medicine today is, in general, oriented to illness and            islatively-assigned functions of federal and state health
technological remedies. Health care professionals are, in the           agencies. In addition, neither the current organization of the
main, in the business of minimizing effects of illness. The             patient's record nor the way public moneys are distributed
payment system supports this set of priorities. How many               force priority attention on the maintenance of health.
insurance policies pay for visits to no-smoking clinics, nutri-              The answer is not to eschew what medical technology
tional counseling, or physical fitness classes?                        has brought us. The most zealous advocate of holistic medi-
      Our strong beliefs in traditional medical institutions and       cine wants modern, well-equipped hospitals and well-trained
medical technology have been eroded by the very small im-              up-to-date physicians, dentists, nurses, and other health pro-
provement in curative medicine during the past quarter cen-            fessionals when illness occurs. However, if we feel the need
tury despite the growing financial burden that saw health              to integrate health promotion into our individual lives and
care costs multiply tenfold. It appears that increased tech-           mission as health professionals, we must program ourselves,
nological investment brings diminishing returns. As a result           our agencies, our public institutions, and our elected repre-
we have difficulty knowing where to turn in our search for a           sentatives. The need for a basic reorientation is hardly a new
disease free status. Turning inward to ourselves, our life-            concept. Lemuel Shattuck and his co-authors of the 1850 Re-
styles, social values and the social system which sustains us          port of the Sanitary Commission of Massachusetts, stated:
are rejected as paltry and pedestrian substitutes for impres-             "We believe that the conditions of perfect health, either pub-
sive edifices, computer printouts, and medical jargon that                lic or personal, are seldom or never attained, though attain-
add the desired mysticism to the patient-health professional              able;-that the average length of human life may be very
relationship. The problem is not one of the orientation and               much extended, and its physical power greatly augmented; -
expectations of patients, but rather of the training and orien-           that in every year, within this Commonwealth, thousands of
                                                                          lives are lost which might have been saved;-that tens of
tation of practitioners of medicine. Over 130 years ago, Dr.              thousands of cases of sickness occur, which might have been
                                                                          prevented;-that a vast amount of unnecessarily impaired
                                                                          health, and physical debility exists among those not actually
     Address reprint requests to Dr. Jonathan E. Fielding, Commis-        confined by sickness;-that these preventable evils require
sioner, Department of Public Health, Commonwealth of Massachu-            an enormous expenditure and loss of money, and impose up-
setts, 600 Washington Street, Boston, MA 02111. This paper, sub-          on the people unnumbered and immeasurable calamities,
mitted to the Journal January 31, 1977, was revised and accepted for      pecuniary, social, physical, mental, and moral, which might
publication June 9, 1977.                                                 be avoided;-that means exist, within our reach, for their

1 082                                                                                               AJPH November 1977, Vol. 67, No. 11

    mitigation or removal;-and that measures for prevention             approach to ensuring more honest self-declaration of alcohol
    will effect infinitely more, than remedies for the cure of dis-     use might be to have automatic cancellation or reduction in
    ease. "2
                                                                        benefit clauses in the policy if a self-declared non-drinker
 While there is no available road map for this long journey,            was found to have an elevated alcohol level at the time of an
following are some concrete notions and specific directions             accident. Likewise the coverage under a car insurance poli-
 which evolved from a recent reevaluation of priorities within          cy might be automatically reduced if the insured was not
the Massachusetts Department of Public Health.                          wearing a seat belt at the time of an accident. An encourag-
 1. Compile and disseminate information demonstrating the               ing sign that administrative problems in identifying risks are
favorable ratio of benefits to costs for health promotion pro-          not insurmountable is health insurance policies, such as that
grams. While cost/benefit studies are available for some pri-           of The State Mutual Life Insurance Company of America
 mary and secondary preventive efforts such as immuniza-                which announced in April 1976 that it was offering discounts
tion, neonatal screening, and flouridation, much less effort            of up to 8 per cent on premiums of all non-smokers because
has gone into making the economic argument for investment               non-cigarette smokers are better insurance risks and should
in other significant issues, such as gun control, improved              receive more favorable premium rates.* Ironically national
nutrition, and product safety. In still other areas of pre-             health insurance is likely to be very egalitarian and reverse
 vention, cost/benefit data may be available nationally but             any progress made in this direction.
need to be broken out to demonstrate their impact on indi-              3. Develop economic incentives for health care institutions
vidual states and municipalities. It is not enough to advise             to invest in health promotion. With the possible exception of
our citizens and elected representatives that attention to the           HMOs, no institutional providers have the proper economic
effects of life-style and our man-made environment on health             incentives to reduce utilization. As hospitals-faced with in-
are just causes. We must, supported by adequate data, con-               creasing pressures for efficient operation-close some un-
vince others that health promotion can effectively reduce the            derutilized services, perhaps they could continue to be reim-
incidence and costs of illness and death during the most pro-            bursed for a portion of the costs eliminated, with the provi-
ductive years of life. Even some areas which to date have                sion that they use such money to develop innovative health
not been associated with proven cost-effectiveness programs              promotion programs.. Priority for such programs could be es-
can justify investment based on the magnitude of the prob-               tablished through a community planning process involving
lem. For example, automobile accidents cost the Common-                 the appropriate Health Systems Agency.
wealth of Massachusetts $200 million last year.3 Studies of             4. Encourage the involvement of civic groups and local
other countries have shown us that use of seat belts could              boards of health in community-based approaches to life-
reduce this figure substantially. Even without proof that               style issues. Chambers of Commerce, Rotary and Kiwanis
marketing programs with increased seat belt use as an objec-            Clubs, church groups, and others can become interested in
tive will be successful, the stakes probably justify the invest-         sponsoring alone or co-sponsoring with local hospitals or
ment if the programs include careful evaluation. Thus, the              health agencies community-wide health promotion pro-
Massachusetts Department of Public Health (MDPH), in co-                grams. The key to gaining their interest is to make a strong
operation with a local hospital, has set up a controlled trial to       case for demonstrable benefits of their efforts and to provide
confirm restraints in cars increases use and if so, for how             at least a small amount of funding to complement their own
long. "A Program for Prevention"* developed by MDPH                     resources. These groups can legitimatize promotion pro-
outlines those areas of prevention where cost/benefit or cost/          grams in their community and reach many more residents
effectiveness have been demonstrated.                                   than can a health care facility with a similar program. The
2. Develop methods to have insurance premiums reflect                   Massachusetts Department of Public Health (MDPH) has
self-imposed health risks. Actuarial information confirms               co-sponsored demonstration projects with four community
that non-smokers should pay lower health and life insurance             groups, ranging from smoking cessation clinics to weekly
rates, as should individuals who wear seat belts or maintain            swimming meets for elderly citizens.
cardiovascular fitness through regular intensive exercise.              5. Adopt a taxation policy that provides disincentives for
Recently introduced legislation in Massachusetts would re-              use of harmful products and provides funds to promote their
quire higher health insurance premiums for smokers than for             non-use. A bill recently filed in the Massachusetts legislature
non-smokers, and higher car insurance for drinkers than                 would dedicate a portion of alcohol tax revenues for alcohol
non-drinkers, with the premiums based on acturial risk as-              detoxification, halfway houses, and outpatient alcoholism
sessment. While such legislation would bring both greater               programs. Another bill would use some cigarette tax receipts
equity and financial incentives for healthful behavior, the             for development of prevention programs. Such legislation
chances for passage are slim because of the administrative              has a chance of passage only if there is a strong constituency
difficulty in identifying and categorizing smokers and drink-           willing to focus most of its resources on securing passage. In
ers, both initially and as personal habits change. A possible           Massachusetts, because there is a strong and coordinated al-
                                                                        coholism program lobby, the alcoholism bill has some
     *Available from Massachusetts State Bookstore, Room 116,           chance of passing. By contrast, weaker and poorly coordi-
State House, Boston, Massachusetts at a cost of 350 to cover post-      nated anti-smoking forces are unlikely to secure passage of
age. 87 pp. The paper outlines MDPH's goals over the next three
years in the area of health prevention. Specific programs which will
be developed to impact on life-style habits through either individual
or government action are also discussed.                                    *A "Program for Prevention." See prior footnote.

AJPH November 1977, Vol. 67, No. 11                                                                                              1 083

  pending legislation that would tax cigarettes differentially       ed health promoting legislation and enhanced public ex-
 based on their tar and nicotine content.                            penditures for innovative programs.
  Ultimately, however, taxing cigarettes based on their rela-        9. Develop partnerships with the media in the promotion of
 tive impacts on health, just as taxing cars based on their          healthful activities. While consumer behavior has been well
 emergency consumption, may gain public support as a                 studied by marketing experts we know more about how to
  "fair" measure. Because of the greater strength of the to-         sell a particular brand of soap or breakfast cereal than how to
 bacco lobby in Congress than in non-southern state legisla-         change ingrained patterns of behavior. Nonetheless, a good
 tures, state passage is more likely than federal action in the      marketing program utilizing radio and television can be help-
 next few years. Necessary prerequisites to passage in Mas-          ful in making the public develop strong negative feelings
 sachusetts are not only coalescence of health interests be-         about unhealthy behavior. For example, a concerted public
 hind such a bill but strong assurances that the tax restructur-     service campaign by all radio and television stations to de-
 ing will not reduce the revenue figure that state budget bal-       pict smoking as unsophisticated, dirty, polluting, and unsexy
 ancers now rely upon from the cigarette tax.                        could be instrumental in reversing the current trend toward
 6. Institute as a part of primary medical practice a clear          more teenage girls smoking. However, to be successful in
 explanation to patients of the risks associated with their life-    countering the massive advertising of tobacco companies to
 style. Practitioners could elaborate the potential health prob-     make cigarette smoking a desirable social attribute, an anti-
 lems that can be eliminated through changing behavior,              smoking program of comparable dimensions is necessary.
 quantifying for each behavior the increased risk of: 1) dying;       Such cooperation in the public interest can be useful ammu-
 2) becoming seriously ill; and 3) loss of income due to each of      nition for radio and television stations when they period-
 these behaviors. One way of assuring that the patient retains        ically come before the Federal Communications Commis-
 this information is to incorporate it as part of an individual       sion (FCC) to justify renewal of their licenses. More diffi-
 health record that each patient keeps. Providing this essen-         culty in getting media support is likely when health interests
 tial information can imbue patients with a greater sense of         clash with commercial interests. A public service advertising
 responsibility for staying healthy and quantify benefits for        campaign to lower cholesterol by reducing consumption of
 reducing avoidable risk factors. State health departments           eggs, whole milk, and red meat could lead to reduced adver-
 can help by compiling information on relative risks and dis-        tising revenues from the meat and diary industries.
 tributing it to all primary care practitioners.                           The Massachusetts Broadcasters Association has tenta-
 7. Develop and utilize school health education curricula            tively accepted an MDPH proposal to cooperate on a year-
 that permit students, from an early age, to understand the          long program with the goal of decreasing the number of smok-
 significance of their individual role in keeping healthy. The       ers in the state by at least ten per cent. In addition, the MDPH
 previously cited 1850 Massachusetts report recommended,             entered into a cooperative venture with a major Boston tele-
 "Every child should be taught, early in life, that to preserve      vision station to motivate people to look at their own habits
 his own life and his own health . .. is one of the most impor-      in the areas of alcohol abuse, smoking, obesity, and lack of
 tant and constantly abiding duties."4 While this suggestion is      cardiovascular fitness. In both cases independent evalua-
 hard to oppose because it makes intuitive sense, the ability        tions of effectiveness in changing behavior are being per-
 of school health education to affect life-styles is question-       formed.
 able. Knowledge of healthful practices does not ipso facto          10. Focus on a limited agenda of measurable objective. Too
 lead to their adoption. This dissociation of knowledge and          few resources are chasing too many problems amenable to
behavior stems in large part from the counterexamples to             preventive efforts. While many voluntary agencies combine
 healthy behavior often provided by parents, sibs, peers, and        in a unified campaign for collection of donations through the
media role models as well as teachers themselves. Removal            United Way, there is much less movement toward pooling
of bad role models based on the other suggestions on this list       program resources to ensure maximum impact. The result is
could lead to student life-styles more in line with what is          both frustration and reinforcement of the public perception
taught in health education courses. At a minimum, educators          that prevention programs are infrequently effective. How-
and health professionals should join to ensure a strong health       ever, again using smoking as a prototype problem, if the
education curriculum that starts in kindergarten and a mini-         American Cancer Society, the American Heart Association,
mum of observable counterexamples among teachers and                the American Lung Association, and the appropriate state
other school personnel.                                             and federal government agencies pooled existing talents and
8. Make health promotion a high priority in the plans of the        resources toward concrete five-year objectives such as: 1)
Health Systems Agencies and State Health Planning and               decreasing the percentage of adult smokers by 20 per cent; 2)
Development Agencies. Public Law 93-641 spells out pre-             decreasing by 30 per cent the average amount of tar smoked
vention of illness as a major priority for these mandated           by adult smokers; and 3) reversing the current trend toward
agencies. Agency plans can bring visibility to the areas            a higher percentage of teenage girls smoking, the objectives
where more health promotion efforts are needed and provide          could probably be met. Quantifiable and highly visible suc-
encouragement for hospitals, health professionals, and inter-       cesses in two or three such programs could lead to greater
ested groups to develop programs designed to maintain               public support for health promotion as well as increased pub-
health. In addition, making prevention an explicit priority at      lic funds for similar programs. MDPH is funding a number of
the local level would be a signal to local legislators that their   primary prevention demonstration projects by community
constituency expects their support of both consumer-orient-         groups to help us define those target areas where measurable

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objectives can be met over a three- to five-year period. Each     untary agencies, local boards of health, and a combined
project is only initiated after careful evaluation methodology    newspaper and television campaign. In addition, Blue Cross
has been established.                                             and Blue Shield of Massachusetts has recently published a
11. Develop and disseminate lists of health promoting re-         Directory of Mutual Help Organizations in Massachusetts
sources for every town, city, and county. When educational        which presents alphabetically, within categories, the name,
and motivational techniques are successful in convincing in-      address, phone number, and a brief description of various
dividuals to take some action, there must be readily available    support and mutual help groups around the state.
ways of linking good intentions with outside help. For ex-             In order for these strategies to work, we need to build a
ample, it is useless to convince an overweight person that he     consensus for change that includes the use of legislative and
or she should get help in reducing if he or she can't find a      financial leverage. Ultimately success requires the real-
self-help group or a Weight Watchers' program and/or an in-       location of dollars within health budgets and investment in
terested physician nearby. Lists of places to exercise, no-       developing better technology for health promotion efforts.
srnoking clinics, garages that can properly install effective
child restraints, and agencies that can help with a drinking
problem are all necessary. Such lists might be distributed free
with (or as part of) local phone books, as inserts to newspa-                              REFERENCES
                                                                   1. Jarvis, E. In Communications, Massachusetts Medical Society,
pers, through service stations, supermarkets, or other simple         Vol. VIII, p. 1.
methods of reaching most people. In Massachusetts a re-           2. Shattuck, L. Report of the Sanitary Commission of Massachu-
source book focusing on smoking, nutrition, alcohol, and ex-          setts, 1850, p. 10. Dutton & Wentworth, State Printers, Boston,
ercise has been developed by the Department of Public                 MA.
                                                                  3. Fielding, J.E. and Walsh, D.C. Comprehensive Health Care and
Health and the Medical Foundation, a non-profit agency in-            Motor Vehicles. N Eng. J. Med. 294:841-843, 1976.
terested in health promotion. It was distributed through vol-     4. Ibid. p. 178.

                 In the article entitled "Hypertension: Effects of Social Class and Racial Admixture," by Julian E.
            Keil, et al., Am. J. Public Health 67:634-639, 1977, the captions for Figures 2 and 3 were transposed.
            They should read as follows:
                                FIGURE 2-Incidence Rate of Hypertension among Black
                                Males by Social Class and Skin Color, Charleston County,
                                South Carolina.
                                FIGURE 3-Frequency Distribution of Socioeconomic Status
                                among Black Males, Charleston County, South Carolina
                                Heart Study.

AJPH November 1977, Vol. 67, No. 11                                                                                             1085