Foreword

This marks the fifth volume of To Improve Health and Health Care: The Robert Wood Johnson Foundation Anthology. The Anthology series tries to present clearly and forthrightly what the Foundation does, why it does it, and what it has learned from its experience. To do this, we ask outside journalists, program evaluators, and other experts to examine their topics with a critical eye, and to report their observations in language that is easily accessible to the lay public. Where chapters explore the inner workings of the Foundation, we ask Foundation staff members to be analytical and hard-headed as they write.

What unifies the Anthology series is the focus: every chapter relates to the Foundation’s work to improve the health and health care of the American people—its mission since it became a national philanthropy in 1972. Beyond that, the book is truly an anthology: a collection of articles about a range of topics by a variety of authors, each with a different style and an individual perspective. Volume V is no exception.

The first six chapters focus on programs that are still running or that ended in the recent past.

In the first chapter, Joseph Alper, a writer specializing in health and science, examines the work of David Olds, whose program has offered nursing care and advice to poor, first-time mothers. This “nurse home visitation” approach, which the Foundation has funded for more than 20 years, and offshoots from it using less well-trained (and less costly) workers, is being widely studied and has been adopted in a number of states with the hope that it will improve the health and well-being of both mothers and their children.

In Chapter 2, Carolyn Newbergh, a California-based journalist with expertise in health care and policy, analyzes Old Disease, New Challenge, a program funded in the early 1990s, at a time when fear of a tuberculosis epidemic was mounting. It tested models of treating tuberculosis in hard-to-reach populations, including migrant workers in Florida, poor inner city people in New York, and migrants crossing the border between Tijuana and San Diego. Newbergh offers detailed case studies of three sites and provides insights gained from the program.

Chapter 3, by Paul Brodeur, a writer and specialist in health and environmental issues, looks at two programs to improve the health of Native Americans. Both programs gave the tribes and tribal organizations great flexibility in designing programs that would be in keeping with their culture and traditions. In his examination of the programs, Brodeur raises fundamental issues about the development of programs when recipients and donors do not share the same traditions, culture and values.

In Chapter 4, Susan Dentzer, the health correspondent for public television’s "The NewsHour," discusses two initiatives in which individuals who provide volunteer services for people with chronic illnesses receive credits that can be used when they themselves need help. She explores the genesis of the “service credit banking” idea, how the programs were carried out, and the reasons they did not work as planned.

The fifth chapter takes a look at a different approach to services for individuals with chronic illnesses: giving them the power to choose the services they use and the people who will provide them. A.E. (Ted) Benjamin, chair of the Department of Social Welfare, School of Public Policy and Social Research at the University of California, Los Angeles, and Rani Snyder, a research associate at the same institution, present three models that were tried at different locations throughout the country: one giving people with developmental disabilities the wherewithal to plan their own services; a second providing people with money to buy services; and a third testing a variety of approaches.

In the sixth chapter, Richard Frank, a free-lance writer and former editor of the National Journal, reviews one of the Foundation’s longest-running programs—the Health Policy Fellowships Program. Begun in 1973 and most recently reauthorized in 2001, it gives health professionals the opportunity to spend a year working on Capitol Hill. Frank chronicles the nearly three decades of the program, pinpointing its shifting priorities and analyzing its successes and failures.

This volume of the Anthology introduces a new section called "A Closer Look." Unlike the first six chapters, which deal with the Foundation’s large national programs, the chapters in this section look at smaller activities, such as those that occur at a single site. It offers a chance to examine activities at a community—or even an individual—level, rather than at the national level.

In Chapter 7, Digby Diehl, a free-lance writer and frequent contributor to the Anthology series, scrutinizes Recovery High, an Albuquerque, N.M., high school for substance-abusing adolescents. It operated between 1992 and 1996, when lack of funds forced it to close. In his examination of this specific school and the people behind it, Diehl raises larger societal issues about the cost of treating drug-abusing children and who should bear it.

In 1989, the Foundation made a grant for the publication of a book, On Doctoring, to be edited by Richard Reynolds, then the Foundation's executive vice president, and John Stone, a physician and writer. A collection of poems, stories and articles about the practice of medicine, On Doctoring is given to every entering medical student in the nation. In Chapter 8, Stone and Reynolds offer a personal reminiscence about how the idea of On Doctoring came about, the way in which they selected materials, and the value of a book designed to impart a sense of nobility, purpose and pride in those who practice the profession.

The Anthology offers an opportunity to reflect upon the Foundation’s past endeavors—to draw lessons from the past that can be useful in the present and the future. Previous volumes of the Anthology series have included chapters on the Foundation’s efforts to develop emergency medical services, regional perinatal networks, dental services, and the fields of nurse practitioners and physician assistants.

In Chapter 9, Ethan Bronner, the education editor of The New York Times, takes a look back at the Foundation's work to develop awareness of AIDS, and ways of preventing the spread of the disease. This was a major endeavor of the Foundation during the 1980s. Bronner traces the history of the Foundation's involvement, examines its large demonstration, research, and communications programs, and offers some lessons that were learned from the Foundation’s experience in the AIDS crisis.

The final two chapters delve into the way the Foundation works. They attempt to demystify the Foundation—to give outsiders a better understanding of the way a large philanthropy operates.

Most foundation dollars are distributed as grants, but there is another, less well-known mechanism available: loans, or, as they are more formally known, program-related investments. In Chapter 10, Marco Navarro, a program officer at the Foundation, and Peter Goodwin, the treasurer and a vice president of the Foundation, discuss when program-related investments are an appropriate funding mechanism, review the Foundation’s experience with them, and examine the pros and cons of program-related investments.

The final chapter, written by Pamela Dickson, a senior program officer at the Foundation, examines how the Foundation maintains the legacy of its founder, Robert Wood Johnson, and how it relates to its neighbors in the New Brunswick area and throughout the state of New Jersey. She explores the tension between the Foundation's approach nationally—one relying on competitive responses to Calls for Proposals for programs with the potential to have a major impact—and its approach in New Jersey, which is, to a great extent, that of a community foundation.

In my foreword to the first volume of the Anthology series, I observed that any single volume would provide only a glimpse of the Foundation's diverse activities, and that a more complete picture would emerge over the succeeding years. In some areas, it is emerging. For example, the five volumes of the Anthology have featured 14 chapters about the Foundation's efforts to improve access to health care—a problem that has remained high on the Foundation's agenda since 1972.

Based on their analysis of these chapters, Stephen Isaacs and James Knickman, in the editors' introduction that follows, identify five complementary approaches that the Foundation has used to address this enduring problem. These approaches, they suggest, illustrate the strengths and limitations of philanthropy in bringing about social change.

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