Your Health, Your Problem?

There is a rich trove of data demonstrating that preventive health measures and health promotion campaigns work. But the will to fund such programs is wavering, said a blue-ribbon panel of experts who met Thursday at a symposium hosted by California State University, Northridge.

“Health promotion and disease prevention are at a fairly critical crossroads right now,” said Daniel Callahan, the co-founder of the Hastings Center, an ethics think tank in Garrison, N.Y. “There is a fair bit of ambivalence about prevention on the part of many people.”

This juncture comes amid a national debate over whether the responsibility for the public’s health lies collectively with government, managed care companies and employers--or squarely with each individual.

“There is a de-investment in public health now and an emphasis on individual responsibility,” agreed Beverly Ovrebo, a prevention expert at San Francisco State University. This is occurring, she added, even in the face of increasing poverty, a growing risk of epidemics and shrinking access to health care.

The idea that each person bears the consequences of unhealthful living crystallized during the early years of the AIDS epidemic, she said. While the government did little to curb the spread of infection, a major public health effort was aimed at encouraging safe sex.

“The onus of responsibility was on the individual to have safe sex,” she said. “This was the first time in history we have taken an infectious disease and said to people ‘you have to protect yourself.’ ”

There is a strong case to be made for taking personal responsibility for one’s own health, especially regarding choices such as not using a seat belt or being sedentary, experts acknowledged during the afternoon-long seminar. But shared responsibility between the individual and society is the most likely combination to produce healthy behavior, Ovrebo told health professionals at the forum co-sponsored by the Hastings Center and the Stanford University Center for Biomedical Ethics. The program was funded by the California Wellness Foundation and the Walter and Elise Haas Fund.

“One of the foremost criticisms of individual responsibility for health is that it blames the victim by ignoring social content,” said Meredith Minkler of the School of Public Health at the University of California, Berkeley. “Holding the individual responsible for health status is most problematic in the case of the poor.”

This approach can also lead to blaming individuals for their health status, she said. For example, some surgeons will refuse to perform additional cardiac bypass surgeries on someone who refuses to quit smoking.

“By equating being ill with being guilty we may stigmatize the disabled, the overweight. . . . Such a perspective lets government off the hook. We need to find a way, as a society, to balance personal responsibility with societal health promotion.”

But will society accept its share of the work? In the early years of managed care companies, for example, it was thought that these providers would emphasize preventive health care services to reduce the costs associated with caring for acutely ill people. But that plan appears to have backfired, says Helen Schauffler, of the School of Public Health at UC Berkeley.

“There is such a large turnover rate in managed care that if they spend money on health promotion, two years later, 30% of the [members] will be in other health plans,” she said. “Many of the original HMOs in the United States had a health education model as part of their mission. But most of the HMOs operating now don’t have this kind of organization.”

Nevertheless, she and other experts noted, many managed care plans advertise heavily that they promote good health--especially in the area of keeping retirees feeling younger than their years.

“Managed care does a better job of offering health promotion, but there isn’t evidence of how well they are doing it. For the vast majority of companies, [the effort is made] for marketing and outreach,” Schauffler said.

Studies show that the managed care prevention and promotion programs are poorly utilized, with participation rates “in the single digits,” she added.

“We need to change our view of managed care as being an incentive for health promotion to the idea that managed care needs to be held accountable for improving health.”

The government, too, should take a leadership role in ensuring the good health of the citizenry.

It has been repeatedly proven in studies--thousands of them--that spending money on health promotion and disease prevention makes people healthier. For instance, an additional tax on cigarettes in California is credited with a drastic drop in adult smoking rates in this decade.

“It’s fairly intuitive that these things work,” said Dr. David Chernof, chief medical officer of LA Care, a managed care plan for Medi-Cal patients in Los Angeles. “They are all about empowering people to make choices that end up having socioeconomic value to the community as a whole.”

But, public health officials often make the flagrant mistake of arguing that prevention and promotion saves money, said Schauffler.

There is scant evidence that it does, she argued. Major reports by three leading U.S. health agencies (including the Centers for Disease Control and Prevention) could cite only five examples of economic savings from health promotion efforts. They include:

* Campaigns to increase the use of the pneumococcal vaccine in older people;

* Prenatal care for poor, uneducated women;

* Management of diabetes in pregnant women;

* Smoking cessation programs for pregnant women;

* Childhood immunization programs.

“We can number these programs on one hand,” she said.

Public health officials need to rethink how to make their case for health promotion.

But, Chernof warned, if the desire to promote these programs wanes now, during what is a prosperous economic period, the future of public health will be bleak.

“If we can’t ensure good health now, it’s never going to happen,” he said. “We need to redouble our efforts.”