For the United States, health reform without a clear plan to mobilize community groups nationwide to put proven prevention programs right in place where they are most needed, will not be "reform", but a continuing disaster in which people are simply more equal in being able to obtain expensive medical "care" for dehabilitating conditions that often could have been prevented.
In contrast to the sudden epiphany of the medical industrial complex, whose leaders gathered a few weeks ago with President Obama to announce that major, major health care savings are available, community groups and a small, but determined cadre of public health leaders have been plugging away for years, using the scant funds available for serious chronic disease prevention research to demonstrate the enormous, and currently unused, potential for chronic disease prevention.
The fact that stands out from this research is that, in the era of chronic disease, much, if not most, savings in not simply costs, but in avoidable sickness, have to be pursued outside the formal health care system which has had the spotlight in the health reform debate. In this era, community-based disease prevention programs and strategies should occupy the same role in public health that community improvements---notably improved sanitation---contributed to the fight against infectious disease.
We will be able to judge both the real intent of the medical industrial complex---and the Obama Administration and the Senate and Congress--by their support for community-based prevention. Right now, it is still routine to read in discussions of healthcare reform that "real" reductions in our overwhelming rates of chronic disease aren't possible---and that it just not true. What analysts who say that are not admitting is that while the ordinary ways of the health care system--drugs, "treatments", surgery, etc.---cannot reduce chronic disease rates, getting prevention out of the health care system, itself, can.
For just one example, it is now so well proven that education beats out medication in preventing diabetes that in the largest American study of its kind, involving 3,000 people across the nation, the National Institutes of Health showed that counseling and coaching "prediabetics" to make modest lifestyle changes was twice as powerful as standard medication in preventing their usual steady progression to diabetes. When given clear guidance, all groups---men, women, blacks, whites, Hispanics---had equal success in losing the small amounts of weight and taking up the modest amount of exercise that proved to profoundly protect their health.
Overall, the Trust for America's Health, after reviewing the often stunning results from even the current scattered and under funded efforts to put well-focused health education, exercise and similar programs into high need communities, has concluded that a mere $10 per American invested each year in such prevention activities would, within five years, save $16 billion annually in direct health costs. These savings, mainly from avoided medical expenses for diabetes, hypertension, stroke and heart disease, do not even count the many human benefits of having a less sick population.
The acute need for effective prevention means that health reform must include a separate and steady funding stream to enable local communities to themselves implement proven prevention activities. This is not widely understood or accepted. There is no possibility that a healthcare industry which has long been hostile to chronic disease prevention which empowers people to better manage their own health will become a paragon of preventive activities no matter how it is financed under health care reform. Indeed, seven years after N.I.H. announced its results, the diabetes education program that powerfully interrupted the usual progression from prediabetes to diabetes is still so unavailable, despite being cheaper than medication, that almost no doctor in the United States---a nation with 54 million prediabetics--- could "prescribe" it for a prediabetic patient. With few exceptions, neither public or private insurance will currently pay for the best demonstrated patient education, much less community activities that widely improve health.
Equally important, to assure widespread prevention, health education and healthful activities must be easily accessible, which means they have to be available outside hospitals--- at community centers, schools, churches, welfare centers, even at Laundromats and barbershops.
But will health care reform finally propel us forward to benefit from the vast potential of community-based prevention? Sadly, there has been so little public focus on including community-based prevention in health reform that, although the major Senate and House bills are expected to recognize that chronic disease prevention must become part of community life, we have few clues what the specific provisions will be. Will there be adequate funding---and a basis to assure steady funding? How will the upcoming legislation promote national standards for effective prevention programs---- but not stifle local work and innovation?
Realistic planning to include community-based prevention as a recognized national goal still needs to become a true part of the health reform dialogue.
For those who have not witnessed it, it is hard to explain the extent to which endemic chronic disease has corroded the very life of American low-income communities. Illness finally comes to almost feed on itself. When our own South Bronx health education organization randomly interviewed 1,000 adults living nearby, 30% already knew they had diabetes---and that doesn't count the many more affected by AIDS, asthma, heart disease and various disabilities. In this atmosphere, people just stop believing that it's possible to be well; children surrounded by sickness lose any sustaining concept of health.
The beauty ---and power---of health prevention and education when undertaken properly in these distressed communities is that local residents, themselves, can become the health educators. The Stanford University Chronic Disease Center is currently testing out a diabetes prevention course which even people without a high school degree could be taught to teach others with just four days of training. We ourselves have trained grandmothers, teenagers, the disabled, parolees, recovering addicts, and people with AIDS, asthma and diabetes alike to be effective peer health educators.
Watching men and women who live in the community---and suffer from the same problems---take up an effective battle for better health is a singular antidote to the communal despair that so reinforces the grip of mass sickness. Letting communities take the lead role in healing themselves is exactly what has not happened until now. Let's hope it is the prescription for the future because it's the only one that will work.
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