Today our nation is facing a health crisis caused by closely related epidemics of chronic disease. These are preventable epidemics enabled by the places, spaces, and relationships that shape our choices and that can challenge our health on a daily basis. Underlying this crisis are what we in the Tennessee Department of Health (TDH) call the "Big 4": physical inactivity, excessive caloric intake, tobacco and nicotine addiction, and other substance use disorders. Collectively, these Big 4 issues are driving all of our 10 leading causes of death in Tennessee and our nation.1 To underscore, for the first time in a decade, the Centers for Disease Control and Prevention notes a rise in the US crude death rate.2 The Big 4 are taking years from our lives and life from our years.
Importantly, the Big 4 are not separate and distinct challenges; they are closely connected. Each of them delights our ancient dopaminergic reward system, the wiring for our very survival embedded deeply in our brain. Each of us has some vulnerability to the attractiveness of the Big 4 and the preventable diseases they drive. Health care can only sometimes return us to optimal health once these diseases take hold. As a nation, we are coming to realize that merely doubling down on health care spending, most of which is actually sick care, does not work. Health care, to merely mitigate the effects of these preventable chronic and life-taking diseases, will not offer us or our children true health equity and optimal health for all. The truth is we cannot spend, regulate, or treat our way out of our current health crisis. We can, however, prevent our way out of it. We must create the conditions in our individual lives, neighborhoods, and communities to block disease before it starts. We need to think and act upstream through primary prevention. If we think of an actual stream, primary prevention best occurs before the waterfall, before the rapids, before the current even quickens.
Primary prevention has long been recognized as the critical value multiplier of the health enterprise. It is where most of our substantial gains in years of life and life in years have occurred.3 Primary prevention can occur at an individual level with regular exercise or a vaccination; or, when these and other interventions are taken to scale, they become the critical "third bucket" of "total population or community-wide intervention" referenced by John Auerbach4 in his "Three Buckets of Prevention" model. Consider, for instance, safe drinking water, a prime "upstream" example of a "third bucket" intervention to avoid a myriad of diseases. Primary prevention is how we, in public health, as engaged as we may be in providing direct services, most effectively leverage our work and resources.
Despite our ever-increasing health care spending, the diseases compounding our health crisis, themselves driven by the Big 4 behaviors, generally cannot be cured by today's health care enterprise, which is currently configured to identify the resulting health problems (secondary prevention) or lessen their adverse consequences. The health enterprise has not yet figured out how to take primary prevention of the Big 4 to scale on its own-it is not generally incentivized to do so-and it is only beginning to have discussions with other sectors about joining forces.
A Return to Public Health's Roots: Primary Prevention
In Tennessee, our approach began with our introspection on public health's greatest accomplishments, the focus of which was not inside the clinic walls but on reshaping places and spaces to engineer and guide healthier, safer behaviors. We created opportunities for our county health departments and their partners to engage communities through an effort we call the Primary Prevention Initiative (PPI). That initiative-created nearly 4 years ago-aims to shift our focus to the upstream determinants of health in order to fulfill our mission to "protect, promote, and improve the health and prosperity of people in Tennessee." The PPI is a statewide, innovative approach that gives TDH employees of all roles and job responsibilities time to target the places and spaces upstream that provide the greatest opportunity for health protection.
A focus on primary prevention, particularly the community-wide interventions of the "third bucket," is what the Department of Health and Human Services' Dr Karen DeSalvo calls for in Public Health 3.0.5 DeSalvo discusses the need to engage in partnerships outside of the health sector to make upstream changes to the policies and decisions that influence health downstream.
By thinking creatively about the role of our public health workforce in upstream primary prevention efforts, we have charged our teams to be part of the solution. There are 2 primary target populations for the PPI: (1) the public health team itself, and (2) the entire population of Tennessee. The PPI is about multidisciplinary teams making primary prevention "infectious" in the broader population of Tennessee and foundational to each community's culture of health. The most successful projects get adopted and replicated by others, engaging actors well outside the TDH public health team.
More than 2030 primary prevention initiatives have engaged stakeholders across Tennessee to make significant upstream progress on the Big 4:
Substance abuse: In partnership with corrections institutions, counseling to prevent unintended pregnancy and Voluntary Long Acting Reversible Contraception (VRLAC) offered to female inmates have reduced infants born with neonatal abstinence syndrome by two-thirds in some counties.
Excessive caloric intake: A total of 654 businesses across the state have taken the pledge to be supportive of breast-feeding in their workplaces through the "Breastfeeding Welcomed Here" campaign.
Physical inactivity: In partnership with the Tennessee Department of Environment and Conservation and local schools, "run clubs" have been established that allow children of any ability to compete against themselves in a peer environment that is supported by trained coaches and mentors, helping foster lifelong habits of joy in physical activity.
Tobacco use: In a unique effort to engage Tennessee youth, the Unsmokeable social media campaign was developed by youth and for youth, has received nearly 3 million shares on social media, and led to the development of a large youth tobacco summit. The Baby and Me Tobacco Free initiative has resulted in 25 fewer preterm births across the state, saving $2.25 million in health care costs.
These are a few among many potential countermeasures to the Big 4 that can help constrain and mitigate the health crisis of our time.
Conclusion
The time has come for the health sector to recognize that reacting to problems is not the same as preventing them. We need to be a partnering and engaging agent, nimble and adaptable to work upstream in different environments with the stakeholders closest to the source of solutions. The PPI is one example of multiple important efforts across Tennessee to reshape our image across local communities, improve our health culture, and reshape the health expectations and outcomes of our state. Leadership in primary upstream prevention, such as the PPI, provides us an opportunity to change the notion that health is only about health care and to engage individuals and communities in solving for the health crisis of our time by making a culture of health everybody's idea.
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