National Prevention Strategy 2012: Applause and Critique, Again

By David A. Kindig, MD, PhD

Last week marked the release of the Annual Status Report and Action Plan of the National Prevention, Health Promotion, and Public Health Council (National Prevention Council). I blogged on this Council when it first met a year ago, offering both “Applause and Critique.”

How should we evaluate progress a year later? My first reaction is gratitude that the effort is underway, apparently alive and well. Unlike many efforts at cross-agency collaboration, the work of the Prevention Council is moving forward, despite the natural obstacles it faces. As my colleague Elizabeth Rigby observed in Health Affairs a few months ago, “For any cross-agency collaboration to be successful, it must secure and sustain support across the relevant agencies. Yet it is well known from previous efforts that calls for collaboration can be threatening to an agency’s autonomy, culture, or mission, particularly when issues fall within the policy space that ’belongs‘ to more than one agency but is divided by rigid institutional structures.” These threats are even more pronounced in the time of fiscal crisis and shrinking budgets agencies find themselves today.

The Status Report provides a brief summary of the year’s activities, including meetings of the council, its Advisory Group, and regional meetings with public and private partners. A useful table highlights a number of featured programs and initiatives cutting across federal agencies like Green Ribbon Schools and the National Forum on Youth Violence Prevention. An Appendix lists a large number of Prevention Indicators linked to Healthy People 2020, although without performance targets.

The Action Plan is a much longer compilation. It lists more than 200 activities being taken in the 17 Departments to respond to the four cross-cutting Strategic Directions  (Healthy and Safe Community Environments, Clinical and Community Preventive Services, Empowered People, and  Elimination of Health Disparities) as well as the seven Strategic Priorities (Tobacco Free Living,  Preventing Drug Abuse and Excessive Alcohol Use , Healthy Eating,  Active Living,  Injury and Violence Free Living,  Reproductive and Sexual Health, and  Mental and Emotional Well-Being). It is beyond the scope of this blog to completely analyze or critique this list; it is an impressive compilation of work being done across these agencies and at the very least serves as a baseline for future reference. The Robert Wood Johnson Foundation’s New Public Health blog posted an interview with Estelle Richman from HUD which gives a good flavor of how the Strategy is being implemented in one department.

While I strongly applaud this work, I do have several concerns.

1. The prevention framework still seems dominated by a health behavior framework, instead of a more upstream “primordial prevention.” While many of the behavioral policies are structural, such as nutrition standards across all DOD facilities and schools, there is nothing about job creation and economic development within either the federal government or the private sector. I believe such policies deserve bipartisan support for their great potential for prevention and disparity reduction. Actually, I was surprised to realize that neither Treasury nor Commerce are represented on the Council and would encourage these be added for the important perspectives they could bring to this work.
2. While this activity is rooted in the Affordable Care Act, there does not appear to be a link to the cost containment policies of CMS. Increasing health care costs eat into resources that could be used to fund many population health improvement efforts. As Rigby says, “non health agencies will probably be more willing to incorporate greater attention to health if doing so does not deplete their own resources.” And, of course, the Prevention Fund continues to face incredible political obstacles.
3. Indicators are not enough; we need targets to work towards and to hold us accountable.
4. The research community must produce evidence of the relative cost effectiveness of the wide range of policies and programs thought to drive population health improvement, including how health and prevention programs impact primary goals that agencies most care about.

Population health advocates on both sides of the aisle should recognize the potential setbacks that could result from a change in administrations. Silo-busting accomplishments such as the National Prevention Council are hard-won. They are very promising but also very fragile; progress will require that a bipartisan majority continue to value and respect this bold, innovative, and vital effort to improve the health of the nation in a cost-effective manner.

David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health. Follow him on twitter: @DAKindig.