Secretary's Council on Health Promotion and Disease Prevention Objectives for 2010

DR. FOX: Yes, one of the things that happened, when I knew I was taking the job in ODPHP, was I started asking people about the Healthy People process outside of public health. I found a number of people who obviously didn't know anything about it, although we have a lot of groups engaged. So one of the thoughts was how do we get the broader community involved.

DR. BOUFFORD: It's a good intro for you, our most visible spokesperson. How do we get the broader community in Healthy People? Welcome, Madam Secretary.

DR. SHALALA: Thank you very much. I'm sorry I couldn't join you. Hi, Phil. I saw Julie on the way out, he said it was a good meeting, so I guess we all passed.

First, let me apologize for not joining you earlier, but everything is happening today. Earth Day starts tomorrow. It's National Immunization Week, and North Dakota is in serious trouble. Let me just urge you to continue the conversations, but I wanted actually to thank Julie and Monty and Bob Windom and Phil because each one of them has played a special role in getting us to this point. We all intend to be around in 2010, so getting this work done is extremely important.

I think that, because of this work, we are focusing on things like what we did today, which is immunization rates. We now have the highest immunization rates in history and infant mortality rates at all time lows, so it's that and all the other things we're going to be doing. But you want to talk about expanding--

DR. BOUFFORD: Earl was just going to give us an intro, one of the issues is that, sort of, corporate America or business has not been involved. There have been members, and there have been Consortium members, but you've been really pushing the issue of getting the entertainment community, for example, to deal with the issue of images, healthy images, unhealthy behaviors. Maybe you could talk a little bit about that, because it could open it up to, really, people's thoughts about--there are some conflicts about the pharmaceutical industry, the tobacco industry, et cetera--but how to structure something so that it doesn't appear to kind of pollute the science base, if you will, of objectives. Clearly it's an arena. We were just talking about resource problems and data, which is another issue close to your heart.

DR. SHALALA: Well, just to give you a feel for--Phil and Jo know that from the moment I came in here, I tried to abolish brochures. This brave new world out here, getting health information to people is not going to be done through brochures. We just put our web site up for all health information in the Federal government. It's called healthfinder(tm). There were two million hits between last Tuesday and today, a million and a half, I think, in the first 48 hours or so. Forty percent of all the people who use the Internet are looking for health information. That gives you some sense of where we need to go.

My campaign has been to integrate health messages into the shows that people watch. It's not that I am absolutely opposed to public service ads, but I actually think that people are about as immune to them as they are to a lot of the other ads that are on television. So we have done our best distribution of AIDS information through soap operas, worrying about character development in soap operas, in sitcoms, in shows that millions of people watch. And getting those writers to incorporate very clear health information is far more effective in reaching millions of people than brochures or posters or the more traditional--or even school education programs, where the kids' eyes glaze over.

I took a theater production from rural Idaho to a local inner city high school. It was a public health show that our rural health people had contributed to with the NEA, and it was basically a play. The kids at our high school saw about 20 minutes of it, and it was a play about teenage pregnancy and drug use. Here was a play written specifically for rural America and the urban kids got it. In fact, the actors said that the urban kids were far more responsive. They were responsive because it was interactive and very effectively interactive, even though everybody up on the stage--it was basically an African American high school and all the kids in the play were rural youth. There were some things that were clearly different than in the inner city. They really got into it and got the messages.

The business community also, as part of other kinds of activities--if you get on Delta Airlines for an overseas flight now, they give you an exercise card of what you can do -- at least they do in business class.

[Laughter.]

But they give you a card, actually, of exercises you can do. I was on Air France and they actually put on the film so you could do exercises while you were on the plane.

The business community, if they're creative enough --I now go into hotel rooms where they not only tell you about the health club, but they have a list of things you can do in the room, including hooking your toes on the edge of the bed, in terms of exercises. There's more information on menus now when you go into restaurants.

There are a variety of different ways in which business can integrate healthy lifestyles and get the word out, and do more work with employees.

DR. BOUFFORD: How did they respond when you met with them--the entertainment community, as such? I mean, you've had a couple of meetings. We were talking about the issue of self interest versus social responsibility. How do you give the message that they ought to get concerned?

DR. SHALALA: My sense is that they all nod their heads and then you've got to make it hassle-free. In fact, I've been urging a couple of foundations to get together and create an institution, an actual organization, that does nothing but deal with the writers and the programs, because we do this very haphazardly.

We have a number that any writer can call to get public health information. They can get our 800 number. We will put them in touch with an expert on the subject that will help them with the script. We've actually reviewed scripts for shows like ER and Chicago Hope. And we have sent script ideas to the Chicago Hope people, for example, and to the ER people that is subject matter that they might cover as part of their shows. The business sponsors--one thing that they tell us is, the sponsors, the advertising sponsors like those shows, because they think that they're socially useful, in addition to being entertaining.

My philosophy for the wider community is, shove in health information wherever you can, but don't think that you can always do it directly. What we have to do is creatively find different ways of doing it. I have long believed--and I believe sometime in the next year, we will see a new organization emerge that will work directly with the entertainment industry and specifically with the script people. We've gotten a lot of movement on breast cancer, obviously. And with special shows about someone who had breast cancer, there will be millions of people that watch it. It's better to get it into ongoing sitcoms where they have huge audiences, or into soap operas. I happen to think that the soap operas are huge communicators.

When I was in South Africa--they watch American soap operas. They're convinced that a lot of the information on AIDS was transmitted through American soap operas, in terms of how it was transmitted. I guess I'm a great believer that, every time you turn around, you ought to get the information, one way or another, on some aspect of something.

DR. DUVAL: I would of course compliment the Secretary for going in this direction. I would say that, for those of us who have been monitoring some of these things, considerable progress has already been made in some regards. You remember the Johnny Carson, for instance, issue of smoking. He constantly smoked on the Tonight Show and he was persuaded not to smoke on screen. Sometimes you could see the smoke coming up over the screen, but he stopped it. If you go to the movies today, generally speaking, you don't see smoking the way you did in the Humphrey Bogart days.

DR. BOUFFORD: It's coming back, though.

DR. DUVAL: It may be coming back, and certainly in independent film channels.

[Laughter.]

I think the direction is the right direction, and I certainly would compliment you for going in that direction.

I also think that we have not paid quite enough attention to whether they can serve as a medium, rather than an endpoint themselves, in looking at other industries. I was, and I won't give you the background on it, but you might wish to notice for instance how much advertising is being done today by Anheuser-Busch that says, in effect, we will not sell to a minor. I think that is superb.

DR. SHALALA: The Spirits Council, as well as the beer people, have been in here a number of times to show me what they're trying to do in terms of--they're also trying to stay on television at the same time. But they are doing some of that.

The baby food companies, for instance, have been terrific on certain kinds of messages. Our Back to Sleep Campaign for SIDS is now being run by Gerbers. They were so sophisticated that they picked out--our problem with SIDS now is in the African American community getting babies on their backs. The Gerber people looked at their marketing studies and picked the products that are bought in the African American community, specifically rice, and used their rice box, the Gerber baby rice box, to send the message on the SIDS Campaign.

The athletic apparel industry is increasingly interested in our Surgeon General's Report on Fitness and are putting out information. As you well know, breast cancer has gotten a lot of activity from the cosmetics industry, as well as hosiery and other kinds of things.

DR. DUVAL: I wasn't quite complete, and I wondered if I wouldn't add also the insurance industry, which sometimes is an enemy and sometimes it's a friend. But their development jointly between the ACLI and the HIAA, or the so-called Partnership for Prevention, has been quite extraordinary. The number of private businesses that are supporting immunization now has grown as a consequence of that activity. I think they're doing a remarkable job. I think that's the kind of thing that should be added to your consideration.

There is also the so-called WELCOA, the Wellness Councils of America, that have probably not been given the attention that they deserve. That also incidentally arises, or originally arose, from the insurance industry. But it has local chapters now in, I don't know, 150 cities of the United States where they have brought together businesses to determine what we can do about the health in our communities. These are all private. They are doing something about it. I just don't think that we should sit still, shall I say, at HHS. Not only acknowledge it, but take advantage of the levers that they bring you into the private community.

DR. SHALALA: I agree with that. My sense is that --and I will be interested in your comments--my political position in the Department is that I might be beating on the insurance industry on quality issues on the health care side. That doesn't mean that I won't work with them on the Healthy People 2010 Campaign, that they can maintain those kinds of relationships as well as anyone. Even though FDA is approving a lot of these products, we still work with all of the companies on these kinds of campaigns. So we really welcome the business community's involvement and sponsorship, with the single exception of the tobacco industry, where we really can't get involved.

DR. FOX: Madam Secretary, I might mention that we are now scheduled to go meet with the board of WELCOA. They have been involved with us, and we also, I think, have been able to get Robert Wood Johnson together with the Partnership for Prevention, and they're going to fund, it appears, a Business Advisory Council, that will be made up of private business leaders, to work with them, and with us, on thinking through where we need to go with getting prevention and the Healthy People 2010 into the business community. I think that's on track, so that, hopefully, will bear some fruit as well.

DR. SHALALA: My biggest concern is the logo problem, and that is that people don't know what Healthy People 2000 is. They know what these various campaigns are. Somehow we've got to throw the Healthy People 2010 or 2000 now onto everything we do, every publication, so that it's connected to every publication, no matter what the publication is, whether it's a Surgeon General's Report, or an individual report. It's just got to be more closely identified.

DR. DUVAL: I've got two Healthy People 2000 T-shirts that came from the big announcement, which incidentally Julie Richmond referred to earlier when Lou Sullivan conducted the announcement and the introduction of the big program, for which there was no follow-up. But my wife and I--my wife used to be with ODPHP--and she and I wear our Healthy People 2000 T-shirts. But I think we've got to get a little bit broader message out there than that.

DR. SHALALA: Bob.

DR. WINDOM: We had spoken earlier about the fact that organized medicine is not involved much with public health. It seems there's been a separation for years. In order to enhance some of this public information, and like you were saying, get the visibility out--the tremendous number of medical journals. What I was thinking earlier-- and I mentioned it to Julie, too, before he left--but here you've got four of us just breaking into the regions, for example. Southeast is where I am; he's southwest. Julie is northeast; he's far west. If you say have, say, monthly in the different journals, a release with the logo and, say, Dr. DuVal is from the southwest, and put in the publication, representing Secretary Shalala, talking about a tip of the month on a certain issue where we are, and bring those things out over and over and over, I think it would be very important.

DR. SHALALA: I was wondering whether we could talk the USA people into, since they're the only really national newspaper we have, into really doing a box once a week that says Healthy People. That really is a matter of the communications people negotiating that, because they do all that fact stuff.

DR. WINDOM: JAMA--when I was here, I wrote a column in every issue of JAMA.

DR. SHALALA: JAMA actually will do it.

DR. LEE: Donna, one area that you haven't mentioned are HMOs. You've done a lot to move that forward in terms of partnership with not only CDC and the other parts of the Public Health Service, including, to some extent actually, NIH beginning to look at that area. Would you want to say a word about where you think that can go or what more any of us might do to foster that, because at least CDC has now got extensive relationships that are very positive?

DR. SHALALA: We have extensive relationships with organized care, in large part, because we're their banker. I believe that the Department has to--and that's why the launching of this is so important. If I had been here earlier, instead of getting pulled off on North Dakota, I would have said to you, the Department needs to use its muscle as the thousand pound gorilla, its purchasing power--

DR. LEE: You gained 200 pounds--

[Laughter.]

DR. BOUFFORD: Eight hundred is HCFA and 200 is the rest of the Department.

DR. LEE: We're now up to 1000, Sally.

DR. SHALALA: --needs to think of itself as buying something. We need to by, both the prevention and the goal part of this. I think that, increasingly, rather than thinking of ourselves as so traditional in the system, we need to use our muscle, because once we do it, then everybody else comes along. We're such a large part. If we and Defense and Veterans Affairs can get together in terms of this agenda, we simply take the private marketplace with us, because we impose such a huge effort. It seems to me, John, that that's also part of the quality movement.

DR. DUVAL: I think, Phil bringing up various and sundry managed care organizations, and you have also Jo earlier today, it is well--

DR. LEE: I only bring up the good ones.

DR. SHALALA: The Californians--if Vladeck was here, we would have him and Phil going at it.

DR. DUVAL: And something productive could emerge from that.

[Laughter.]

One of the things I'm concerned about--I'm from a State, specifically Arizona, where the penetration now is such that approximately 80 percent of all the people are covered in some managed care--I think it's either one or two in the country. I'm very impressed, as you deal with managed care organizations, that if you want to get them involved, for instance in Healthy People 2000 or 2010 objectives--if it's going to cost them any money, they won't do it unless it's offset by some kind of an economic return. Under the circumstances, I won't say that they are not interested. I am simply saying that they will be a more difficult audience. The delivery system has changed in the United States so substantially that some of those things that we talked about doing for the year 2000 objectives may not actually be useful in approaching the 2010 objectives, part of which incidently goes back to the data conversation we had earlier, because much of the data that you may want from the delivery system today is going to be considered proprietary. It's going to be harder to get as soon as you move out of the public sector.

DR. SHALALA: That will be part of our dilemma because we're not going to be able to do research unless we loosen some of this up.

DR. BOUFFORD: You can stay until the end. We were going to wrap up, but it's been very helpful.

DR. SHALALA: It's very nice to see you all. I apologize again for not getting in.

DR. BOUFFORD: It's good to know we have your support for all these things we've got cooked up for you to do.

Just other comments on the business piece, because I think you can see from our Secretary that she got the message. She's been leading us in this direction, really involving a much wider network from what we're doing.

DR. LEE: Jo, a useful tool is the Cost Effectiveness of Health and Medicine Panel Report for Business specifically because they are interested in the bottom line. That panel report really is state-of-the-art of where we are, and I think there's a good summary that's been put out on it and, of course, there's the book itself and a planned conference. I mean, there's a series of things. I think this can be a very useful tool for us with big business on the point that Marty is making about the bottom line.

DR. BOUFFORD: Yes, I think that's right. I was invited to be a Fed in a group of medical directors of corporate purchasing organizations and sort of big corporate providers. The medical directors--many of whom, in fact, interestingly, are public health professionals--were saying I've got to be able to tell my CFO that it's going to be worth it to them to invest in these preventive steps. If I can prove it, they will give me the money. It was just that kind of pleading, but also many of them had no idea what kind of databases we had or what kind of research base. I immediately sent them all this material, but I think it's part of this networking in the right places, because there are people looking for the data.

DR. DUVAL: But there is an example of the kind of thing that doesn't cost them anything and could save them money and could have an enormous impact. And that is, for instance--supposing private employers in the United States said to young people, you understand, don't you, that, if you smoke, we won't employ you? Nothing illegal about it. I wrote a letter to the editor of our major newspaper citing this as something private industry can do. Three immediately came forward and said, we're adopting this. See? That has impact of a type that telling a youngster that, 45 years from now, they may have a carcinoma of the lung--no interest. You've got to strike their value system. I'm saying that I think private industry is mobilizable and it could hit the bottom line favorably, not unfavorably.

DR. BOUFFORD: Bob.

DR. WINDOM: In our State, we have a council of 100, and I presume most States do, of the leading business CEOs who get together on a regular basis, an organization. If we could go there under some auspices of the Department and sell ourselves as coming to talk about this issue, I think we could have some clout and also mobilize some of their response.

DR. BOUFFORD: Obviously, Chambers of Commerce also are places where people come together.

DR. FOX: Let me just mention this business advisory council that would hopefully be funded through RWJ and be under the focus of health prevention. I think the real intent of that is that, one--it would help us think through both to set the framework, the objectives, and do it before we get the whole thing planned. I think, if we want them to use it, we've got to get them involved now. The second is that we want them to help us think through how we can expand the Consortium and bring in other business groups that we don't have. We only have 31 on the current Consortium. There's some who might argue--we have the Salt and the Sugar Institutes, and you could argue about their objectivity in Healthy People 2000.

But then, the final thing is to really also engage them in the dialogue around prevention. I think there may be other agencies that this group might be useful to as well, not just ODPHP, but the Department as a whole in trying to think through how we can get the broader business community to adopt prevention strategies and to do things that will propel along prevention as well as Healthy People 2010. That's really what we hope will come out of this advisory body. So it should be a real interesting endeavor.

DR. WASSERMAN: Just one comment. Every time I've gone to the business community and talked prevention, if anything, the words that they make me respond to are--you have to use the words productivity and profitability when you deal with them. So I just leave that as a message, that until I can show them that what I'm offering them has some payoff to them, they just don't listen. They said, take profitability and productivity, so I say it, but if I can't back it up, and I haven't been able to back it up sufficiently to get sufficient support out there....

DR. BOUFFORD: It's one of the interesting issues, I think, if you look at--obviously, the big bang is, obviously, the national businesses--but at the local level, there actually is a lot of business interest in social responsibility and the community service dimension, I think, that may be actionable at the local level, that may not be at the level that you're talking about. So we will see. I appreciate the first message.

DR. WASSERMAN: They will do it if it's profitable.

DR. BOUFFORD: Well, if it makes them look good, too, for local customers. That's one of the problems with these national companies, that it's not local.

DR. BLUMENTHAL: I just want to say that I think--in going into a meeting like this--being armed with some of the health economics data on cost benefit, I think, would be very helpful. We have a lot of that data, so I think it is a point....

DR. BOUFFORD: One of the issues, too, is to identify companies that have good practice to share with each other and to show how it makes a difference in their workforce in terms of productivity.

DR. FOX: That was my comment to you, Marty. One of the things we want to do with this advisory committee is really let them sell the rest of the community. We're using groups like the Washington Business Group on Health, and some of the others, to ask them to identify corporate entities in this country, and individuals, who have been very proactive in this area and then can turn around and make the case, so we don't have to make the case to the rest of the business community. I think that's something that we would hope to achieve with this group.

DR. BOUFFORD: I'm going to sort of wrap it up-- yes, Bill?

MR. BENSON: I was just going to say, in Illinois, we have a Business and Aging Leadership Roundtable that consists of a number of representatives from the business community, even several Fortune 500 companies, organizations that particularly have had an interest in elder affairs issues, less from a marketing standpoint, more from a worker standpoint. I think this is a group that would be one that we could probably tap into here, some very responsive folks, frankly.

DR. BOUFFORD: Ed.

DR. SONDIK: It's also about what should be in the document, I think. We need that kind of information in the overall document. I guess it makes it, if you will, a strategic document, in the sense that it musters those arguments.

DR. BOUFFORD: It's back to this audience question of multiple audiences.

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