HARNESSING THE FULL POWER OF THE FEDERAL GOVERNMENT TO PROMOTE GOOD HEALTH

Part of the Health Promotion FIRST (Funding Integrated Research, Synthesis and Training) legislation we have been advocating calls for developing a strategic plan for how to harness the powers of Departments of Transportation, Education, Agriculture, Commerce, and other departments of the federal government to integrate health promotion concepts into society¹. This is in addition to separate strategic plans we are proposing about how to develop the basic and applied science of health promotion and how to utilize the authority of the Department of Health and Human Services (HHS) to integrate health promotion concepts into health care and other elements of society. 

This proposed strategic plan is consistent with Executive Order #13266, issued by President George W. Bush on June 20, 2002, which directed the following: "The Secretaries of Agriculture, Education, Health and Human Services (HHS), Housing and Urban Development, Interior, Labor, Transportation, and Veterans Affairs, and the Director of the Office of National Drug Policy shall review and evaluate the policies, programs, and regulations of their respective departments and offices that in any way relate to the personal fitness of the general public. Based on that review, the Secretaries and the Director shall determine whether existing policies, programs, and regulations of their respective departments and offices should be modified or whether new policies or programs could be implemented. These new policies and programs shall be consistent with otherwise available authority and appropriated funds, and shall improve the Federal Government's assistance of individuals, private organizations, and State and local governments to (i) increase physical activity; (ii) promote responsible dietary habits; (iii) increase utilization of preventive health screenings; and (iv) encourage healthy choices concerning alcohol, tobacco, drugs, and safety among the general public." It further directed the secretaries to report their findings to the President within 90 days and to form a "Personal Fitness Interagency Working Group", composed of the Secretaries or Director of the departments and office and required them to meet no less than twice a year.²

Planning across federal government departments is important because these departments reach beyond the medical care and health related educational systems influenced by HHS to impact much of the rest of society. It is very clear that we need to impact many parts of our society if we are going to eliminate barriers to good health and create environments that truly inspire health. What are some of the barriers in society that make it difficult for people to practice lifestyles that contribute to optimal health? How might federal policies reduce those barriers? These questions are addressed below very briefly to give a sense of the issues that might be considered in the proposed strategic plan.

Societal Barriers to Health 

Access to Nutritious Food. Early in my career, while I was still a graduate student, I was volunteering at a free clinic. One day a single middle-aged mother of three came in and wanted to talk about problems she was having raising her kids. Despite the fact that she had dropped out of high school and had no formal training in nutrition, she was convinced one of the reasons her kids were so wild was the fact that they ate so much candy and fast food. She had decided the best diet for her and her kids was a primarily vegetarian diet consisting of fresh fruit and vegetables, whole grains, and beans. I was interested to hear this because I had recently made the decision to become a vegetarian myself. She told me it was hard for her to get these foods. With the pride of a young naive health educator, I told her I knew what she meant; most supermarkets did not really carry very good vegetarian foods. I told her about the produce market where I bought my vegetables and fruit, the hippie co-op where I bought my fresh bread, nuts, grains, and beans, and the supermarket I reluctantly visited for a few remaining items. . .all within bicycling distance of my house. She smiled as I spoke and even congratulated me for taking such good care of myself. Then she told me she did not have a car, and the last grocery store within a mile of her apartment had closed last year. The only store that sold food in her area was a liquor store, and their options were limited to party foods and a small selection of canned goods. I gulped, decided not to apologize and really started to listen to her. I had very little to share with her besides my attention, but she had a lot to teach me. Knowledge and motivation were not a problem with this women. Access to good food was the problem. How can federal policy help her have better access to fresh produce, whole grains, and other healthy foods?

Access to Exercise Options. Just last year, I was sitting on a bench in a mall a few miles from my house reading the New England Journal of Medicine. I was waiting for my wife and daughter to finish their shopping. An older woman, dressed a little different from everyone else at the mall, stopped in front of me, smiled and asked if I would mind if she sat down on the bench. I said "No problem" and went back to my reading. A few minutes later, she tapped me on the shoulder and asked if I was a doctor. She had noticed the journal I was reading. I still haven't figured out a short way to tell people what I do, but by the time I was finished she had a big smile on her face because she was excited about what she was doing. Ten months earlier, she had a heart attack. Her doctor told her that she would probably have another one unless she lost weight, changed her diet, and started to exercise. Her husband had a stroke a year earlier and she didn't want her daughter and son to be orphans. She quit smoking when her husband died, made a lot of improvements in her diet, and was finally starting to exercise. Every weekend she would take three buses from downtown Detroit (15 miles away) to get to this mall. She had tried to exercise close to home but the park, which was two blocks from her house, was dominated by drug dealers and prostitutes. Walking in her neighborhood was hard because a freeway cut through the blocks on one side of her house and the park was on the other side. She was also worried about the high temperatures in the summer and icy sidewalks in the winter. She loved walking in this mall because she could stroll along, watch the people, and look in the store windows. However, she did feel out of place, it was far from her house and expensive to get to on the bus, so she could come only once a week. What can federal policy do to help this woman have access to safe places to exercise or at least walk in her neighborhood?

Small Business. Virtually every large employer has a health promotion program and is well aware of the health, morale, and financial benefits of programs. Unfortunately, most employers are small. In fact, 89% of the 5,652,544 employers in existence in 2001 had 20 or fewer employees and 48% had one to four. Only .31% (three tenths of one percent) had more than 500 employees, .06% (six hundredths of one percent) had more than 2500 and only .02% (two hundredths of one percent) had more than 10,000 employees. The reality is most small businesses don't enjoy the economies of scale necessary to cover the start-up costs and overhead of a health promotion program. Furthermore, most health promotion venders don't make an effort to sell to businesses with fewer than 1000 employees because the revenue from the sale does not justify the time required to make the sale. What can federal policy do to make health promotion programs available to small businesses?

Schools. Ironically, schools, which are often equipped with gyms and other exercise facilities, often don't provide their students with sufficient exercise opportunities or provide healthy foods in their cafeterias. Physical education class schedules have been reduced and sometimes eliminated to make more time available for academic programs or to reduce the length of the school day. School cafeterias and vending machines often serve high-sugar and high-fat foods to maximize sales revenue or to fulfill revenue quotas they promised to soft drink venders. What can federal policy do to encourage schools to offer more opportunities for physical education and physical activity, encourage schools to offer nutritious foods in their cafeterias and vending machines, and make exercise facilities available to the community?

Impact of Federal Policy on Health 

It is clear that people and organizations need more than education programs, or medical coverage for health promotion services to enable them to practice a healthy lifestyle on a regular basis. What changes in federal policy are needed to improve these and other situations? The truth is, I really don't know. That is why we need a strategic study to figure this out. However, a number of innovative programs have already been proposed or implemented that illustrate the types of programs that might be proposed in a strategic plan.

Pedestrian and Cyclist's Equity Act (PACE) HR. 2568. This legislation, introduced by Congressman James Oberstar (D-MN), ranking Democrat on the House Transportation Committee would become part of the pending Transportation Equity Act Legacy for Users (TEALU) $375 billion, six-year budget for the omnibus transportation bill. It would use a small portion of the existing funds for this bill to provide $25 million per year for six years to fund grants to local, regional, and nonprofit agencies to develop plans on how to create environments that encourage active living; $250 million per year for six years to create programs, infrastructure improvements, a clearinghouse, and a national task force for safe routes to school; and $215 million over six years to create and evaluate three pilot active living communities.³

Fresh Produce for Schools. The U.S. government will spend an estimated $8.4 billion on school breakfast and lunch programs in 2004⁴. Although these funds must be spent on foods that meet specific federal nutrition standards, those standards are so broad that catsup counts as a vegetable. To provide better access to fresh fruit and produce, Senator Harkin initiated legislation that created a provision in the Nutrition Title of the 2002 Farm Bill (passed every six years) to provide $6 million per year to fund a pilot effort to provide free fresh fruit and vegetables to students in 107 schools in four states and one Indian reservation.⁵ The pilot has worked well and may be expanded to all 50 states. 

These are just two examples of what are likely to be many innovative strategies that can be developed by tweaking existing federal funding for existing federal programs to have a significant positive impact on health. The reality is the 15 departments and 17 other offices and agencies of the federal government will spend approximately $2.2 trillion in 2004.⁶ We need to know the impact of these programs on health and how they can be modified to enhance health. To do this we need to answer the following questions:

1.  How can the $74 billion annual budget and the programs of the Department of Agriculture be leveraged to provide fresh produce, whole grains, and other healthy foods to inner city, isolated rural populations and all other populations?
     
2. How can the $59 billion annual budget of the Departments of Education be leveraged to provide physical education for all school children on a regular basis, integrate positive health messages in the community, and make exercise facilities available to the community? 
     
3. How can the $11 billion annual budget and the programs of the Department of the Interior, the $37 billion annual budget of the Departments of Housing and Urban Development, and the $54 billion annual budget of the Department of Transportation be leveraged to help build communities that stimulate active transportation options, safe and cohesive social relationships, and provide outstanding recreation opportunities? 
     
4. How can the collective $65 billion annual budget and the programs of the Departments of Labor, Commerce and the Small Business Administrative be leveraged to help all employers be aware of the benefits of health promotion programs, make programs available to all workers, and support the growth of the health promotion industry? 
     
5. How can the $10 billion annual budget and the influence of the Departments of State be leveraged to spread the health promotion concept globally? 
     
6. How can the $58 billion annual budget and the programs of the Office of Personnel management be leveraged to provide outstanding health promotion programs for all federal employees? 
     
7. The Department of Treasury oversees the Internal Revenue Service, the Secret Service, U.S. Mint, Bureau of Alcohol, Tobacco & Firearms and other functions and has an annual budget of $392 billion. Our interest is not in this operating budget, but in the tax policy it implements. What changes in individual or corporate taxes would enhance health practices? 
     
8. How can these departments work together synergistically to create a healthy nation? That is the primary question that must be answered by the strategic plan we are proposing.  

If we can harness the powers of these departments, as well as the Department of Health and Human Services, we can create a nation that provides excellent health and medical programs to encourage healthy lifestyle, and environments that provide opportunities to practice and maintain these behaviors. If we focus only on Department of Health and Human Services, we will have excellent educational and medical programs, but environments that continue to motivate people to practice destructive lifestyles.

References 

1. Health Promotion Advocates. Available at: http://www.healthpromotionadvocates.org/. Accessed January 20, 2004. 
2.  The White House, Executive Order Activities to Promote Personal Fitness. Available at: http://www.whitehouse.gov/news/releases/2002/06/20020620-4.html. Accessed January 16, 2004.
3. Pedestrian and Cyclist Equity Act of 2003 HR 2568 IH. Available at: http://thomas.loc.gov/cgi-bin/query/z?c108:H.R.2568. Accessed January 20, 2004.
4. Joe Richardson, Child Nutrition and WIC Z Programs: Background and Funding, CRS Report for Congress, January 6, 2004, Domestics Policy Division (Order Code RL 31577).
5. Guthrie JF, Kantor LS. Evaluation of the USDA Fruit and Vegetable Pilot Program: Report to Congress. Jean C. Buzby, Economic Research Service, May, 2003.
6. Budget of the United States Government, Fiscal Year 2004, Office of Management and Budget. Available at: http://www.whitehouse.gov/omb/budget/fy2004/. Accessed January 16, 2004

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