Declaring a goal of changing America's "sick-care system to a health-care system," the Obama administration Thursday announced a sweeping strategy to emphasize prevention in all walks of life.
The plan builds on initiatives such as Michelle Obama's campaign for healthy eating and the Food and Drug Administration's new power to regulate tobacco. More broadly, it requires a range of federal agencies to consider prevention in everything they do - and asks the rest of the country to think of health care as something that goes well beyond drugs and scans to include safer streets, cleaner water, and easier access to healthy foods.
"Why is it so hard to be healthy?" asked Sen. Tom Harkin (D., Iowa), an advocate for prevention, at a news conference in Washington.
Cities and towns have been asking that question and trying to make changes. In Burlington City, exercise stations were added last month to the Riverfront Promenade. Kennett Square has organized neighborhood "captains" to lead walks - and is hoping to build sidewalks to help people in low-income neighborhoods get to shops less than a mile away.
"It's crazy. Some of them now walk on the railroad tracks to get to the shopping district," said Tom Gallagher, who chairs the Activate Kennett committee for the local YMCA. A YMCA also helped fund the exercise stations in New Jersey.
The new National Prevention Strategy, which Surgeon General Regina M. Benjamin described as "America's plan for health and wellness," seeks to guide and encourage such thinking among governments, organizations, businesses, and everyone else.
It includes no new funding - a painful irony to public health workers who have seen their funding cut by local, state, and federal governments as tax revenues fell during the recession. But the strategy is one of many low-profile elements of President Obama's health-care overhaul, which provided $17 billion in grants to communities that try to improve public health and prevention. Republicans have been trying to repeal the funding.
The strategy includes a commitment from 17 federal agencies - some, like the Departments of Defense and Housing and Urban Development, not traditionally associated with health - to find ways to emphasize prevention in their normal activities.
"The theory behind the strategy is that we don't need legislation," said Jeff Levi, executive director of the Trust for America's Health, who chairs an advisory group that is helping oversee the effort.
"For example," he said, "as the Transportation Department considers a new street, how are they contributing to active living as opposed to just building a road? When Housing is developing a new project, how accessible is it to people with disabilities? Does it promote physical activity? Are they bringing in supermarkets?
"It's adding a health lens to the work that people are already doing."
Health care, at least in the western world, typically is viewed as treating injuries or diseases. Yet seven out of 10 deaths are due to chronic conditions that can largely be prevented by reducing smoking, increasing exercise, and eating healthier, said Melody Barnes, director of the White House Domestic Policy Council.
"The biggest challenge is going to be changing how we think about health in this country," said Benjamin.
Temple University obesity researcher Gary D. Foster praised the strategy's broad-based efforts while cautioning that the issues are "infinitely complicated."
When it comes to obesity, "there's not a whole lot of definitive evidence in prevention strategy," said Foster. "We have some good guesses, but it's not like we know, the way we know Lipitor lowers cholesterol."
Still, "it is much easier to create a healthy lifestyle than to change an unhealthy lifestyle," said Ari Brown, a pediatrician in Austin, Texas, and the author of several books on parenting and pregnancy. "Smoking, drinking, not exercising, those are very hard to change."
While many local communities have been piloting prevention in bits and pieces, Philadelphia over the last few years has taken the kind of broad approach envisioned by the national strategy.
Some has been legislative. The city last year began enforcing the strictest requirements in the country for nutrition labeling on chain restaurant menus, and several months ago raised penalties for merchants who sell tobacco to underage youths.
Mayor Nutter fought hard (until City Council's rejection of it Thursday) for a tax on sugary drinks, to discourage purchases by consumers concerned about price - a strategy that has been credited with reducing cigarette smoking nationwide.
But many of the city's initiatives have involved cajoling merchants into selling healthier foods and making them more visually appealing. Vending machines in city buildings, for example, limit the size of sugar-sweetened beverage containers to 12 ounces, and place them in the bottom position.
"The goal is to make healthy behavior the default behavior," said Giridhar Mallya, director of policy and planning for the Philadelphia Department of Public Health.
A program that gives low-income people $2 in coupons for every $5 in food stamps they spend at participating farmers markets has resulted in a significant increase in purchases over the last two years, he said, and the city has also worked to open new markets in communities where fresh fruits and vegetables are hard to find.
The city also has been working with corner stores, where many children buy candy and sodas on the way to and from schools, to change their offerings.
Pedestrian and bicycle paths are being expanded.
One clear benefit of the prevention focus in Philadelphia, Mallya said, has been with smoking.
The city's 2006 ban on smoking in restaurants resulted in the first drop in smoking rates in several years, he said, amounting to "25,000 fewer smokers."
Nutter last month banned smoking at city playgrounds, recreation centers, and pools. Results of that move won't be known for a while, but "there are a million visits to any one pool," Mallya said.
The National Prevention Strategy sets four broad goals - healthy and safe environments, clinical and community preventive services, empowering decisionmaking, and elimination of health disparities - and seven priorities to achieve them.
There are many recommendations for each priority. Some examples;
1. Tobacco-Free Living
Example: Encourage businesses to provide quit-smoking aids.
2. Preventing Drug Abuse and Excessive Alcohol Use
Example: Develop ways to help people easily dispose of unused medications.
3. Healthy Eating
Example: Work with manufacturers to reduce sugar and saturated fat in processed foods.
4. Active Living
Example: Urge employers to provide bike racks and showers.
5. Injury- and Violence-Free Living
Example: Promote exercise programs aimed at reducing falls by elderly.
6. Reproductive and Sexual Health
Example: Enhance HIV screening programs.
7. Mental and Emotional Well-Being
Example: Promote environments where people can connect and stay engaged.
For more information
Go to www.healthcare.gov