Expanding the Focus of The Robert Wood Johnson Foundation

Expanding the Focus of The Robert Wood Johnson Foundation
Health as an Equal Partner to Health Care By J. Michael McGinnis and Steven A. Schroeder

A 1993 article in the Journal of the American Medical Association by J. Michael McGinnis and William Foege estimated that more than 40 percent of all deaths in the United States could be attributed to behavior-related causes. For example, the authors attributed 400,000 deaths in 1990 to tobacco, 300,000 to diet and activity patterns, and 100,000 to alcohol. This widely cited article served to wake up many in the health field to the fact that medical care alone can not always ensure better health, nor is it a dominant determinant of health status. It was among the factors that led the Foundation to reconsider its priorities and, in 1999, to make an important change in its focus.

This chapter offers a detailed examination of why and how the Foundation moved from an approach focusing largely on improving health care services to one that gives equal importance to addressing the behavioral and social causes of poor health. It explores the ramifications of this shift-including the largest-ever reorganization of the Foundation's staff into two groups, one focused on health care, the other on health. Additionally, it lays out a blueprint for a grant making program that is currently being developed by the health group.

The authors are well positioned to provide an insiders' view of this change in the Foundation's priorities. Steven A. Schroeder is the president and chief executive officer of The Robert Wood Johnson Foundation. J. Michael McGinnis, the co-author of the 1993 article that helped trigger the change, was named a senior vice-president of the Foundation in 1999. He is the director of the Foundation's health group.

This is the latest in a series of chapters in the Anthology series in which senior executives of The Robert Wood Johnson Foundation explain how the Foundation sets priorities and makes funding decisions. In the 1998-99 Anthology, Robert Hughes explained the process that led the Foundation's trustees to adopt substance abuse prevention and treatment as a Foundation goal. In that same volume, Steven Schroeder discussed the core values that guide the Foundation's grant making. In the 2000 Anthology, James Knickman described priority setting in Foundation-supported research and, in a chapter that appears in this Anthology, Frank Karel details the Foundation's strategies in the communications area. Viewed as a whole, these chapters take some of the mystery out of the seemingly impenetrable world of philanthropy.

At the founding of The Robert Wood Johnson Foundation, its mission was clearly and simply stated: to improve the health and health care of all Americans. Throughout its existence it has been the largest philanthropy devoted exclusively to this field. Yet for much of its first twenty years the Foundation attended predominantly to the medical care element of its mission.¹ That is, it focused on health care delivery, with special emphasis on providing medical services-the health care dimension of its mission. By contrast, it neglected the non-medical care factors that influence a person's health, such as choices about smoking, diet, sexual behavior, and physical activity, as well as environmental exposures and other factors-the health dimension of its mission.

Over the most recent decade, a shift occurred, first with the incorporation of a major emphasis on substance abuse as a primary source of preventable illness and injury among Americans, and, in 1999, with the decision by the Robert Wood Johnson board of trustees to give formal standing to the health dimension. Today, the Foundation consists of two distinct, overlapping, and roughly equivalent program groups-health and health care. How and why did this evolution occur, and what are its implications?

That the early emphasis was on medical care is not surprising. The Foundation's endowment derived from Robert Wood Johnson, who made his family's business, Johnson & Johnson, pre-eminent in the manufacture of medical supplies, devices, and pharmaceuticals; the Foundation's founding president, David Rogers, was a physician and a former medical school dean; and it was created in 1972, as the establishment of Medicare and Medicaid was beginning to funnel tremendous resources and influence into medical care and before the political and medical communities fully realized that many health problems could be prevented. Moreover, the speed of such substantial changes in health financing gave an aura of inevitability to the advent of national health insurance, and instilled some urgency to the idea of increasing the capacity of health care delivery to accommodate the anticipated demand.

During the 1970s and 1980s, however, it became increasingly obvious that the situation was not so simple. National health insurance proved elusive. Indeed, as a result of the formidable political, social, and economic barriers to expanding health insurance coverage, a greater percentage of Americans had health insurance three decades ago, when the Foundation was established, than have it now.^2,3 The Foundation maintained its faithfulness to the principle of better and more equitable insurance coverage, but new concerns arose. The development and the application of new diagnostic and therapeutic technologies, combined with the expanded capacity of the health care system, generated a rapid increase in health care costs, raising the specter of unaffordable care and accentuating the disadvantage for those who were uninsured.

As a proportion of the Gross Domestic Product, medical care costs nearly doubled in the two decades of the 70s and 80s, increasing from 7.4 percent of gross domestic product in 1970 to 13.6 percent in 1992. This alarmed health policy makers and the business community alike; medical cost containment supplanted health insurance expansion as the nation's number one health policy concern and prompted a shift in The Robert Wood Johnson Foundation's concerns away from expanding health care supply to constraining it. The Foundation joined, and even led, elements of the health policy community in exploring and testing attempts to stem the growing costs. These efforts were largely unsuccessful in the near term but offered interesting insights into the entrepreneurial nature of the health delivery and health financing structures that had evolved.⁴

While The Robert Wood Johnson Foundation's funding focused on the medical care system, scientific evidence was accumulating to show that medical care was only one of many contributors to personal and national health status.⁵^,6 Though the United States was the acknowledged world leader in its supply of sophisticated medical technologies for diagnosis and treatment, it lagged far behind other developed countries in traditional health status measures such as infant and maternal mortality rates and life expectancy from birth. Some of that gap reflected limited access to medical care among the poor and the uninsured, but much of the difference was due to factors that lay outside traditional health care delivery-genetic predispositions, social circumstances, physical environments, and behavioral choices (see Figure 1.1 below).

In the mid to late 1980s, several programs were initiated at The Robert Wood Johnson Foundation that transcended the traditional health care boundaries of Foundation support. One, the Infant Health and Development Program, tested whether supportive services to vulnerable infants and their parents could improve subsequent health and educational status. Another tested the impact of home visits by nurses. In contrast to those in comparison groups, 15-year-olds who had been born to unmarried teens in poverty who had received nurse home visits during pregnancy and after birth reported substantially lower rates-often half or less-of arrests, of convictions, of lifetime sex partners, of cigarettes smoked per day, and of days having consumed alcohol in the last six months.⁷

Other programs, such as funding for Fighting Back, a multi-community effort to combat drug abuse and alcoholism, and the Partnership for a Drug-Free America, a media campaign to make illicit drug use socially unacceptable, extended the Foundation's field of interest directly into near-term efforts to reduce risky behavior. The Foundation's willingness to address the prevention of AIDS also mandated attention to behavioral issues of sexuality and drug use.

As a result of these early programs, in 1988, when the Foundation articulated three new target priorities and ten specific new areas of interest, health issues became a priority for the first time-albeit a relatively low priority. The inclusion of "destructive behavior including drug and alcohol abuse, and mental illness" within the ten areas of specific interest opened the door for more expansive grant making in health. Still notable by its omission was the problem of tobacco use, which contributed more to mortality than alcohol and drug abuse combined.⁸

With the recruitment in 1990 of a new Robert Wood Johnson Foundation president, Steven A. Schroeder, who was committed to public health and prevention and with a mandate from the trustees to reconsider grant making priorities, the Foundation began a sustained effort to stop the damage caused by harmful substances, including tobacco. Substance abuse seemed an appropriate focus for several reasons. A base of experience had been established through the Foundation's early work in the area. Other foundations had limited involvement with relatively narrow components of the problem, but their support and their programming in this area were negligible. Government activities in the areas of tobacco and alcohol were often politically constrained because of the influence of powerful industry groups. Most important, the evidence about the medical and social damage caused by these substances was irrefutable and compelling.

The program emphasis on substance abuse generated considerable internal debate at the Foundation. Initially, most Robert Wood Johnson staff members were more supportive of developing antidrug programs than of efforts to combat alcohol and tobacco abuse. There was widespread press attention and popular concern about the impact of illegal drugs on society, the federal government had created a drug czar to lead the national assault, and there was no ambiguity about either the pernicious nature of the problem or the politics involved. On the other hand, grant making related to alcohol was complicated by emerging evidence that people who drank in moderation might have better health outcomes than either heavy users or abstainers. And with respect to tobacco, many felt that the antitobacco war had already been won, rendering Foundation support irrelevant.

At a special retreat held in February, 1991, three proposed new goals-targeting substance abuse, access to care, and care for chronic conditions-were brought forward for consideration of the trustees. Only the substance abuse goal received much debate, and the trustees quickly found themselves at an impasse. While all agreed that the public health case was strong, there was substantial debate about becoming involved in tobacco and alcohol. Proponents argued that it would appear hypocritical to limit the focus to the issue of illicit drugs, given that the toll from tobacco and alcohol was so much higher. Opponents countered that tobacco and alcohol were legal substances, that people had the right to choose whether and to what degree to use those substances, and that controversy would result from the inevitable conflict with the powerful tobacco and alcohol industries.⁹ A compromise was reached whereby all three types of substances would be included, with initial programs aimed at tobacco and alcohol use directed only at children and young people, for whom these substances were illegal. Thus, for the first time a health topic emerged as a separate Robert Wood Johnson program goal, and grant making in the substance abuse area flourished over the next decade.

After early experience with grants aimed at reducing youth exposure to tobacco and alcohol, the target age group gradually expanded to include binge drinking by college students, tobacco cessation for adults in managed care, state coalitions against tobacco use, and other substance abuse efforts. The issues debated in the 1991 board retreat have often resurfaced in subsequent discussions among both staff members and trustees: tensions between public health and civil liberties; the role of government in safeguarding the health of the public, especially young people; and the Foundation's role vis-a-vis industry. Nevertheless, over time the Foundation clearly became more comfortable with grant making in this arena, solidified its original sense that philanthropic efforts in substance abuse had great potential to improve the health of the public, and was able to enlist other foundations and organizations to join with it.

A notable example was the start-up of the National Center for Tobacco-Free Kids in 1996. The Foundation and the American Cancer Society were the two major founding sponsors, and they were joined by the Annie E. Casey Foundation, the Conrad Hilton Foundation, the Henry Ford Health System, the Henry J. Kaiser Family Foundation, the American Heart Association, and the American Medical Association in the effort. Concurrently, the national attitude toward the tobacco industry was also shifting, in part because of other developments such as the release of industry documents about concealment of intent, the successful litigation strategies of state attorneys general, and scientific evidence demonstrating changes in the brains of addicted smokers, paralleling similar changes in drug addicts.

As people recognized not only the importance of this issue in general but also the Foundation's leadership in particular, staff and board concerns were replaced by pride at the Foundation's contributions to preventing substance abuse. By the end of 1999, the Foundation's active commitments for substance abuse amounted to $361 million or 27 percent of all of its commitments at that time, and substance abuse was clearly established as a crucial part of the Foundation's sphere of interest. For the period January 1972 through December 1999, the Foundation's total commitment in substance abuse equaled $820 million in both active and closed programs.

Coincident with the evolution of programming in substance abuse as a clear and central focus for the Foundation's agenda, evidence was accumulating that future improvements in health status were more likely to come from influences outside the medical care domain.^{10,11,12,13,14} Epidemiological studies that were begun with the rapid growth in the National Institutes of Health in the 1950s and 1960s generated important insights in the 1970s and 1980s on the role of a variety of behavioral factors underlying the nation's leading killers-heart and lung disease, cancer, stroke, diabetes. Findings from environmental and occupational studies identified several serious long-term effects from exposure to a variety of environmental toxins, including lead, asbestos, radon, mercury, polychlorinated biphenyls (PCBs), nitrates, and certain atmospheric pollutants. Work in genetics offered increasing evidence on human biological predispositions to certain diseases, and vulnerabilities to behavioral and environmental exposures. Interesting hints began to emerge in the 1980s and 1990s of pathways by which the stress of social circumstances might affect susceptibility to certain diseases. As understanding deepened regarding the origins of and vulnerability to disease, additional opportunities emerged for broader health initiatives that had the potential to make a difference in the health of Americans.

As knowledge was growing, so were the Foundation's resources. Because of the sustained bull market of the 1990s, the Foundation's assets-and thus the size of its grant making-grew at a rapid pace, climbing from $2.6 billion in 1990 to $6.7 billion by the start of 1998. It became apparent that the increased growth was stretching the Foundation in several ways. First, although staff growth lagged significantly behind asset growth, the sheer number of professional staff members made the old collegial style of everyone's sitting around a table and debating proposed programs less tenable. This was symbolized physically by the fact that we outgrew our meeting room. Second, the previous structures and processes that governed grant formation and oversight were in danger of breaking down under the increased workload. In addition, it became evident that the Foundation could benefit from bringing on staff with special expertise, such as health care financing or treatment of alcoholism. Yet the old organizational format was not ideally aligned for such specialized recruiting, because it lacked specific objectives. Furthermore, a reorganization might provide new opportunities to improve the strategic focus of grant making.

In January 1997, the President's Message to the trustees signaled that change might be necessary to accommodate the Foundation's growth. It seemed appropriate to accommodate growth by investing further in grant making in health, because the Foundation's experience to date had been so positive and the evidence of possible return so compelling. Given the growth in assets, it appeared that the Foundation could have its cake and eat it too-that is, it could retain its traditional emphasis on health care delivery while at the same time moving toward parity in its health grant making. The message prompted a great deal of discussion among the trustees and staff about the issues and possible approaches. For example, the possibility of creating a sub-foundation-located in another city-that would specialize in substance abuse was seriously explored. Such a move would relieve the problem of overcrowding and provide an interesting model of decentralized and focused grant making. Over the next two years, staff members and trustees held meetings, interviews, and planning sessions to consider the various options. The trustees rejected the idea of a stand-alone substance abuse foundation because they were more comfortable with the tighter governance model provided by having all programs and staff under the same roof. Instead, they adopted a different form of decentralization: the Foundation reorganized into two distinct but overlapping groups, or clusters of staff interested in kindred issues, one to focus on health and the other on health care. This reorganization established health as an equal partner with health care for the first time. A national search was conducted for leaders of the two groups, and in the spring of 1999, two new senior vice presidents were appointed. Jack Ebeler was brought in to direct the Health Care Group, and J. Michael McGinnis to direct the Health Group.

Throughout 1999, the Health Group worked to identify those areas where Foundation leadership and investment could best influence the health of the general population. Because even a foundation the size and reach of The Robert Wood Johnson Foundation could not reasonably expect to provide leadership in all the areas that influence health status, the immediate challenge has been to identify those that present the greatest opportunities for the Foundation at this time. Three criteria have helped guide our choices: addressing the problems of greatest importance to the health of Americans; building on the strengths and experience of The Robert Wood Johnson Foundation in philanthropy; and working in ways in which Foundation leadership might make the most lasting contribution to building the field of population-wide health improvement.

The primary influence that stands out as a critical controllable determinant of the health of Americans is behavior. Behavioral factors have been estimated to account for more than 40 percent of deaths among Americans, with the most prominent contributions coming from tobacco, patterns of diet and physical activity, alcohol, risky sexual behavior, use of guns, drug use, and operation of motor vehicles. The first three of these alone account for about a third of all deaths.¹⁵

Social circumstances are also a major determinant of health. Educational level, poverty, and race all contribute to health disparities. Among people aged 25 to 64 years in the United States, the overall death rate for those with less than 12 years of education is twice that of people with 13 or more years of education.¹⁶ People in poverty have about a one-third higher risk of dying in any given year than those in the general population.¹⁷ Even after adjusting for tobacco and alcohol use, obesity and physical activity levels, people who have sustained economic hardship for long periods are nearly three times more likely to be disabled than those who have not sustained such economic hardships.¹⁸ Relative to other Americans, African Americans are more likely to die in infancy, the teen years, and adulthood.¹⁹ People who perceive themselves to be socially isolated-that is, who feel particularly disadvantaged or estranged from others in society as a result of economic, geographic, cultural, or other personal circumstances-report added stress and often have two to three times the risk of health problems.²⁰ How people view their place in society may also work to increase their risk.²¹

The physical environment is also important to health prospects. Some of our greatest health gains have come as a result of improvements in the quality and the safety of our water, air, and food supplies. On balance, the safeguards in these areas are working reasonably well. The principal challenges from our physical environments are twofold: maintaining our capacity and our vigilance to safeguard water, air, and food; and understanding and monitoring the influence of global factors-such as climate change, atmospheric pollution, and infectious diseases emerging in new places as a result of ecosystem change-that will shape the magnitude of the environment's influence on our health.

Genetics is another area of increasing importance to health. Although purely genetic diseases are rare and of limited impact on the health of the entire population, developments from the human genome project can be expected to add to the capacity to target preventive interventions for individuals and populations at greatest risk. The important issue is not how much disease and disability is caused by genetic aberrations but how genetically determined susceptibilities interact with environment, behavior, and social conditions to bring on disease.

As we explored ways to build on the established record of the Foundation, three areas where the Foundation had relevant experience emerged: the experience gained in substance abuse; that gained in working in communities to reach disadvantaged populations; and that gained through leadership development programs such as the Clinical Scholars Program that draw the best and brightest professionals at the postdoctoral level into fields they might not otherwise have had the opportunity to explore.

In a way, a similar opportunity now exists for creative thought and policy leadership for population-wide strategies for health improvement. A new field of population health is emerging, a field that addresses the root causes of disease and disability-identifies them, characterizes them, and intervenes against them through clustered programs-and, by doing so, seeks an allocation of social resources for health improvement that is both more effective and more efficient.

To design and implement our contributions to the health field, we have chosen to structure the activities of the Health Group around five teams: tobacco; alcohol and illegal drugs; health and behavior, with a special emphasis on physical activity; community health, with emphasis on social connectedness; and population health science and policy. We have chosen tobacco, alcohol, and illegal drugs as priorities because they represent the most pronounced influence on early death, disability, and dysfunction among Americans, and because the Foundation has developed a strong record of leadership in the field. We have chosen physical activity as a priority because we now know it is a matter of vital importance to the health of every American, the prevailing trends have been in the wrong direction for a generation and because no alternative sources of national leadership with substantial resources to address the problem exist. We have chosen community health and a focus on socially isolated populations, both because of the need for more understanding and action in the area and because the Foundation has a long record of community-based programs. And we have chosen population health because the field is in its infancy and requires resources devoted to research and policy development in order to build it.

Tobacco The tobacco team seeks to decrease the number of Americans who use tobacco. We have a well-established and active agenda of current programs in tobacco.²³ A special opportunity is offered to the field of tobacco control with monies now available through the states' tobacco settlement, so The Robert Wood Johnson Foundation will now focus on preventing tobacco use by stimulating stronger state and federal policy actions and helping addicted tobacco users quit by promoting the use of effective treatments.

The alcohol and illegal drugs team aims to reduce the negative health and social consequences that abuse of alcohol and illegal drugs has on people. Over the last decade, the Foundation has provided leadership on and visibility for the issue of substance abuse.²⁴ One of the principal shortfalls remains the failure to apply appropriate treatment, despite increasing evidence of the effectiveness of treatment protocols. The combination of target populations that are hard to reach, society's natural aversion to drug addicts, payment systems that do not include substance abuse treatment as a part of routine medical care, and a lack of professional interest in confronting substance abuse problems make this an especially challenging and important problem.

The health and behavior team is attempting to increase Americans' healthy behavior, especially physical activity. Health-related behavior change is not a new focus for the Foundation-many substance abuse programs have focused on behavior change-but the emphasis on physical activity does represent a new departure. Information from epidemiological studies conducted over the last decade offers powerful testimony about the importance of physical activity across the life span in protecting against a variety of health problems. Compared to earlier generations in which work and living styles were more active, our population has become increasingly sedentary; in 1997, 40 percent of adults performed no leisure time physical activity at all.²⁵ Producing even small changes in activity levels might yield major health benefits. The Foundation, therefore, is supporting efforts to bring physical activity back into Americans' lives, and specifically hopes to increase the activity levels of sedentary middle-aged and older adults. In the broader arena of health behavior, the Foundation is seeking to promote more attention to these issues by doctors and nurses during the course of routine medical visits.

The community health team is addressing the community and social factors that promote individual health, primarily by focusing on bringing those whose social circumstances leave them feeling estranged from others and at increased risk for adverse health outcomes-such as pregnant teenagers in poverty, juveniles who are chronically truant or in trouble, or older people living alone-into better supportive relationships. Although the work of this team offers a new grouping for community-based activities, the Foundation has long funded community-level health programs. Examples of such programs include home visiting by nurses, family resource centers, and interfaith volunteer caregiving. Given the increasing body of knowledge confirming the importance of strong community ties in enhancing the health prospects of individuals at risk of social isolation, the community health team is focusing on improving community outreach to socially isolated individuals and understanding better how social support and connectedness can improve health.

The population health science and policy team seeks to promote knowledge, leadership, and methods of enhancing population-wide health improvement strategies and programs. In order to achieve the goal of improving the health of all Americans, the Foundation needs to make long-term investments that will increase the number of researchers working to understand factors that promote healthy lives; it also needs to improve the quality and use of methods that can measurably improve a community's health. Existing investments in this area include the Turning Point program that is attempting to revitalize public health at the state and local levels; an effort, now in the planning stage, to create a center fostering the application of commercial marketing techniques for health improvement ("social marketing"); work to foster improved understanding of the effectiveness of childhood immunization; and a range of programs to encourage the development of leadership in the public health field. We envision major initiatives in the coming years to take advantage of Internet and web-based health information technology for consumers and for public health; to engage highly trained scholars in issues important to population health; to sponsor centers of research, analysis, and practice targeted to population health improvement; and to encourage policy interventions that support population health improvement.

Expanding our health grant making holds the promise of focusing our attention and resources on the many powerful determinants of health status that lie outside the reach of medical care. As has sometimes happened in the past, by focusing its attention on a field, The Robert Wood Johnson Foundation might spur other foundations, government entities, and the media to give it attention as well. If this happens, the Foundation could be a catalyst in a nationwide effort that results in Americans living healthier lives. Certainly, a shift in priorities that gives as high a place to healthy behaviors as to good medical care would be salutary.

Whether these promises will be realized depends on how well we develop strategies, identify the right initiatives and grantees, and evaluate and communicate the results of programs. This is a major hurdle, one that the program teams are devoting great effort to overcoming. Moreover, the success of these efforts will depend on the extent to which The Robert Wood Johnson Foundation can forge partnerships with other philanthropies and with public agencies. Under the best of circumstances, establishing collaborations is complicated;²⁶ in an area new to the Foundation, it may be even more challenging.

Another challenge is maintaining focus while we carry out a greatly expanded mandate. While we must stretch our horizons and extend our reach in order to build the nation's capacity to understand, take action, and formulate policies related to health improvement, it is clear that a single foundation cannot do everything. We have limited our health grant making to five discrete areas, albeit broad ones.

The very notion of trying to build a field-in this case the field of population health-carries with it interesting challenges. In philanthropy, we often think of ourselves as seeking to enhance the development of a field in one aspect or another-and there have been some discernible successes in that respect. The early contributions of the Rockefeller Foundation to the green revolution that increased global food production come to mind, as do the work of the Carnegie Corporation with libraries and the Ford Foundation with schools of public policy. The Robert Wood Johnson Foundation has gained, over the years, considerable experience in helping to establish and strengthen new fields-from emergency medical services to tobacco policy research. As part of our efforts to develop the field of population health, we will bring to bear the experience of our foundation as well as those of other foundations that have helped establish new fields.

The Foundation's reorganization offers both opportunities and challenges. Under any circumstances, change is difficult; massive change is even more unnerving. In the case of The Robert Wood Johnson Foundation, three changes are taking place simultaneously: a new strategic vision that gives health an equal status with health care; a reorganization of the staff into two groups (with distinct mandates but inevitably overlapping interests) and eleven program management teams; and development of new, quantifiable objectives for each program area. The way in which the Foundation adapts to change and meets the challenges inherent in each of these areas will affect its ability to reach its aspirations and will provide lessons of interest to our colleagues in the philanthropic community.

It is clear that improving the health of the American population will require fundamental changes in human behavior.^27,28 Merely providing more and better access to medical care-as important as that is-will not be sufficient to make us a healthier nation. Nor will investment in basic research alone-as promising as this may be-bring fundamental improvement in the health of our population. Obviously, it is easier to say that improvements in health determinants are essential than it is to make those improvements a reality. Nevertheless, by establishing health as a full and equal partner with health care, The Robert Wood Johnson Foundation has pledged to do its part in pursuing that goal.