A NEW VISION, A NEW PLAN 

We are publishing this special issue on A New Vision for Health Promotion just at the time we are developing a new plan for our health promotion advocacy efforts. In this compendium of invited articles from leading health professionals, I see a clear and compelling alignment between the direction these authors believe health promotion needs to go and the goals that have guided our advocacy campaign. Our intent in devoting a special issue to a ‘‘new vision’’ was to continue to build a case for the significant resources needed to improve the capacity of our profession and the nation to achieve new levels of health, productivity, and cost containment. The articles in this issue affirm not only what’s possible, but they also offer the profession thoughtful foundations on which to build. 

Almost three years ago, in this column, I made a public declaration of the need to build health promotion into the national agenda.¹ This led to the creation of our volunteer advocacy group called Health Promotion Advocates (http:// www.HealthPromotionAdvocates.org). Almost all of my columns since that one have focused on this effort. How much progress have we made in those three years? From one perspective, we have made more progress than we should have hoped for. From another perspective, too little has changed. We also need to recognize that circumstances have changed considerably since we started this effort. Considering what’s worked and what hasn’t, where do we go from here? 

Excellent Progress 

Given that we started with scarce experience in advocacy, no funding, no volunteers, no committee members or staff, we have come a long way. We have a grass roots network of over 700 advocates, 50 talented committee members, and fi- nancial contributions that almost cover our basic costs. We have staged three national conferences on this topic, met with the staff of over 200 members of congress, including all of the important committee members and the leadership of both chambers. We have good working relationships with a dozen of these offices and have discovered a handful of effective health promotion champions. We introduced resolutions in the Senate and House that attracted 112 cosponsors. Furthermore, discussion drafts on our Health Promotion FIRST legislation have been prepared in both the Senate and House of Representatives. 

Our efforts have played a role in generating broad conceptual support for health promotion among the vast majority of members of Congress. The scientific community, including the leadership at the National Institutes of Health, the Centers for Disease Control and Prevention, the major academic health centers, and many members of the Institute of Medicine are gaining a more complete understanding of the importance of health promotion and are making public statements about its importance in national health policy. 

These are all significant positive and necessary developments, but they are not yet sufficient for achieving what we set out to accomplish. 

New Circumstances 

We need to recognize that critical events have changed the legislative environment in which we are operating. The 9-11 attacks, development of the homeland security department, and wars in Afghanistan and Iraq have diverted a large portion of the federal government’s discretionary spending to defense. Equally important, the recession and the tax cuts have reduced tax revenues to the extent that the government is now operating at a deficit. When we started these efforts in 2000, the government was enjoying a tax surplus that was forecast for the foreseeable future. Our original strategy was to capture some of that surplus for health promotion. Now, we need to cut or divert budgets of existing government programs to fund any new health promotion efforts. 

What Has Not Changed

 The only way a major shift in federal government policy occurs rapidly is through significant financial contributions from lobbying groups OR strong support from the President. The health promotion field does not have the money to support even modest financial contributions or lobbying efforts, so we were counting on President Bush’s strong personal commitment to health promotion to translate into policy support. The opposite has occurred. For example, through the efforts of the President, CDC’s budget was cut from $7.7 billion in 2002 to $7.3 in 2003. His 2004 budget called for further cuts to $6.6 billion, with 20% cuts in programs to address nutrition, physical activity and obesity; 90% cuts in the Youth Media Campaign; and 100% cuts in the Extramural Research Program. These cuts were not just objective cost cutting required by the budget deficit, they were cuts targeted to CDC. The budgets of other agencies within Health and Human Services (HHS) were increased, including the National Institutes of Health, the National Science Foundation, Veteran’s Administration, and the Food and Drug Administration. Intensive work by the public November/December 2003, Vol. 18, No. 2 v health community has restored most of the 2004 funding for these programs to their 2003 levels. The bottom line is that the President made the public health community work very hard to restore the base they had in 2003, rather than help to build the health of the nation. 

The lack of presidential support for health promotion is equally visible through directives to government agencies. Tommy Thompson, Secretary of Health and Human Services (HHS), has become dedicated to health promotion as a result of his own personal lifestyle transformation and has stated publicly that health promotion is critical to addressing the health needs of the nation. Furthermore, HHS listed prevention as the number one priority in its strategic plan. However, rather than developing a systematic plan which will make health promotion an integral part of national health policy, Secretary Thompson is focusing his efforts on a newly developing and still underfunded grant program called Steps to a Healthier US. Other disappointments at the department level, which reflect lack of support for health promotion, include Secretary of Education Rod Paige’s reticence to make health promotion a priority in schools. Secretary Paige is uniquely qualified with his PhD in physical education and his experience creating a health promotion program for the Houston school system. 

Another disappointment has been the failure of any of the established health advocacy organizations to adopt the health promotion issue as a priority. The public health community was clearly engaged when Research!America launched its Prevention Research Initiative² to increase public support for prevention research. Research!America is a not-for-profit, membership-supported, public education and advocacy alliance that is credited with unifying the medical research community to advocate for doubling the NIH budget from $13 billion in 1999 to $27 billion in 2003. However, when it came to advocating an issue, Research!America stuck to traditional medical research. For example, in the fall of 2003, Research!America concentrated its efforts on passing a special amendment to the Senate Appropriations bill to increase the 2004 NIH budget by 9.2%. At the same time, they advocated for restoring the 2004 CDC budget to 2003 levels, an increase of 0%. Research!America is understandably following the wishes of their members who represent research organizations, trade associations, and other groups that receive billions of dollars in research grants from NIH. CDC on the other hand, serves poor people, community health departments, foreign populations experiencing epidemics–groups that have scarce resources to support advocacy or lobbying efforts. 

A final disappointment was our delay in introducing Health Promotion FIRST (Funding Integrated Research, Synthesis, and Training). As I have explained in earlier columns³, Health Promotion FIRST directs HHS to formulate strategic plans to develop the basic and applied science of health promotion and integrate health promotion concepts into all aspects of society, creates a new program in workplace health promotion research, makes existing research funds available to a wider range of organizations, and identifies increased funding needs of existing federal health promotion efforts. Senators Lugar (R-IN) and Bingaman (D-NM) agreed to take the lead in introducing this legislation. In July 2003, we met with representatives of HHS to request a formal statement of support for Health Promotion FIRST. HHS felt they already had the authority to perform many of the functions outlined in the legislation and believed they were making good progress in some other areas, so they declined to endorse our effort. Without their support, it was unlikely that President Bush would have signed the bill, even if we were successful in getting the bill passed in the Senate and House. 

Where Do Go From Here? 

Have our efforts been futile? Absolutely not! Do we need to adjust and adapt? Most assuredly! Our plans are outlined briefly below. 

First, through the efforts of Senators Lugar and Bingaman, we will be working more closely with Secretary Thompson’s office to redevelop Health Promotion FIRST to better meets HHS needs. This is a positive development because until this point, we have worked primarily at the agency level and have not had good access to the Secretary’s office.

 Second, we are working with Senators Frist (R-TN), Bingaman (D-NM), and Dodd (D-CT) and Representatives Bono (R-CA), Granger (R-TX), and Lowey (D-NY) to pass The Improved Nutrition and Physical Activity Act (IMPACT) (S.1172 and H.716). IMPACT provides training for health professionals and students on how to identify those at risk for overweight and obesity and how to treat and prevent these conditions; provides grants to communities, schools, and clinical organizations for obesity intervention programs; collects additional data on children’s fitness and exercise levels; studies the impact of Department of Agriculture food supplement programs; conducts reviews of effective programs; and adds obesity to the list of programs appropriate for state Preventive Services Block Grant programs. Additional funding will be approximately $60 million per year. 

Third, we are working to build a larger and broader coalition. It is unlikely that the health promotion field will ever have sufficient financial resources to marshal the magnitude of lobbying funds necessary to compete with major or even minor lobbying efforts. Fortunately, we are advocating for an issue which makes imminent sense for the nation, is understood by members of Congress, and has few detractors. Our message is welcome whenever it is conveyed; we just need to have it presented more often. To make that a reality, we need to build influence by multiplying our voices through dozens of professional associations, advocacy groups, and other organizations. We welcome your efforts in helping us link with other groups who support this concept. We also encourage you to join our grass roots advocacy network through our website (http://www. HealthPromotionAdvocates.org). 

Fourth, we need to secure sufficient funds to support a small but stable professional advocacy effort. We welcome your recommendations on how to best reach that goal, and of course we welcome your contributions. 

References

1. O’Donnell M. Building health promotion in the national agenda. Am J Health Promot. 2000;14(3):iv. 

2. Research!America’s Prevention Research Initiative. Available at: http:// www.researchamerica.org/programs/pri.html.

3. O’Donnell M. Health Promotion F.I.R.S.T.: Introducing the legislation. Am J Health Promot. 2003;17(5):iv. Michael P. O’Donnell, PhD, MBA, MPH Editor in Chef and President American Journal of Health Promotion

Michael P. O'Donnell, PhD, MBA, MPH
Editor in Chief, American Journal of Health Promotion