Encouraging trends in health promotion in the United States

Although the United States has long been a leader in many fields of biomedical science and medical technology, it has been slow to assume a similar role in promoting health. However, in the past two decades, particularly the last 5 years, two major developments have led to an expanded focus on health promotion in this country. The first development was an evolutionary change in the concept of health promotion. Early in this century, following the successful use of population-based approaches to assure clean air, clean water and safe food, the challenge to public health was to control infectious diseases. Efforts concentrated on medically driven technologies such as vaccinations and screenings, with followup medical treatment with a focus on disease prevention to reduce mortality and morbidity. In short, epidemiologic methods and data drove the practice of public health. Although community and school health programs existed, health education was seen only as a complementary strategy to the practice of clinical preventive medicine and the implementation of disease-specific public health programs. As die disease burden shifted from infectious to chronic diseases, public health continued to focus on disease prevention, and epidemiology remained as the principal science. However, in the 1970s an important change took place in health education; this discipline broadened from patient education to include intervention strategies designed to produce individual behavior change. During this decade a number of early governmental policy decisions were made recognizing that health behaviors were related to social and environmental issues. As a result, the goal of health promotion came to be defined as the absence of disease, with an emphasis on reducing risk factors by changing behaviors. Health education and health promotion were, however, not vigorously embraced by the United States government, but two events are changing the federal perspective. One was the advent of HIV, with no medical intervention available to prevent or control the infection. Only health education and health promotion strategies are effective in preventing the spread of the virus. The second event is the increasing realization that most deaths in the United States are preventable. For example, in a paper published in 1993 that received considerable attention from federal, state and local public health officials, McGinnis and Foege argued that the real causes of death are related to behavior or the environment. Tobacco and diet/inactivity account for more than 700 000 deaths, or 30% of total deaths, annually in the United States. Sexual behavior, use of antimicrobial agents, firearm use, drug and alcohol use, toxic agents, and motor vehicles are the other culprits. Indeed population-wide approaches aimed at reducing the effects of these behavioral or environmental factors could prevent as many as 70% of early deaths. Acknowledging and accepting the role that behavior and the environment play is a critical first step away from the medical model for those who are entrenched in that framework if they are to design comprehensive, multi-strategy intervention programs that will prevent disease and death.