Prevention Science Should Be a Higher Federal Funding Priority
Dean and DeLamar Professor of Public Health, Columbia University Mailman School of Public Health
One of the great ironies of American health care is that we have the highest per capita spending among industrialized countries, yet we rank near the bottom in preventable health outcomes. A new study sheds much-needed light on the genesis of that irony and proposes a way to reduce it. It should spark a national discussion about striking a proper balance for federal funding of health-related research.
The study, published earlier this week in the American Journal of Preventive Medicine, analyzes the "National Institutes of Health Funding for Behavioral Interventions to Prevent Chronic Diseases." Co-authored by Chris Calitz, MPP, Keshia M. Pollack, PhD, Chris Millard, MPP, and Derek Yach, MBChB, the study was partially funded by the Vitality Institute on whose Commission on Health Promotion I recently served.
The study notes that seven out of 10 deaths in the United States annually are due to non-communicable chronic diseases (NCDs), and treating people with those conditions accounts for approximately 84 percent of annual health care expenditures. From a policy standpoint, the problem stems from the fact that much of this illness can be prevented, yet the focus of American health care -- and of health-related research -- is on treatment, not prevention.
An estimated 50 percent of those diseases, according to the study, can be prevented by modifying major risk behaviors -- and another 20 percent to 30 percent by addressing social and environmental factors in health. Accounting for more than 50 percent of premature deaths and considerably more illness and disability are these six largely modifiable risk behaviors and factors: tobacco use, poor nutrition, physical inactivity, alcohol abuse, drug abuse, and poor mental health.
National health care spending is heavily skewed toward prescription drugs, medical devices, and clinical services. In fact, 97 percent of U.S. health-related spending goes to medical care while public health and prevention activities represent only 3 percent of annual spending.
That's an extraordinary misalignment of the resources that hold great promise for better health. In its 2012 report, "Living with Chronic Illness: A Call for Public Health Action," the Institute of Medicine states, "The epidemic of chronic illness is steadily moving toward crisis proportions." Still we are focusing most health care dollars on treating preventable illness rather than preventing it. Why should we not be at least as interested in ensuring that future generations do not suffer illness unnecessarily?
The challenge, of course, is not only to shift our health care economy from treatment to prevention but to invest in the science that can help us establish evidence-based prevention strategies to reduce the burden of disease effectively. Greater investment also stimulates academic interest in the area, leading to scientists, educators, and policymakers, trained, passionate, and committed to prevention. That's where the focus of research funded by the National Institutes of Health becomes even more important. The NIH's newly created Office of Disease Prevention is certainly a step in the right direction, provided it is staffed and funded appropriately to meet its aspirations.
The National Institutes of Health receives $30 billion annually in federal funding. It spent an estimated $6 billion in fiscal year 2012 on prevention research including infectious disease prevention.
The question that the study addresses is: How aligned is the NIH's current research portfolio with the modifiable behavioral risk factors associated with the most costly NCDs: cancer, coronary heart disease, hypertension, stroke, diabetes, and obesity? In assessing that, data were analyzed from eight NIH Institutes and Centers that are significant funders of NCD prevention: the National Cancer Institute, National Heart Lung and Blood Institute, National Institute of Child Health Development, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Mental Health, National Institute of Drug Abuse, and National Institute on Alcohol Abuse and Alcoholism.
Based on observed proportions, the study found that the NIH currently invests an estimated $2.2-2.6 billion in understanding, directing, and evaluating behavioral interventions to prevent NCDs -- roughly 7 percent to 9 percent of total annual expenditures. In addition, most of those behavioral interventions were secondary prevention interventions to slow disease already present (65 percent) rather than primary prevention interventions that prevent disease from starting (23 percent). And, most projects were focused on individual or family-level interventions (71 percent) rather than population level approaches which are vital and more cost-effective (22 percent).
This study highlights inadequate investment of federal funding for science that will help us better prevent chronic disease. Investing in prevention -- and prevention science -- should become a much higher priority for federal research. It's essential if the United States is to improve the health of our population and save future generations of Americans from the burden of preventable disease.