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8 Advocacy and Resource Allocation The Capitol Building in Washington, DC. xxcheng/iStock/Thinkstock Learning Outcomes After reading this chapter, you should be able to Differentiate between advocacy and lobbying. Explain the use of data and media for public health initiatives. Examine the importance of resources in public health advocacy. This chapter highlights the importance of public health advocacy and resource allocation. In fact, public health professionals use advocacy far more often than lobbying. It is rare for public health professionals, particularly those working for health departments, to lobby at all. While lobbying and advocacy are closely related, lobbyists are paid professionals and advocates are not. This chapter will discuss the key differences between lobbying and advocacy and examine the purpose behind public health’s use of one versus the other. Public health data is used for both advocacy and media attention. While this chapter focuses more on advocacy work, it is important to recognize that advocates can receive evidence from data that supports their side of an argument or their point to enact a policy. This chapter will explain some of those uses, in addition to examining resource allocation and its importance to the public health realm. 8.1 Effecting Change in Public Health The terms advocacy and lobbying are often used interchangeably, but they are distinctly different. Advocacy seeks to affect society—to change a belief or behavior, or convince individuals to act or not act on an issue. Lobbying is typically an act by special interest groups or industries to attempt to convince Congress to enact legislation on a particular topic. In public health, it is rare to find a lobbyist. While individuals in the role are important to effecting change in legislation, public health finds itself more aligned with initiatives to create change in population behaviors, regardless of whether the initiative is a law or a recommendation. In this regard, advocacy work is the key, and one of the most important elements, for successful public health endeavors that reach large populations. The Role of Research Research into health issues can often translate into advocating for improvements in the public’s health, from developing healthy eating habits to eliminating behaviors that can lead to poor health. For example, it wasn’t until piles of research finally uncovered the link between smoking and cancer that public health professionals advocated for tobacco control (see A Closer Look). When the law was proposed, lobbyists would have likely come from tobacco companies to oppose it because it would affect sales. In this case, advocacy was focused on simply changing the public’s behavior through regulation of any sort, while lobbying focused on specifically stopping the passage of the particular act. A Closer Look: The Family Smoking Prevention and Tobacco Control Act The Family Smoking Prevention and Tobacco Control Act is considered the most comprehensive federal initiative against smoking since 1971, when radio and TV advertising for tobacco products was banned (Manz, 2009). What drove the act into existence was research that showed the following staggering statistics in 2009: 21% of American adults smoke cigarettes 23% of high school students smoke cigarettes 438,000 deaths each year can be attributed to smoking A stack of cigarette packs with visible surgeon general’s warnings. Stock Connection/SuperStock One of the requirements of the Family Smoking Prevention and Tobacco Control Act is that manufacturers provide information about the ingredients in tobacco products. Where did those statistics come from? Public health research! As research continued to show smoking caused poor health issues, including death, so did advocacy efforts to make a rapid and positive change. Advocates from numerous agencies, including the American Public Health Association, American Cancer Association, and American Lung Association, campaigned for stronger controls on tobacco. In a collective effort, these advocates wrote letters and attended meetings and official briefings in front of legislators across the nation. While that may appear similar to lobbying, the advocacy methods used did not necessarily support any legislation. Lobbying efforts, on the other hand, would have specifically asked Congress to pass that particular law. And it is likely that some lobbying efforts were done in that regard. The advocacy efforts were simply for stronger policies on tobacco control. The end result was this act. Another driving force behind the law was the “endless series of multimillion-dollar lawsuits filed by individuals against major tobacco companies” (Manz, 2009, p. 2). Furthermore, Medicaid, health insurance for low-income individuals in the United States, was footing the bill of more than $360 billion for more than 25 years of treating illnesses from tobacco use (Manz, 2009). Considering that Medicaid is paid by the tax dollars of all Americans, it was a significant chunk of money for U.S. residents to pay—whether they smoked or not. Thanks to the advocacy work of public health professionals as well as nonprofit organizations vested in smoking cessation (such as the American Lung Association), there is now regulation on the manufacturing, distribution, and marketing of tobacco products. The act does the following: Restricts tobacco marketing and sales to youth Bans sales to minors Bans vending machine sales Bans free giveaways of sample cigarettes for promotional purposes Bans tobacco-brand sponsorships of sporting, entertainment, or cultural events Requires smokeless tobacco product labels that contain four key warnings: Can cause mouth cancer Can cause gum disease and tooth loss Is not a safe alternative to cigarettes Is addictive Ensures “modified risk” claims are supported by scientific evidence (companies cannot state their product is “light,” “mild,” or “low” without filing a modified risk tobacco product application) Requires disclosures of ingredients in tobacco products Preserves state, local, and tribal authority, meaning that these entities are the authorities over their specific jurisdictions Sources: Manz, W. H. (2009). Congress and the tobacco industry: A legislative history of the Family Smoking Prevention and Tobacco Control Act of 2009. Retrieved from https://www.wshein.com/media/brochures/69124.pdf?d=20171021 U.S. Food and Drug Administration. (2018). Family Smoking Prevention and Tobacco Control Act – An overview. Retrieved from https://www.fda.gov/TobaccoProducts/Labeling/RulesRegulationsGuidance/ucm246129.htm Who Advocates? Who advocates for public health? That question could be answered by two simple words: nearly everyone. However, there are specific individuals and groups that advocate for specific elements of public health. At the individual level, the most common acts of advocacy come in the form of protests and letters. One example is pride parades, which celebrate the community of the LGBTQ population and are a statement of equal rights for this group—especially health. Pride parades are annual events across the globe that bring awareness to the inequalities and disadvantages experienced by LGBTQ persons. According to Guinness World Records, the 2006 Gay Pride Parade in São Paulo, Brazil, was the largest pride parade ever held, with an estimated 2.5 million participants (Ukrop News 24, 2016). Whether intentional or not, the efforts of these individuals coming together comprise an advocacy effort. See Spotlight on Public Health Figures for an example of an advocate who sought to improve the quality of life for African-American communities. Spotlight on Public Health Figures: W. E. B. Du Bois (1868–1963) W. E. B. Du Bois in 1918. Underwood Photo Archives/SuperStock W. E. B. Du Bois was an advocate for basic civil and human rights for Black communities in the United States. Click each of the questions provided to learn more about W. E. B. Du Bois. Who is W. E. B. Du Bois? William Edward Burghardt Du Bois was born in 1868. He was the first African American to earn a doctorate degree from Harvard University. Although his skin color was considered “black,” he was mixed race and was able to attend schools with Whites during a time when most schools were segregated. It wasn’t until long after his education that he discovered most Blacks across the nation were treated quite differently. This unfair difference compelled him to study the issue of equality and advocate for equal rights. He died at age 95 in 1963. What was the political climate at the time? The Jim Crow laws, a racial caste system that separated people by color, pervaded the southern states during Du Bois’s time. Although Lincoln had long ago freed the slaves, Black people had very few rights, including basic human rights. They were considered second-class citizens. The Jim Crow laws legitimized racism against Blacks, under a very rigid series of anti-Black laws primarily found in the southern and southern border states. The political realm supported them through pro-segregation speeches. Blacks who violated the Jim Crow laws were subject to personal violence, typically in the form of lynching. Lynchings were often public, the murders of Black people were not considered vicious crimes, and the criminal justice system favored Whites regardless of the situation. What was his contribution to public health? Once he learned about the Jim Crow laws and the poor treatment of Blacks, Du Bois began to serve as an advocate for civil rights. He founded the Niagara Movement, which was an African-American protest group of scholars who focused on advancing the rights of Blacks. He was also one of the founders of the National Association for the Advancement of Colored People (NAACP) and served as its director for several decades. Furthermore, he wrote a significant number of works detailing the inequities of Blacks in a world where slavery was illegal. Among his most influential works on Black health was The Philadelphia Negro: A Social Study, published in 1899. Du Bois devoted all of his efforts to gaining equal rights for Black people—which improved the overall health of the population (especially in the South, where large populations of Blacks resided). What motivated him? Brought up in a predominantly White neighborhood, he had never encountered racism until he moved to Nashville, Tennessee, in 1885 to attend Fisk University. It was there that he first learned about the Jim Crow laws. Once he learned of this discrimination, he felt motivated to do something about it. This prompted his activism for equal rights for Black people. Sources: Biography.com. (n.d.-c). W. E. B. Du Bois biography. Retrieved from https://www.biography.com/people/web-du-bois-9279924 Ferris State University. (n.d.). What was Jim Crow. Retrieved from https://ferris.edu/jimcrow/what.htm National Association for the Advancement of Colored People. (2018). NAACP history: W. E. B. Du Bois. Retrieved from https://www.naacp.org/oldest-and-boldest/naacp-history-w-e-b-dubois/ At the group or organizational level, there are specific groups of people who advocate under a single name for a cause. In public health, a good example is the American Public Health Association, which actually writes letters, visits politicians, and focuses on activities that lead toward improved health outcomes. The APHA has advocated for cities to become smoke-free through its speaker network as well as formal letter-writing campaigns. Most organizations that advocate for public health are nonprofit organizations with a charitable purpose. Charitable groups are not supposed to engage in paid lobbying; therefore, they focus on advocacy. At the committee level, there are groups that focus only on advocacy and, in some cases, lobbying efforts for a cause. For public health, these are often political action committees (PACs) that work toward defeating candidates with opposing views. For instance, a PAC was developed to represent gun and firearms issues through the National Rifle Association. PACs often lobby rather than advocate, as they are focused on the passage or elimination of legislation. Governmental agencies are typically barred from advocacy or lobbying work. These are the organizations that enact the policies and legislation that others lobby/advocate for or against. However, in terms of taking a stance, governmental public health organizations can use media outlets for educational purposes. Consider the CDC’s focus on prevention. Through its National Prevention Information Network, the CDC can “advocate” for healthier behaviors to improve population well-being. Activities include education on immunization, smoking, and HIV/AIDS awareness (CDC, n.d.-d). Policy Advocacy Policy advocacy promotes or defends a position, person, interest, or opinion. The act of policy advocacy is very closely aligned to lobbying, and it is under this definition that lobbying and advocacy efforts are interchangeable. The International Centre for Policy Advocacy (2014) has outlined several strategies that policy advocates use to preserve, remove, replace, or revise a policy: Pressuring decision makers for a policy. This may be the local, state, or federal legislators who have influence over a particular law or policy. The idea is to focus on the decision makers in all advocacy efforts. Pressuring those affected by the policy to take action. This area involves using the public as a means of communicating to lawmakers about their concerns. This type of effort typically involves a multitude of mass communication efforts to garner support for a particular project. Building a coalition of community members to carry out the direction of the advocate. In this strategy, a small group of community members collectively focuses on influencing the outcome of a policy. Typically, an organization will take multiple approaches to effect policy. This would include a little bit of all of the aforementioned strategies, and more. One of the most critical pieces for advocates to maintain is an understanding of the decision-making process. It’s not a simple job to just write a letter or have a face-to-face meeting; it is about understanding how decisions are made and how to effect those decisions at the right time. Public health professionals have been trying for years to reduce the smoking incidence and death rates through advocacy. While it may seem obvious to some that removing cigarettes and other tobacco products from the market would eliminate the problem, it is not that simple. In fact, even asking for more governmental regulation wasn’t that simple. It took until 2009 to pass the law (as highlighted in A Closer Look: The Family Smoking Prevention and Tobacco Control Act). Why then? The timing was right. There are a number of ways to predict when an advocacy effort will be influential or fall on deaf ears (International Centre for Policy Advocacy, 2014). The first is when new evidence comes forth to set the agenda for meetings. This does not mean regular evidence of issues, but rather new research. Two key pieces of information that helped drive the passage of the smoking regulations in 2009 were new and astounding: 438,000 deaths each year could be attributed to smoking, and $360 billion in Medicaid dollars had been spent for smoking-related treatments over 25 years. (Education plays a role in identifying new findings and creating public interest in public health. See Spotlight on Public Health Figures for more about one individual who helped make such topics more accessible to citizens.) Second, new technologies and trends can help address a policy issue. While this element was not in play for the 2009 smoking act, it could be relevant in other health areas. Third, changes in leadership in the government can predict a successful advocacy effort. When a Republican takes over for a Democrat in the president’s seat—or vice versa—the time is ripe to push advocacy efforts, especially if these efforts align with the new political party in office. Finally, emergency events can drive change. For instance, Hurricane Katrina led to a significant change in the National Incident Management System (see Chapter 7). Advocates for stronger protocols during emergency times would have played a role in the NIMS changes. Spotlight on Public Health Figures: Charles-Edward Amory Winslow (1877–1957) The American Museum of Natural History in New York circa 1902. Quint & Lox Limited/SuperStock The American Museum of National History in New York in 1902, where Charles-Edward Amory Winslow served as the curator of public health. Winslow started his career as a physician but later shifted his focus to public health. Click each of the questions provided to learn more about Charles-Edward Amory Winslow. Who is Charles-Edward Amory Winslow? Charles-Edward Amory Winslow was an only child born in 1877 to wealthy parents in Boston. His father was a Harvard graduate and a successful businessman, and his mother was an actress known for playing many Shakespearean heroines. He had intended to enter the Massachusetts Institution of Technology (MIT) and become a physician until he met a biology professor, William Sedgwick. Sedgwick was a bacteriologist researching in the public health field, a new field at the time. He studied the link between unsanitary conditions, such as sewage and water systems, and health issues and diseases. Winslow was so intrigued by the idea of reaching an entire population rather than treating one patient at a time as a physician that he moved into the newly emerging field of public health. What was the political climate at the time? Life in the United States during Winslow’s time was fairly good. The country had established itself as a world power, and industrial growth continued to bloom across the nation. Vaccinations were just becoming commonly available, though infectious diseases were still a public health problem. The solid economy and growing interest in public health opened the doors for Winslow to pursue his passion. What was his contribution to public health? Winslow is considered the first public health educator in modern times. The field of public health was just emerging when Winslow stepped onto the scene. During his public health education career, he became curator of public health at the American Museum of Natural History in New York. He focused his attention on preventing infectious diseases through educating people on proper sanitation. He was a proponent of germ theory and taught others how to keep themselves healthier through cleanliness and health education. He developed the first-ever exhibition in America on the etiology of vector-borne diseases. What motivated him? Winslow’s largest influence was his biology professor, Dr. Sedgwick. Sedgwick showed Winslow the possibilities in a newly emerging and intriguing field. He was fascinated by the prospect of helping thousands of people as public health educator. Furthermore, he focused his attention on preventing those diseases by understanding the link between sanitation and disease. Sources: Kemper, S. (2015, June 2). C-E.A. Winslow, who launched public health at Yale a century ago, still influential today. YaleNews. Retrieved from https://news.yale.edu/2015/06/02/public-health-giant-c-ea-winslow-who-launched-public-health-yale-century-ago-still-influe Library of Congress. (n.d.). America at the turn of the century: A look at the historical context. Retrieved from https://www.loc.gov/collections/early-films-of-new-york-1898-to-1906/articles-and-essays/america-at-the-turn-of-the-century-a-look-at-the-historical-context/ 8.2 Public Health Advocacy in Action Every nongovernmental public health organization and group performs advocacy work at some level, but the largest contingent of public health advocates hails from the professional organization known as the American Public Health Association (APHA). This is a membership-based organization whose mission is to “improve the health of the public and achieve equity in health status” (APHA, 2018a, para. 1). It comprises multiple sections and interest groups that focus on specialized areas in public health, including international health, law, mental health, epidemiology, health information technology, and food and nutrition (to name just a few) (APHA, 2018a). APHA has an entire department devoted to advocacy for public health. It acts in “coordination with its members and state and regional affiliates to work with decision-makers to shape public policy to address today’s ongoing public health concerns” (APHA, 2018b, para. 1). It has representatives from the headquarters offices in Washington, DC, focused on a variety of topics. Currently, there is a petition circulating from APHA to include maintaining the public health gains made from Affordable Care Act, and a briefing that was sent to the president about investing in an environmental health system to combat climate change (APHA, 2018b). An auto collision involving two vehicles. RobertCrum/iStock/Thinkstock Research has shown that the reduction of speed limits and use of traffic lights led to fewer accidents. These results were enough to promote the benefits of such public health safety measures. Public health researchers all aspire to have their work recognized in the form of some resulting policy. While research is the foundation behind public health advocacy work, not all public health research leads to policy action, nor does it have to. Very little research actually results in advocacy efforts. In some cases, research simply needs a little publicity—not formal advocacy work—to obtain results. For example, the risk reduction from the use of speed limits did not require much advocacy. Publicizing the results of fewer accidents and highway safety was enough to promote speed limits, traffic lights, and other safety aspects of highway driving. But, when the issues are ambiguous, it is up to public health advocacy groups to provide clarity. Advocacy seeks to change attitudes, beliefs, behaviors, and even policy and law. Often, just keeping the issue within public awareness can effect change, promote new beliefs, and push policymakers to develop a new law to address the issue. Some advocacy groups can butt heads with the opposition, as was the case with the featured smoking law. What about when advocacy efforts to change or create policy affect individual liberties or even the free enterprise system itself? The smoking issue certainly did bring opposition from the tobacco manufacturers, who, thanks to the new law, are now subject to far more regulatory processes. During the public comment period when the law was proposed, advocates and opposition alike were heard through an administrative process. Obviously, the advocates won in this case; however, it took significant work to point out the societal benefits of enacting the law. For policy advocacy to work effectively, there must be a significant amount of support behind the effort followed by solid evidence from professional and valid research. Without both, the advocacy efforts may simply fail as the opposition will bring forward a stronger case. Data-Centered Advocacy Data, facts, and statistics collected for reference, or analysis, are the crux of all advocacy uses. Without carefully researched evidence, public health officials are just offering an opinion on an issue. While someone’s opinion may be a good one to consider for policy change, it must be supported by evidence before any formal action will take place. A teenager consuming an energy drink. Universal Images/SuperStock Reports about highly caffeinated and sugary beverages, such as Red Bull, provided a look at consumption patterns among youth and possible health risks associated with such behaviors. Campaigns such as Kick the Can are attempting to reduce adolescent consumption of such beverages. One of the most common public health advocacy groups in the nation is known as Public Health Advocates. Based in California, this nonprofit organization supports various strategic public health initiatives across the nation by using research to support its view (Public Health Advocates, 2018). That research is the solid evidence for effecting change at the community and policy levels. A recent publication from Public Health Advocates provided evidence against the consumption of sugary beverages by the general public, but more specifically children and youth (Pirotin, Becker, & Crawford, 2014). The group has tracked various research projects from the early 2000s to today to provide evidence for reducing the overall consumption of sugared beverages. One of the most comprehensive was a 74-page report showing nutritional data from 22 sugar-laden drinks including Red Bull, Gatorade, Kool-Aid, Vitaminwater, and Snapple (Pirotin et al., 2014). The study further outlined the energy drink consumption patterns of youth and pulled information from outside research as well as the 2010 National Youth Physical Activity and Nutrition Survey (NYPANS). The NYPANS was conducted in 2010 with three main purposes: 1) to provide nationally representative data on behaviors and behavioral determinants related to nutrition and physical activity among high school students, 2) to provide data to help improve the clarity and strengthen the validity of questions on the Youth Risk Behavior Survey, and 3) to understand the associations among behaviors and behavioral determinants related to physical activity and nutrition and their association with body mass index (CDC, 2017t). The Youth Risk Behavior Survey is an annual survey that monitors health-risk behaviors in youth (CDC, 2016m). Once the information was presented, the research focused on the health issues connected to each ingredient in those drinks, including caffeine, various sugars (glucose, dextrose, sucralose, and aspartame), ginseng, and ginkgo biloba (Pirotin et al., 2014). The latter two elements are of concern because of their purported energy assistance for the consumer. Health concerns included blood pressure and heart issues, neurological problems, sleep disruptions, and obesity (Pirotin et al., 2014). The research showed that such drinks have had adverse health effects on children and youth. Since then, advocacy efforts have pushed for healthier options for this population. One such movement is known as “Kick the Can,” an advocacy campaign that focuses on pushing the beverage industry to quit marketing such drinks to children and youth (Kick the Can, 2018; “National Movement Against,” 2012). As a direct result of the advocacy campaign, six states now have proposed soda taxes. Table 8.1 shows a list of those states and the proposed tax rate. Table 8.1: Proposed legislation resulting from Kick the Can advocacy efforts State/jurisdiction Legislation Date introduced Tax rate Santa Fe, NM Sections 18–20, SFCC 1987 10/13/2016 2 cents per fluid ounce of sugar-sweetened beverages Illinois House Bill 2914 2/9/2017 1 cent per fluid ounce of bottled or canned sugar-sweetened beverages containing more than 5 grams of caloric sweeteners per 12 fluid ounces Illinois Sections 1–97, Senate Bill 0009 1/11/2017 1 cent per fluid ounce of bottled or canned sugar-sweetened beverages containing more than 5 grams of caloric sweeteners per 12 fluid ounces Massachusetts Senate Docket, No. 1722 1/20/2017 Tiered tax system: 1 cent per ounce for beverages with 5–20 grams of sugar per 12 fluid ounces; 2 cents per ounce for beverages with 20 grams or more of sugar per 12 fluid ounces; requires warning labels on sugary drinks, prohibits marketing of sugary drinks in schools, and sets standards for beverages sold with children’s meals Seattle, WA Not publicly available 2/21/2017 2 cents per fluid ounce of sugar-sweetened beverages Washington State New chapter to Title 82, House Bill 1975 2/6/2017 2 cents per fluid ounce of sugar-sweetened and diet beverages Source: Adapted from “Proposed Soda Taxes 2017 Overview,” by Center for Science in the Public Interest, 2017 (http://www.kickthecan.info/sites/default/files/documents/proposedSodaTaxes2017Overview.pdf#overlay-context=cspi-proposed-soda-taxes-2017-overview). The Role of Media Advocacy While it may seem like the media is often focused on advocating for or against a cause, that has not often been the case. According to the Public Health Institute (1987), as an institution, the media has traditionally focused on documenting personal health habits such as eating, sleeping, or exercising. Mass media also tends to report on new medical breakthroughs or medical miracles. Today’s advocacy efforts using mass media are focused on social change and are known as media advocacy. Rather than providing health information to the general public, these mass media advocacy efforts promote health-related policies that give the population a voice on public health issues. As mentioned earlier, the Kick the Can campaign utilizes the media to effect change. This particular campaign has used social media outlets such as Facebook and Twitter in addition to public service announcements on television. As noted with the proposed legislation, the campaign has seen some successful movement on identifying health problems associated with sugary drinks. Another successful media campaign example took place in Australia through the Queensland AIDS Council, a community-based health promotion nongovernmental agency (Butteriss, 2017). The council was formed in 1984 by a group of gay men to provide education and services for people with HIV. The media campaign started with billboard advertisements to reach the gay community, but these were eventually removed due to a significant number of complaints against such information (Butteriss, 2017). The backlash was a sign that media certainly did work to grab people’s attention. The council moved its message to a social media platform with its “rip & roll” campaign (Butteriss, 2017). Using YouTube, the council developed a series of videos targeting men who have sex with other men. The campaign was an instant hit, advocating for men to use condoms and other safe sex methods to avoid HIV and other sexually transmitted diseases. Thanks to the campaign’s overall success in reaching a vulnerable population, a policy changed to allow for outdoor advertising again across the nation (Butteriss, 2017). In many cases, advocacy efforts using the media are often free for the organization. From the media’s point of view, these are public service announcements. Many media outlets allow a certain percentage of free public service announcements for nonprofit organizations; however, if the advocacy content is too political (e.g., pushing for a specific piece of legislation), the public health organization must purchase the advertising space. Social media sites such as Facebook and Twitter are free, so organizations need only set up a page and hope people will click on the “like” or “follow” buttons to receive continued advocacy efforts. In some cases where more media advocacy is desired, groups, businesses, or community members will underwrite the costs of the advocacy campaign. 8.3 Public Health Resources One of the key ingredients of successful public health changes is money. Public health is financed through a mixture of funding sources including federal, state, city, county, and local dollars. States are provided with a certain dollar amount to disseminate for public health issues in their jurisdiction. Figure 8.1 shows a typical distribution of public health funding for one state. Figure 8.1: State health agency funding source Health agencies at the state level are primarily funded through the federal government—funds that come mostly from tax dollars. The distribution of public health services does include a mix of other sources, including fees, fines, state funds, and Medicare and Medicaid income. Pie chart providing an overview of health agency funding for one state. Funds from six different sources are identified. The largest portion (45%) is from federal funds and second largest (23%) is from state general funds. The smallest portion (4%) is from Medicare and Medicaid. Note: As of September 2011. Based on funding reports provided by 48 agencies. Source: Adapted from “Public Health Financing,” by Centers for Disease Control and Prevention, 2013 (https://www.cdc.gov/stltpublichealth/docs/finance/public_health_financing-6-17-13.pdf). The federal government provides the largest chunk of money for public health across the nation. That number exceeds $6 billion annually, divided across all 50 states and the District of Columbia (CDC, 2013c). Several factors influence how much is allocated to each state, including congressional authorizations or directives and eligibility to apply for funding, as in cases of Medicaid and Medicare. Medicaid provides health insurance needs to low-income families; Medicare provides the same for senior citizens. Most of the general fund dollars (non-Medicaid/Medicare) are awarded directly to health departments by competitive grants or merit-based awards. The latter is highly dependent upon the success of a public health program in a state with a proven track record. A good example would be a smoking cessation program that has shown progress. If the results show a steady decline in smoking reduction rates, or even a decrease in health-related issues from smoking or tobacco use, then the federal government would be more likely to grant awards to continue that program. Funding received by the state is then distributed to the counties at multiple levels, such as nonprofits, academia, businesses, community groups, and other organizations focused on public health initiatives. In addition, awards made to the states are also transferred to national associations to carry out programs such as the American Red Cross’s disaster relief efforts. The CDC (2013c) has noted that Congress largely determines how funds are allocated: Only Congress can raise revenue, borrow funds, and provide funding to federal agencies for public health concerns. Congress decides what agencies are authorized to do. Congress decides the purpose and amount of all funds. Congress decides the time period in which the funds can be spent. Congress can highlight what agencies cannot do with federal public health dollars. It is important to recognize the role of Congress in the allocation of resources for public health and the connection to advocacy. The stronger the case for a cause, the more likely it will be known to Congress. That strong case is built through data, research, and evidence used to formulate an advocacy campaign to effect change. The Prevention and Public Health Fund The Prevention and Public Health Fund was a major milestone in public health resource allocation. It drove additional money toward prevention and public health efforts and was the nation’s first-ever mandatory funding stream dedicated to improving the population’s health (APHA, 2018c). The act was created by Section 4002 of the Affordable Care Act, passed in 2010. According to the text of the law, the Prevention and Public Health Fund must be used “to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public health care costs” (42 U.S.C. § 300u-11[a]). Research supported by advocacy efforts has shown that if the nation doubled the amount of federal funding for public health prevention, bringing the amount to $12 billion, it could adequately control the costs of medical care from illnesses and diseases (APHA, 2018c). So far, the fund has provided only $2.25 billion in prevention funding to support public health activities. After President Donald Trump took office in 2016, Congress asked that the Department of Health and Human Services provide information on the activities and programs that have been funded through the Prevention and Public Health Fund. Table 8.2 shows the most recent distribution of funds. Table 8.2: Prevention and Public Health Fund distribution, 2017 Agency Activity or program Allocation ($) Planned uses of funds Administration for Community Living (ACL) Alzheimer’s Disease Prevention Education and Outreach 14,700,000 To fund new grants to states that expand specialized services and support targeting certain categories of individuals living with Alzheimer’s disease or related disorders; to initiate a new public awareness campaign to encourage consumers experiencing memory loss to seek medical advice and to address the stigma associated with dementia ACL Chronic Disease Self-Management 8,000,000 To fund a national resource center and award new competitive grants to help older adults and adults with disabilities from underserved areas and populations (including tribal communities) better manage their chronic conditions by providing access to evidence-based chronic disease self-management programs; to assist grantees with developing and implementing strategies for sustainable program funding beyond the scope of the grant period ACL Falls Prevention 5,000,000 To fund a national resource center and award new competitive grants to implement evidence-based community programs that have been proven to reduce the incidence of falls for older adults and adults with disabilities (including tribal elders), as well as identify sustainable funding mechanisms for these programs; via the resource center, to promote the importance of falls prevention strategies and provide public education about the risks of falls and ways to prevent them CDC Hospitals Promoting Breastfeeding 8,000,000 To fund community initiatives to support breastfeeding mothers and support hospitals in promoting breastfeeding CDC Diabetes Prevention 72,000,000 To implement improved and enhanced diabetes prevention and control strategies within state and local organizations that address primary prevention and support the National Diabetes Prevention Program lifestyle change intervention CDC Epidemiology and Laboratory Capacity Program 40,000,000 To enhance the ability of state, local, and territorial grantee capacity for detecting and responding to infectious diseases and other public health threats CDC Healthcare Associated Infections 12,000,000 To strengthen public health infrastructure for HAI activities related to monitoring, response, and prevention across all health care settings and to accelerate electronic reporting to detect HAIs at the state level CDC Heart Disease and Stroke Prevention Program 73,000,000 To implement improved and enhanced heart disease and stroke prevention efforts CDC Million Hearts Program 4,000,000 To improve cardiovascular disease and stroke prevention by promoting medication management and adherence strategies and improving the ability to track blood pressure and cholesterol controls CDC Office of Smoking and Health 126,000,000 To raise awareness about the harms of tobacco use and exposure to secondhand smoke in areas of the country with high rates of tobacco use CDC Preventive Health and Health Services Block Grants 160,000,000 To support programs that focus on the leading causes of death and disability and the ability to respond rapidly to emerging health issues, including outbreaks of foodborne infections and waterborne diseases CDC Racial and Ethnic Approaches to Community Health (REACH) 50,950,000 To improve linkages between the health care system and minority communities with unique social, economic, and cultural circumstances and change the chronic disease conditions and risk factors in local communities CDC Immunization 324,350,000 To improve the public health immunization infrastructure in order to maintain and increase vaccine coverage among children, adolescents, and adults CDC Lead Poisoning Prevention 17,000,000 To support and enhance surveillance capacity at the state and city level to prevent and ultimately eliminate childhood lead poisoning CDC National Early Child Care Collaboratives 4,000,000 To support efforts to improve physical activity and nutrition environments in early childhood education (ECE) settings Substance Abuse and Mental Health Services Administration (SAMHSA) Garrett Lee Smith Youth Suicide Prevention 12,000,000 To fund continuation grants for Youth Suicide Prevention–States grantees Total 931,000,000 Source: From “Prevention and Public Health Fund,” by U.S. Department of Health and Human Services, 2017 (https://www.hhs.gov/open/prevention/index.html). More funding is available, but to obtain the funds, states must apply through a grant process. If an agency believes it has a program that fits within the parameters of public health, it is recommended that it advocate for the grant through its state. A good example of the use of Prevention and Public Health Fund monies can be found in Case Study: Community Transformation Grant Program. Case Study: Community Transformation Grant Program The Iowa Department of Public Health received a grant funded through the Prevention and Public Health Fund to expand access to blood pressure and tobacco use screens at dental practices across the state. The strategic vision was to increase the number of referrals to the state’s tobacco “Quitline” service and target interventions across the state where stroke mortality rates are high. Twenty-five intervention counties were identified through local boards of health and their community coalitions. The main targets were rural males ages 45 to 50 and people with disabilities. One particular success story that came out of the initiative involved the Iowa Primary Care Association, which had trained and provided technical assistance to three community health center dental clinics to 1) refer dental patients who screened for high blood pressure and tobacco use and 2) document blood pressure, tobacco use, and Quitline referrals in the electronic medical record. Of the 2,535 dental exams completed, 741 adults (30%) received blood pressure screening, with 8% being referred for high blood pressure. Furthermore, 68% reportedly completed the referral. One man was so thankful for being immediately referred to his medical provider for a very high blood pressure reading that he sent roses to the dental hygienist who made the referral. Source: Community Transformation Grant. (2011). Retrieved from https://www.legis.iowa.gov/docs/publications/IH/17177.pdf Current lobbying activities at the congressional level are pushing for the removal of the Prevention and Public Health Fund, which would mean less money for prevention and a continued increase in medical spending on disease treatment. Currently, there are numerous battles of advocacy and lobbying both in favor of and against keeping the fund. Health Care Expenditures in the United States Public health advocacy efforts promote healthy behaviors and push key legislation through Congress. As the previous section explained, the funding for this comes mostly from the government, and the money goes toward population-based initiatives, not individual health concerns. Currently, the nation has an uneven funding distribution between health care, which focuses on the health of the individual, and public health, with most funding heading toward the health care sector. The United States’ health care system is often touted as being the best in the world; however, according to a study performed by the Commonwealth Fund (Schneider, Sarnak, Squires, Shah, & Doty, 2017), it ranks last in terms of positive health outcomes among 11 high-income countries. The Commonwealth Fund is a private foundation that focuses on evaluating health care system access, quality, and efficiency. The organization performs a significant amount of advocacy for improved health care in the United States. The study found that the United States leads the world in spending, yet the population is sicker than ever—and more likely to die of preventable diseases. Figure 8.2 shows the different countries’ expenditures on health care as a percentage of their gross domestic product (GDP) from 1980 to 2014. Figure 8.2: Health care spending as a percentage of GDP, 1980–2014 The expenditures in health care have grown in nearly every country since 1980. However, the health care spending in the United States has increased significantly more than spending in other industrialized nations. Line graph identifies the trends in health care spending as a percentage of GDP for 11 countries between 1980 and 2014. Ten of the countries have similar trends, with the percentage rising from between 5% and 8% to between 9% and 11%. The United States, however, shows a more drastic increase, starting at 8% and ending at just over 16%. Note: GDP refers to gross domestic product. Source: Adapted from “Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care,” by E. C. Schneider, D. O. Sarnak, D. Squires, A. Shah, & M. M. Doty, The Commonwealth Fund, 2017 (http://www.commonwealthfund.org/interactives/2017/july/mirror-mirror/assets/Schneider_mirror_mirror_2017.pdf). In 1980, the United States was aligned with most of the nations in terms of health care expenditures. It was spending just over 8% of GDP on health care, while the United Kingdom was just over 5% (Schneider et al., 2017). Since then, the gap has increased, with the United States spending 16.6% on health care in 2014 versus the U.K. spending 9.9% (Schneider et al., 2017). In 2014, the country spending the lowest percentage of GDP was Australia (Schneider et al., 2017). According to Figure 8.2, most of the countries sustained a slight spending increase in health care while the United States appears to be off the charts in terms of health care expenditures. Researchers looked at five key areas and found that the United States was significantly lacking in each. The top ranked country, the United Kingdom, showed excellence in all of these areas, especially prevention. The five key areas are care process, access, administrative efficiency, equity, and outcomes. Subdomains of the care process were safe care, coordination, and patient engagement. In the United States, care is typically measured by the doctor–patient relationship; however, the flow of information among all care providers, specialists, and service providers is far more important. This is why the care process was ranked poorly in this study. Under access, the United States performed worst in health care affordability. One reason for this is because it was the only nation of those examined that did not offer universal health care coverage. While the Affordable Care Act has helped, there are still many Americans facing high insurance deductibles and higher out-of-pocket expenses, both of which lead to poorer outcomes. When faced with such costs, Americans will generally avoid seeking care until the health issue is chronic. The third key area, administrative efficiency, refers to ease of obtaining medical records and working with insurance companies and the number of patients seeking treatment at the right location. The study reported that doctors in the United States spend far more time on issues related to claims or insurance battles than on quality of patient care. Furthermore, U.S. residents often seek treatment in an emergency room even when a primary care physician could offer better treatment. All of these deficiencies lead to poor and cumbersome administration processes. The fourth key area is equity. While human health is an important factor for any individual, the United States ranks very low in serving low-income individuals. There is a huge health disparity between lower- and higher-income adults. Low-income adults typically do not have a primary care physician and do not seek treatment. Furthermore, sometimes doctors will spend more time with a patient who has money than one who does not. This creates a true inequity in health care for low-income individuals. Lastly, the United States ranked poorly in health care outcomes despite having the largest expenditure among the 11 countries studied. According to the report, the United States has the highest rate of mortality directly related to health care access/cost/issues (Schneider et al., 2017). In addition, more adults in the United States have multiple chronic conditions. For example, 21% of the nation’s population suffers from at least two chronic diseases (such as cardiovascular disease and diabetes), compared with only 10% in the United Kingdom. Figure 8.3 shows the distribution of multiple chronic diseases among the 11 countries in the Commonwealth Fund study. The country with the next closest percentage is Canada with 16%, which is 5 percentage points lower than the United States. Figure 8.3: Percentage of adults ages 18 to 64 living with at least two chronic diseases Although the United States spends far more dollars on health care than other industrialized nations, it has significantly poorer health outcomes. Twenty-one percent of the U.S. population is living with at least two chronic diseases. Bar graph showing the percentage of the population living with at least two chronic diseases for 11 countries. For 10 countries, between 8% and 16% of the population has at least two chronic diseases. In the United States, however, 21% of the population has at least two chronic diseases. Source: Data from “Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care,” by E. C. Schneider, D. O. Sarnak, D. Squires, A. Shah, & M. M. Doty, The Commonwealth Fund, 2017 (http://www.commonwealthfund.org/interactives/2017/july/mirror-mirror/assets/Schneider_mirror_mirror_2017.pdf). Aside from the Commonwealth Fund’s country comparison, the Centers for Medicare and Medicaid Services (CMS) provided similar details in terms of actual dollars. U.S. health care spending increased to $3.3 trillion in 2016, or $10,348 per person (CMS, 2016). Table 8.3 shows a breakdown of where those expenditures were made. Table 8.3: Distribution of health care expenditures in the United States, 2016 Type of care Amount Approximate % of total expenditures Private health insurance $1.1 trillion 34% Hospital care $1.1 trillion 32% Medicare expenditures $672.1 billion 20% Physician/clinic services $664.9 billion 20% Medicaid expenditures $565.5 billion 17% Out-of-pocket expenses $352.5 billion 11% Prescription drugs $328.6 billion 10% Other professional service (physical therapists, optometry, podiatry, chiropractic; excludes dentists and physicians) $92 billion 3% Dental services $124.4 billion 4% Health, residential, personal care services (home care including ambulance needs and residential substance abuse facilities) $173.5 billion 5% Home health care (free-standing home health care agencies) $92.4 billion 3% Nursing care facilities and retirement communities $162.7 billion 5% Durable medical equipment (retail spending such as contact lenses, eyeglasses, hearing aids) $51 billion 2% Other medical products (over-the-counter medicines, medical instruments, surgical dressing) $62.2 billion 2% Source: Data from “National Health Expenditures 2016 Highlights,” by Centers for Medicare and Medicaid Services, 2016 (https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf). Public Health Versus Health Care Expenditures The United States spends $6 billion annually in public health needs. The implementation of the Prevention and Public Health Fund added another $2.25 billion to that figure, bringing the total to $8.25 billion (APHA, 2018c; CDC, 2013c). Meanwhile, the United States spent $3.3 trillion in 2016 on health care (CMS, 2016). With a ratio of 0.0025 to 1, the United States spends trillions more on treatment than it does on prevention. For every $1 spent on health care, only one quarter of a cent is spent on prevention. Public health professionals point out that this is why it is difficult to obtain positive health outcomes. A customer purchasing products from a pharmacist. Thinkstock Images/Stockbyte/Thinkstock The United States spends more on health care treatment than on preventive care. Why is so little spent on prevention and so much on health care treatments? This question does not have a definitive answer. The media has taken several stabs at why this may be the case. For example, CheatSheet, an online media outlet, has suggested that insurance companies, health care providers, pharmaceutical companies, and other health care businesses are not nonprofit. They need to make money to pay their employees, conduct research for new products, and basically “keep the lights on” (Becker, 2017, para. 3). An article in the New York Times has suggested that it is the market price point. If people need it, they will buy it, or demand will drive up price (Frakt & Carroll, 2018). Fortune magazine has speculated that it is due to the social, economic, and environmental conditions that people live in and have learned to accept (Galea, 2017). Perhaps all of those opinions are correct. How can the nation reduce the costs of health care and improve health outcomes? This is the key question for health professionals, whether they work in public health or medical care. From the public health angle, sinking more dollars into prevention to reduce the prevalence of preventable diseases is the answer. If the threat is removed, then so is the need for treatment. On the other hand, medical practitioners want more research into cures and better treatments that enable healthier living. Which should take priority? Summary & Resources Chapter Summary Advocacy seeks to change a behavior or belief, sometimes by convincing individuals or legislators to act or not act on an issue. Lobbying is used to convince Congress to enact a specific piece of legislation. Both are persuasive in nature, but advocacy is used in public health more often. Lobbying is not the only way to effect legislation. Several advocacy strategies work to preserve, remove, replace, or revise laws and policies. These include pressuring those who can actually make changes to policies, such as members of Congress; garnering support from people who would be affected by the legislation and influencing them to participate in advocacy work; and building a coalition within a community or several communities to perform advocacy work. These have all been successful methods over time, as demonstrated by the Family Smoking Prevention and Tobacco Control Act. The use of evidence and research data to support advocacy efforts is a key principle in public health. Without evidence, or data, that shows a change is needed, then public health officials are just providing opinions. But public health cannot rely on viewpoints for policy action; it needs supportive evidence. Advocacy groups such as Public Health Advocates continually provide up-to-date research on health issues to support advocacy efforts across the nation. Thanks to the 2010 Affordable Care Act, the United States has additional money for prevention through the Prevention and Public Health Fund. Still, that money pales in comparison with what is spent on medical care. The nation spends one quarter of a cent ($0.0025) on public health prevention efforts for every dollar spent on health care. It seems that a paradigm shift is needed to change the priorities to prevention. Currently, the focus is on treating the problem after it arises. Public health professionals seek to eliminate the problem so that it never needs to be treated in the first place. That idea takes resources—including money. Critical Thinking and Review Questions Explain the difference between advocacy and lobbying. Explain why policy advocacy is used in the public health realm. Why is data-driven advocacy work important for public health initiatives? Consider the use of media for advocacy efforts. Describe one current campaign that is successfully using the media to change behavior. Review Table 8.2, which contains the 2017 distributions from the Prevention and Public Health Fund. What programs or projects in your community could be added to this list and why? Consider the program or project you thought of for question 4 and describe how you would advocate for more money to fund it. Why do you think the United States spends significantly more money on treatment rather than prevention? Should professionals in the field continue to advocate for behavior changes, policies, and funding? Why or why not? The United States spends significantly more on health care than any other nation. Name two or three reasons why you believe that is the case. If you had control of the United States’ money, how would you divide your funding between prevention and treatment? Explain your reasons. Additional Resources The Trust for America’s Health https://www.tfah.org/ This site provides real-time updates on activities related to prevention policies. The National Prevention Information Network https://npin.cdc.gov/ This website connects public health professionals with work in the field on health advocacy and education efforts. The American Public Health Association https://www.apha.org/policies-and-advocacy/advocacy-for-public-health https://youtu.be/KynoKd-Y0a8 Visit the American Public Health Association’s advocacy page to learn more about this member-based organization with an advocacy role in public health. Watch the video to learn about what you can do as a citizen. The Public Health Advocates’ Kick the Can campaign http://www.kickthecan.info/ Visit this site to learn more about Public Health Advocates’ campaign to reduce and eliminate the consumption of sugar-loaded beverages. Key Terms advocacy An act to change a behavior or belief or convince individuals to act or not act on an issue. American Public Health Association (APHA) A membership-based organization whose mission is to improve the health of the public and achieve equity in health status. lobbying An act by a special interest group or industry to attempt to convince Congress to enact legislation on a particular topic. media advocacy The use of mass media to effect social change. policy advocacy An act to promote or defend a position, person, interest, or opinion. Prevention and Public Health Fund A national fund that is the United States’ first-ever mandatory funding stream dedicated to improving the population’s health. Public Health Advocates A nonprofit organization that focuses on strategic public health initiatives across the United States using research to support its view.