Prevention Policy Statement

Each year, chronic diseases and injuries contribute to more than 1.8 million U.S. deaths,¹ cost over $1.7 trillion in lost productivity and health care expenditures,^2,3 and have a significant impact on our health and our economy. State and territorial health agencies are strategically positioned to provide leadership to develop, coordinate and implement comprehensive, evidence-based approaches to wellness and the prevention of chronic diseases and injury. Several national resources provide guidance for state health agencies to direct prevention efforts. Healthy People 2020 establishes 10-year national objectives for health promotion and disease prevention. To achieve these objectives, the National Prevention Strategy⁴ and several other national and federal strategies, such as the National Stakeholder Strategy for Achieving Health Equity,⁵ the 2011 National Drug Control Strategy,⁶ and Ending the Tobacco Epidemic: A Tobacco Control Strategic Action Plan for the U.S. Department of Health and Human Services⁷ provide a path forward to address the many challenges facing our communities and our nation.

Modifiable behavioral risk factors, such as tobacco use, poor diet, physical inactivity, alcohol consumption and drug abuse remain major contributors to U.S. mortality rates.⁸ The majority of U.S. deaths (nearly 70 percent) are caused by chronic diseases, such as cancer, stroke, heart disease, diabetes and chronic lower respiratory illness, and unintentional injuries.⁹ Unintentional injuries, such as those sustained in motor vehicle-related crashes or as a result of poisoning and prescription drug misuse, represent the leading cause of death for people ages 1-44.¹⁰ Given that three-quarters of all deaths among young people are attributed to injuries and forms of violence, such as homicide or suicide,10 continued focus on the prevention of injury-related death and disability and a strong infrastructure to sustain these efforts to prevent and reduce injury is required.

The impact of these challenges is staggering: while national health expenditures increased to $2.5 trillion in 2009, more than 75 percent of these health care costs are due to chronic conditions.¹¹ Annually, the number of missed work days due to chronic diseases and co-morbid conditions totals 2.5 billion, resulting in a loss of $1.1 trillion dollars due to absenteeism and decreased productivity. Combined with another $277 billion spent on treatment, a total of $1.3 trillion is spent annually on chronic conditions.² Injuries in the United States account for more than $406 billion annually in medical costs and lost productivity, including hospitalizations and emergency department visits.³ Nonmedical use of prescription painkillers, for example, costs health insurers up to $72.5 billion annually in direct health care costs.¹²  

To reduce these adverse outcomes, it is essential to promote social mores and an environment based on principles of wellness and healthy lifestyle choices and to invest in programs and implement policies that foster healthy, balanced, safe lives and communities. Priority attention is required to ensure health equity for all people through public and private sector initiatives and partnerships to help racial and ethnic minorities and other underserved populations reach their full health potential.⁵ To this end, it is critical to address social determinants of health, including economic, social and geographic conditions that influence the health of populations and contribute to chronic diseases.

State and territorial health agencies must remain national leaders in the promotion of chronic disease and injury prevention education, programming, and policy. Some fundamental obligations of health agencies include assessment, surveillance, reporting, policy development and targeting of resources for optimal health of the population. State and territorial health agencies approach this mission by fostering environments, programs, policies, public education and relationships that will reduce and ultimately eliminate the incidence and burden caused by chronic diseases and injuries.

To accomplish these goals, ASTHO encourages state and territorial health agencies to utilize the National Prevention Strategy and evidence-based strategies to:

• Develop comprehensive and systematic approaches to prevention.
• Build and sustain internal and external collaboration and partnerships.
• Make the “business case” for the value of prevention.
• Lead by example: develop employee wellness programs for their staff that serve as models for others.
• Encourage development and preservation of healthy communities.

1. COMPREHENSIVE APPROACHES TO PREVENTION 

The state public health system is charged with improving health and reducing the economic burdens imposed by the nation’s leading causes of death and disability. ASTHO supports:

1. Sustaining and developing state, territorial, local and federal public funding streams that permit efficient collaboration across and within agencies to address prevention comprehensively.
2. Sustaining and developing federal funding for states, territories, and tribal nations that permits the flexible use of resources to address unique needs as they arise (i.e., Preventive Health and Health Services Block Grant), rather than prescriptive programs that may not reflect a state’s health priorities or challenges.
3. Encouraging of public health programs that build on the individual strengths of states, territories, local entities and tribal nations while leveraging efforts to target behaviors and social determinants of health that affect many categorical programs.
4. Sustaining public-private partnerships among state and local governmental public health agencies and other stakeholders to implement proven strategies and improve health outcomes in communities.
5. Developing public health surveillance systems that inform prevention activities and decision-making.
6. Assessing and identifying interventions to address health disparities as part of any comprehensive program or policy.

2. BUILD AND SUSTAIN INTERNAL AND EXTERNAL COLLABORATION AND PARTNERSHIPS 

Large employers, insurers and others have major financial stakes in the health and wellness of their constituencies. The health expertise, surveillance capacity and leadership provided by state health agencies are crucial assets for other partners. To address the many dimensions of chronic disease and injury prevention, ASTHO supports:

1. Collaboration within state and territorial health agencies coupled with efforts to engage tribal nations; other sectors such as transportation, education, agriculture and energy; health care, mental health and substance abuse; environmental health; the private sector and local governmental entities, such as city councils and mayors, as well as other key stakeholders.
2. Interdepartmental collaboration for federal, state, local and territorial public health grant programs.
3. Frequent collaboration among chronic disease and injury prevention programs and other stakeholders to develop comprehensive solutions to these public health challenges.
4. Demonstration of the value of prevention investments as a crucial component of any transformative national health agenda to the private sector, insurers, medical providers, researchers and elected officials.

3. INVESTING IN PREVENTION:  MAKING THE BUSINESS CASE  

State and territorial health agencies have documented how small investments in prevention have yielded significant cost savings for medical treatment and lost productivity. Adequately funded programs are essential to make a health impact and to affect the bottom line. For example, state investments in tobacco control are directly correlated with a decrease in smoking rates. If every state and territory funded their tobacco programs at CDC’s recommended levels between1995 and 2003, there would be between 2.2 million and 7.1 million fewer smokers,¹³  saving the nation $20 billion to $67 billion in health care costs.¹⁴ The private sector shares a similar interest in reducing costs and promoting wellness among its workforce. ASTHO supports “making the business case for prevention” among health agencies and their external partners, by:

1. Educating policy-makers at the federal, state and local levels about the significant cost savings that result from only modest increases in prevention funding.
2. Educating private sector and insurance executives about the potential savings and increased productivity that can arise from employers and insurers promoting wellness and prevention.

4. LEAD BY EXAMPLE: SERVING AS ROLE MODELS FOR EMPLOYEE WELLNESS PROGRAMS 

State governments are the largest employer in many states; state and territorial health agencies have an obligation to set statewide examples by implementing comprehensive wellness policies; eliminating unhealthy food choices; and developing safe, healthy work environments. ASTHO supports the development of policies within health agencies that provide incentives to foster healthy environments at the workplace and in communities.

5. ENCOURAGING HEALTHY COMMUNITIES 

ASTHO supports state and territorial health agency efforts to:

1. Foster healthy communities through land use policies that include walkable/bike-friendly transportation design, mixed-use development, healthy food access and safe routes to school and work.
2. Work with community leaders, planners, transportation and developers to create mixed-use, healthy communities that are safe and accessible, have comprehensive tobacco free  policies and provide opportunities for physical activity and access to healthy foods for all populations.

CONCLUSION:  

Taken collectively, this prevention focus will significantly reduce the burden of disease and injury and will consequently result in optimal health for all, as well as a longer lifespan and healthier quality of life for succeeding generations. We envision a 21st century nation which prioritizes prevention and wellness; includes healthy environments, communities and lifestyles; provides, at a minimum, preventive and primary health care for every person; eliminates inequities in health status; and protects people and communities from existing and emerging health threats.¹⁵ 

Definitions: 

Social determinants of health: the economic and social conditions that influence the health of individuals, communities and jurisdictions as a whole.¹⁶ 

Health disparities: “A particular type of health difference that is closely linked with social or economic disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social and/or economic obstacles to health and/or a healthy environment based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation; geographical location; or other characteristics historically linked to discrimination or exclusion.”¹⁷ 

Health equity: “attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities.”¹⁸ 

Approval History
Prevention Policy Committee Review and Approval: November 2011
Board of Directors Review and Approval: December 2011
Ratified by the ASTHO Assembly of Members: December 2011
Policy expires: December 2014
ASTHO policies are broad statements of enduring principles related to particular policy areas that are used to guide ASTHO’s actions and external communications.

Related ASTHO Documents:
Policy Statements:
Health Equity Policy Statement
Position Statements:
A Transformed Health System for the United States in the 21st Century
Obesity Prevention and Control Position Statement
Tobacco Use Prevention and Control Position Statement
External Cause of Injury Codes Position Statement

Notes 

1. Centers for Disease Control and Prevention. Deaths: Leading causes for 2007. National Vital Statistics Reports. 2011; 59(8): 1-96. http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_08.pdf. Accessed Nov. 14, 2011.   
2. DeVol R, Bedroussian A. An Unhealthy America: The Economic Burden of Chronic Disease Charting a New Course to Save Lives and Increase Productivity and Economic Growth. The Milken Institute. http://www.milkeninstitute.org/healthreform/pdf/AnUnhealthyAmericaExecSumm.pdf. Published 2007. Accessed Oct. 28, 2011.
3. Finkelstein EA, Corso PS, Miller TR, Associates. Incidence and economic burden of injuries in the United States. New York, NY: Oxford University Press; 2006. http://www.cdc.gov/injury/overview/. Accessed on November 14, 2011. 
4. National Prevention Council, National Prevention Strategy, Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011.
5. Beadle MR, Graham GN. National Partnership for Action to End Health Disparities. National Stakeholder Strategy for Achieving Health Equity. Rockville, MD: U.S. Department of Health and Human Services, Office of Minority Health, 2011.
6. Office of National Drug Control Policy. National Drug Control Strategy. 2011.Washington, DC: Executive Office of the President.
7. U.S. Department of Health and Human Services. Ending the Tobacco Epidemic: A Tobacco Control Strategic Action Plan for the U.S. Department of Health and Human Services. Washington, DC: Office of the Assistant Secretary for Health, November 2010.
8. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004; 291(10): 1238-1245.
9. Centers for Disease Control and Prevention. Deaths: Leading causes for 2007. National Vital Statistics Reports. 2011; 59(8): 1-96. http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_08.pdf. Accessed Nov. 10, 2011.
10. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System [WISQARS]. Available at: http://www.cdc.gov/injury/wisqars/index.html. Accessed November 9, 2011.
11. Centers for Medicare and Medicaid Services. National Health Expenditures, 2010. https://www.cms.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp#TopOfPage. Accessed Oct. 28, 2011.
12. Centers for Disease Control and Prevention. Vital Signs – Prescription Painkiller Overdoses in the U.S. November 2011. http://www.cdc.gov/vitalsigns/PainkillerOverdoses/index.html. Accessed Nov. 15, 2011.
13. Farrelly, MC, et al. The Impact of Tobacco Control Programs on Adult Smoking. American Journal Public Health. 2008; 98(2): 304-309.
14. Campaign for Tobacco Free Kids (2008). Well-Funded Tobacco Control Programs Can Reduce Number of Smokers by Millions. www.tobaccofreekids.org/Script/DisplayPressRelease.php3?Display=1058.  Accessed November 15, 2011.
15. Association of State and Territorial Health Officials. A Transformed Health System for the United States in the 21st Century. Position Statement, 2008. Available at: http://www.astho.org/Advocacy/Policy-and-Position-Statements/A-Transformed-Health-System-in-the-21st-Century-Position-Statement/. Accessed Nov. 10, 2011.
16. Raphael, D. Introduction. In D Raphael (Ed.), Social Determinants of Health: Canadian Perspectives. Toronto: Canadian Scholar's Press. 2004.
17. Office of Minority Health. National Stakeholder Plan to Achieve Health Equity. Available at http://minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1&lvlid=34. Accessed on 5/18/11.
18. Office of Minority Health.