Prevention, Preparedness, Promotion: The Fourth National Prevention Summit FocusThe Nation faces a pair of major public health challenges that at first glance appear to be quite different from one another, but in fact share a number of common features. These two challenges—growing obesity among the Nation’s children and the need to prepare for unpredictable public health emergencies, whether they be pandemic diseases such as avian flu or natural disasters such as Hurricane Katrina—were the focus of the Fourth National Prevention Summit, held October 26–27, 2006, in Washington, DC. Participants from across the country explored what these challenges have in common and which approaches are most effective in meeting them. The ChallengesRear Admiral Penelope Slade Royall, P.T., M.S.W., Deputy Assistant Secretary for Health for Disease Prevention and Health Promotion in the Office of the Secretary of Health and Human Services (HHS), opened the Summit with a welcome and an explanation of why these apparently disparate challenges belong on the same public health continuum.
Planning, preparedness, and prevention are the keys to successfully overcoming both of these challenges, Admiral Royall continued. In more than 60 speeches and workshop presentations and 50 poster presentations, Summit speakers highlighted the interconnectedness of these crucial goals and showcased a range of programs and strategies for accomplishing them, all within a framework of “Healthier People, Healthier Places, and Healthier Practices.” Childhood ObesityFor more than 82 percent of the Nation’s children, the health picture is very good, Admiral John O. Agwunobi, M.D., M.B.A., M.P.H., Assistant Secretary of Health, HHS, told Summit participants in the keynote address he presented on the first day of the Summit. The teen pregnancy and infant mortality rates are down, as is the proportion of children exposed to second-hand smoke. Vaccination rates are at all-time highs and, for the first time in 10 years, do not vary significantly by race. Counterbalancing these public health successes, however, is the increase in childhood obesity. It threatens not only the future of many individuals’ health and the Nation’s health indicators, but also the ability of the Nation’s health infrastructure to continue to meet the needs of tomorrow’s Americans. Diabetes, cardiovascular disease, certain cancers, and other obesity-related health problems can rob individuals of years of healthy life; burden the families that have to cope with the effects of these serious conditions; and severely strain the healthcare resources of the Nation at large. Unless current trends are altered, the demand for care of these obesity-related chronic conditions will overwhelm the ability of the health system to respond with high-quality services. If only to ensure the future of prevention in the Nation, Admiral Agwunobi said, the runaway epidemic of childhood obesity must be brought under control. Childhood obesity has been increasing at an alarming rate. Over the past 20 years, the percentage of obese children aged 6 to 11 has doubled and the percentage of obese teenagers has tripled. Nearly 16 percent of America’s children are obese. And children and adults of some groups—especially Hispanics, African Americans, and Native Americans—face an even higher risk. Lifestyle choices, primarily unhealthy diets high in fats and carbohydrates and too little physical activity, contribute to the increase in childhood obesity. Effective prevention efforts include getting children to be more physically active, to spend less time in sedentary activities such as playing video games and watching TV, and to make sensible food choices by selecting foods low in fats, sugars, and “empty” calories and high in needed nutrients. Given current tastes for fattening snacks and the attraction of computer- and TV-based entertainment, getting action will take grassroots efforts in communities across the Nation, Admiral Agwunobi emphasized. Parents, caregivers, school officials, and others must be sensitized to the need to fight overweight and obesity. And they must become aware of effective means of achieving that result. Media aimed at children could be harnessed to present positive messages about healthful eating and physical activity in place of messages that encourage inactivity and fattening snacks. Families, schools, and communities can develop attractive and accessible opportunities for children to make increased physical activity part of their daily lives, especially among groups at special risk for overweight and obesity. Admiral Agwunobi highlighted some ongoing efforts. Action for Healthy Kids, a national coalition of more than 50 private organizations and government agencies, is partnering with HHS to promote physical activity and a healthful diet for schoolchildren. The Clinton Foundation, founded by former President Bill Clinton, has worked with major companies on voluntary guidelines to give children opportunities to make healthier snack choices in schools. The Walt Disney Company has adopted food guidelines based on the 2005 National Dietary Guidelines for Americans. A panel discussion following Admiral Agwunobi’s keynote address highlighted other active programs to fight childhood obesity. Lisa Hark, Ph.D., R.D., director of the Nutrition Education and Prevention Program at the University of Pennsylvania School of Medicine, who was host of The Learning Channel’s TV 2005–2006 series “Honey, We’re Killing the Kids,” discussed the program’s main focus on issues that families face in encouraging their children to make healthier choices. Parents must make healthy eating a high priority, the food industry must offer a wider selection of creatively packaged healthy foods for children, and schools must be mandated to provide daily recess and at least weekly physical education classes for all children, she said. Ms. Gloria Britten, a single mother who appeared in the inaugural episode of the series, provided insight into her experience guiding her four children, aged between 3 and 14, from an unhealthy to a healthy lifestyle through steps such as changes in food selection and cooking methods and limiting the time spent watching TV. David McCarron, M.D., president of Shaping America’s Youth, a public-private initiative to promote the prevention of childhood obesity, spoke about town meetings the organization presents in cities across the country that bring community members together to share ideas, priorities, and information to develop workable strategies to provide better nutrition and physical activity for local children. Jennifer Kotler, Ph.D., of Sesame Workshop, which for almost four decades has produced the iconic and highly influential children’s television program, discussed Healthy Habits for Life, a multi-year initiative to help caregivers and young children lay the foundation for potentially lifelong habits of healthy eating and physical activity. Renee Jenkins, M.D., president-elect of the American Academy of Pediatrics, presented additional data on the trend in childhood obesity, emphasizing the resulting increased risk that today’s children, and especially minority children, face of contracting diabetes and other serious conditions. The Academy considers reversing this trend a major strategic priority and is working to increase awareness among physicians that obesity prevention should be a routine part of all children’s regular medical care. Following the plenary sessions, the first day included many breakout sessions exploring issues and approaches that can help Americans take effective action to defeat the epidemic of childhood obesity and safeguard today’s children—and the future of the American health system—from the looming threat that obesity presents both to individuals and to the entire Nation. Additional details on these presentations can be found at www.healthierus.gov. Public Health EmergenciesThe second day of the Summit explored the threat posed by acute, widespread health emergencies, including pandemic infectious diseases such as avian influenza and natural disasters such as Hurricane Katrina. In these cases as well, wise choices by informed citizens will be instrumental in protecting the health of Americans and preventing needless suffering and death. Key to these choices will be planning and preparedness at all levels in communities across the Nation. The day’s keynote address by Rajeev Venkayya, M.D., Special Assistant to the President for Biodefense in the White House Homeland Security Council, emphasized the close and crucial bond between prevention and preparedness, both of which make use of the same resources and infrastructure. The Threat of Avian FluIn 1918, an influenza pandemic ravaged the world, touching every continent and killing millions of people. Now, experts believe, mutation of the H5N1 strain of avian influenza could create the potential for a similar catastrophe today. Were that potential to become reality, the toll on the United States as well as other countries would be heavy, Dr. Venkayya said. The large number of people killed in a short time would include as many children as would normally die in the United States in 20 years. Such a pandemic could seriously disrupt the Nation’s economic, educational, and social life, not only through deaths, but also because of the widespread dislocation caused by steps taken to stem the spread of the virus, by the illness of countless individuals of all ages, and by the need to have healthcare professionals and family members who are still healthy to care for them. Hospitals, clinics, doctors’ offices, pharmacies, and other healthcare facilities would be overwhelmed by the demand for care, as would the people staffing them, many of whom would themselves fall ill. Businesses, organizations, and agencies of all kinds would be hard pressed to continue their activities in the absence of workers. Careful planning, community preparedness, and wisely chosen actions would be crucial to cope with the emergency and prevent the collapse of many important services and functions within the society. Whether people take the right actions will depend on whether the public receives and acts on accurate and timely information to guide their choices. A vaccine, the most effective weapon against influenza, would probably not be available during the pandemic’s first wave, Dr. Venkayya warned. Antiviral treatments would be able to help individual patients somewhat but would not slow the virus’s spread. Crucial for halting the virus’s spread, however, would be actions taken by countless individuals, institutions, and communities. These would include personal hygiene efforts such as hand washing, as well as broader public decisions on methods of increasing social distance, such as closing schools, businesses, and workplaces, canceling public gatherings, and similar steps. As studies of the 1918 pandemic have shown, such steps, if taken promptly and properly, can sharply slow the spread of a pandemic infection within a community and substantially reduce the disease and death tolls. These steps, however, also can impose serious economic, educational, and other costs on individuals, families, and communities, and must be planned and carried out with care. To prevent the haphazard and misguided local reactions to the pandemic that in 1918 resulted in some communities suffering needlessly high death tolls, the Federal Government has developed guidance for communities for choosing the best uses of the resources at their disposal. To prepare the Nation to effectively counter the avian influenza threat, the Federal Government issued the National Strategy for Pandemic Influenza on November 1, 2005, and an implementation plan on May 3, 2006. Both documents are available online at www.whitehouse.gov/homeland/pandemic-influenza.html. The implementation plan lays out hundreds of specific actions and expectations for government entities at all levels, as well as for the private sector, the healthcare system, other institutions and organizations, and individual families and citizens. Communicating effectively with the public about risks and responses will be crucial during any pandemic, Baruch Fischhoff, Ph.D., of the Department of Social and Decision Sciences at Carnegie Mellon University, told the Summit in a panel discussion following Dr. Venkayya’s keynote address. Citizens will need accurate and trusted information to meet the crisis, deal with the aftermath, take part in decision-making, and maintain social solidarity, Dr. Fischoff emphasized. Because what people know will affect what they do, messages must provide them with detailed information on specific choices. For example, what type of face masks should they wear or not wear? Which symptoms require immediate action? And what sort of action? Is there a best way of washing the hands? Research has shown, however, that in late 2002, most citizens did not have such basic facts about potential public health emergencies—for example, that anthrax does not easily spread from person to person, that smallpox vaccinations can work even if given after a person has been exposed to the disease but before symptoms appear, and that sheltering in place may be a better choice than evacuating after the explosion of a dirty bomb. Public health crises, however, will provide only small windows of opportunity to get the facts to the public so that they may take effective action. If people do get adequate, credible information, however, they generally will make sensible choices, Dr. Fischoff said. And in a public health emergency such as an influenza pandemic, communication becomes a form of medical treatment that can lead to either good or bad medical outcomes. The safety of the Nation and its people, therefore, demand that preparations for a pandemic—including preparing the communications that will play such a vital role in individual and community responses to the emergency—be taken well before the emergency strikes. The Lessons of KatrinaThe unprecedented catastrophe of Hurricane Katrina, with its large population dislocations, vast destruction of facilities, intense demand for emergency and health services, widespread danger and suffering, and many deaths, also threw into intense focus the need for planning in advance of public health emergencies. Planning that takes place before an emergency can help mitigate its effects. This was a conclusion of an account presented by Regina M. Benjamin, M.D., M.B.A., of the Bayou La Batre Rural Health Clinic in Louisiana. She recounted the experience of providing primary care after the hurricane, despite the destruction of both the clinic where she practiced medicine and the homes of nearly all local residents. Before Hurricane Katrina, the clinic had received a Federal outreach grant from the Office of Rural Health of the Health Resources and Services Administration. Because of the grant, the clinic had established formal relationships among various local organizations as well as an advisory board with representatives of local health, mental health, charitable, government, and other groups and agencies. These clearly delineated and well-functioning relationships enabled the clinic to mobilize local resources when disaster struck. In Katrina’s aftermath, furthermore, disaster planning has continued, including plans for building a new clinic that will be raised above the ground and equipped with an automatic generator, and even more importantly, with an electronic record system. Karen B. DeSalvo, M.D., M.P.H., M.Sc., of the Division of General Internal Medicine and Geriatrics at the School of Medicine of Tulane University Health and Sciences Center also discussed New Orleans’ response to Hurricane Katrina. Countless individuals with multiple chronic diseases or serious mental illnesses, along with many who were elderly, homeless, or uninsured, found themselves without access to health care when the centralized system based at Charity Hospital, which had long served the poor, collapsed during the disaster. Beyond that, the first responders who filled the city after the hurricane also needed health care. The scattered doctors and other health professionals in the area were forced to piece together a makeshift health safety net that they invented “on the fly,” with little or no access to medical records or the facilities and equipment in ruined hospitals, clinics, and offices. Based on the lessons of the hurricane, the city’s healthcare strategy changed from care by centralized institutions to an all-hazards planning approach that emphasizes systems, communication, and redundancy, Dr. DeSalvo said. Effective emergency planning and preparedness for caring for vulnerable populations during and after disasters also requires healthcare providers knowledgeable about the community, its culture, and its needs, she added. Following the day’s plenary sessions, an array of sessions allowed participants to explore and share insights, strategies, and techniques that have been developed across the Nation for dealing with acute public health emergencies. Additional details on these presentations can be found at www.healthierus.gov. ResourcesShaping America’s Youth presents a wide range of information and resources about preventing and dealing with childhood and adolescent obesity at www.shapingamericasyouth.org/default.aspx. Healthy Habits for Life presents Sesame Workshop resources on preventing childhood obesity with resources for parents and children at www.sesameworkshop.com/healthyhabits. Childhood Obesity, presented by the American Obesity Association, a research and public policy organization, offers a range of resources, including growth charts to help parents determine whether their children are obese or headed toward obesity. For more information, visit http://obesity1.tempdomainname.com/subs/childhood/. Action for Healthy Kids provides resources to help youngsters develop lifelong healthy habits of physical activity and healthful eating at www.actionforhealthykids.org. CDC News: CDC Learns From Katrina, Plans for Pandemic is a summary of lessons learned from Hurricane Katrina and their application to future disasters, such as a pandemic disease. The summary is available at http://www.cdc.gov/news/2006_11/katrina.htm. The Homeland Security Council’s National Strategy for Pandemic Influenza presents U.S. Government planning for a pandemic and is available for free download at www.whitehouse.gov/homeland/nspi.pdf. The National Strategy for Epidemic Influenza Implementation Plan, also prepared by the Homeland Security Council, is available for free download at www.whitehouse.gov/homeland/nspi_implementation.pdf. Small Step Kids, part of HealthierUS.gov, presents resources on activity and healthy eating aimed at kids and is available at www.smallstep.gov/kids/flash/index.html. It is available in Spanish at www.smallstep.gov/kids_esp/html/index.html. Children’s Health Topics: Overweight and Obesity presents a range of resources from the American Academy of Pediatrics for families, physicians, and advocates at www.aap.org/healthtopics/overweight.cfm. ActivitiesVERB™ It’s What You Do is a national campaign sponsored by the Centers for Disease Control and Prevention encouraging young people age 9–13 (“tweens”) to be physically active. The campaign Web site provides resources to make regular physical activities for tweens fun and includes virtual games such as Kickball Derby, Snowshuffle, The Deep End, and Yellowball, which also have a physical component. To learn more, visit www.verbnow.com. The Power of Choice: Helping Youth Make Healthy Eating and Fitness Decisions, a CD developed by the Food and Drug Administration and U.S. Department of Agriculture’s Food and Nutrition Service, is designed for leaders of after-school programs working with young adolescents. The CD contains 10 interactive sessions on healthy eating and physical activity and includes activity materials. To learn more, visit www.fns.usda.gov/tn/Resources/power_of_choice.html. The Science of Energy Balance: Calorie Intake and Physical Activity is a component of the National Institutes of Health Supplement Series containing lessons and activities for grades 7 and 8. A teacher’s guide with lesson plans, implementation support, and interactive materials for students, as well as printed materials, are available at http://science.education.nih.gov/supplements/nih4/energy/default.htm. We Can! (Ways to Enhance Children’s Activity & Nutrition), a national obesity education program sponsored by the National Heart, Lung, and Blood Institute and designed for families and communities to help children achieve a healthy weight, focuses on improved food choices, increased physical activity, and reduced screen time. Materials for parents and caregivers can be downloaded from www.nhlbi.nih.gov/health/public/heart/obesity/wecan/. In addition to print materials, the Web site contains a body mass index calculator, growth charts, and a video as well as materials for health professionals. Emergency Preparedness Resource Inventory (EPRI) is a tool designed by the Agency for Healthcare Research and Quality to help local, regional, and state planners create an inventory of resources for responding to public health disasters such as a flu pandemic or bioterrorism incident. In addition to a Web-based software tool, EPRI provides an implementation report and a technical manual. To download the tool and its components, visit www.ahrq.gov/research/epri/.
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