By Dave A. Chokshi, MD, MSc, and Marc N. Gourevitch, MD, MPH
Achieving a threshold level of vaccination helps protect a population against an infectious disease. What could bring us closer to an analogous “herd immunity” for chronic diseases such as obesity and opioid use disorder? Prevention would have to be reimagined as something not delivered person by person, like vaccines, but instead through changes to health-related policies, the built environment, and our approach to healthful behaviors.
Community-level prevention complements clinical prevention but often adds the benefit of immediate population-level scale. For example, nationwide adoption of policies that raise the minimum legal age for the sale of tobacco products to age 21 years would reduce initiation of smoking among children and avert millions of years of life lost. Yet only 9 states have enacted this lifesaving policy.
Why are proven population-level preventive interventions like “Tobacco 21” still more the exception than the rule? Prevention is always a tough sell. Success is largely invisible, and it typically takes time before health rewards emerge. In addition, benefits infrequently accrue to the payer, and corporations with vested interests in unhealthful behaviors often oppose prevention initiatives. These contribute to the political challenges that typically accompany robust regulatory approaches such as smoking bans and soda taxes.
Even community-level approaches that skirt controversial policies usually require intersectoral coordination, which is difficult to implement. For instance, the Safe Routes to School intervention, which encourages student physical activity through active transport to school, requires alignment and action across education, transportation, and health sectors.
Another part of the problem is attentional. Dariush Mozaffarian, MD, DrPH, and colleagues point out that the 2018 Farm Bill encompasses $86 billion in annual food spending—far more than the combined budgets of the National Institutes of Health, Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration. Yet health opportunities related to the Farm Bill remain “hidden in plain sight”: despite far-reaching effects on diet-related diseases, health policy makers pay it little attention.
Similarly, the burgeoning dialogue around addressing social determinants of health tends to focus on “innovative” pilots over policy. A new app to locate food banks should not garner the same attention as proposed restrictions on food stamps, estimated by the US Department of Agriculture to affect 755 000 US residents, 88% of whom live below 50% of the federal poverty level.
Focusing on What Works
The challenge of scaling community-level prevention is not primarily a lack of evidence. The CDC’s Community Guide collates evidence-based findings of the Community Preventive Services Task Force (CPSTF); 141 interventions earned the rating of “recommended,” reflecting strong and sufficient evidence of efficacy. The Community Guide also tabulates economic reviews for all interventions deemed effective, marrying estimates of economic effectiveness with public health impact. In 2016, the CDC focused on 14 interventions with positive health impact, economic effectiveness, and results in a time frame of 5 years, known as Health Impact in 5 Years, or “HI-5,” ranging from access to clean syringes to clean diesel bus fleets. More recently, the Promoting Health and Cost Control in States guide outlines proven interventions for state-level policy makers.
New resources help city and community leaders set goals for local action. The City Health Dashboarda and County Health Rankings & Roadmaps provide localities with granular data to help prioritize which interventions to pursue for the greatest health gain. CityHealth approaches the problem from the other direction, zeroing in on 9 evidence-based policies, assessing whether the 40 largest cities have adopted them, and tracking year-over-year improvement.
Charting New Directions
Despite the strides made with respect to evidence, local uptake remains a patchwork. More can be done to spur widespread impact, as summarized in the following 4 recommendations.
First, though misalignment of financial incentives continues to hinder investments in community-level prevention, promising approaches exist. For example, the Centers for Medicare & Medicaid Services could tie enhancements in Medicare or Medicaid reimbursement to decreases in area-wide smoking prevalence, thereby incentivizing local health systems to partner with other sectors in achieving this important health goal. Care must be taken to avoid unintended consequences, such as penalizing those jurisdictions with fewer resources to accomplish community goals. “Backbone” organizations can also help solve intersectoral coordination issues. For instance, Prosper Waco provides a platform for nonprofits and community leaders to align around measurable goals for improving education, health, and financial security. Area-focused philanthropy can support similar backbone coalitions with “seed crystals” of funding, as the California Endowment is doing with its Building Healthy Communities program, attracting additional investment from sources like community development financial institutions.
Second, community-level prevention can be lifted up through tighter linkages with clinical prevention. The US Preventive Services Task Force (USPSTF) and the CPSTF already collaborate—for example, they release their annual reports to Congress concurrently. But greater alignment is needed to strengthen clinical-community linkages in a meaningful way and to better bridge health care and public health. For example, the USPSTF and CPSTF could issue joint recommendations on urgent prevention priorities, such as opioid use disorder. More broadly, clinicians could serve as important liaisons to policy makers on community-level prevention. The American Academy of Pediatrics (AAP) is a leader in this respect, with a muscular advocacy component, evinced by the organization’s policy statements on youth and sugary drinks or e-cigarettes, and poverty and child health. Clinical organizations like the AAP can help build intersectoral coalitions, as was seen across health, education, and agriculture with the passage of the Healthy Hunger-Free Kids Act in 2010.
Third, network science could be harnessed to accelerate the adoption of effective community-level prevention initiatives. Nicholas Christakis, MD, PhD, and James Fowler, PhD, describe this phenomenon: “People are placed at risk for bad or good health by virtue of their [social] network position, and it is to this position that public health interventions might beneficially be oriented.” Using this type of social network targeting, they demonstrated how to more quickly spread the use of multivitamins for nutrient deficiencies in Honduran villages. Network science holds promise as a powerful intermediate approach between person-directed clinical interventions and population-level community interventions.
Finally, framing community-level prevention more holistically offers a chance to access deeper partnerships and engagement by linking to other important local priorities. School-based violence prevention, early childhood education, and improvements in public transportation are all evidence-based community-level interventions that, while not focused primarily on health improvement, yield substantial health dividends. Reciprocally, they offer a chance to build coalitions beyond health care and public health, around a common pursuit of community well-being.
aDr Gourevitch serves as primary investigator for the City Health Dashboard.
About the authors:
Dave A. Chokshi, MD, MSc, is the chief population health officer of New York City Health + Hospitals—the largest municipal health system in the United States. He is a primary care internist at Bellevue Hospital and clinical associate professor of population health and medicine at the New York University School of Medicine. He also serves as a member of the board of directors of the nonprofit Primary Care Development Corporation. Twitter: @davechokshi. The views expressed in this post do not necessarily reflect the position of NYC Health + Hospitals or NYU. (Image: NYU Langone Health)
Marc N. Gourevitch, MD, MPH, is the founding chair of the Department of Population Health at NYU Langone Medical Center, where he is the Muriel and George Singer Professor of Population Health. The focus of Dr Gourevitch’s work is on developing approaches that leverage both health care delivery and policy- and community-level interventions to advance the health of populations. Dr Gourevitch leads the City Health Dashboard initiative, funded by the Robert Wood Johnson Foundation, to equip city and community leaders with an accurate understanding of the health of their populations, including its social, economic, and environmental drivers, to support population health improvement. (Image: NYU Langone Health)
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