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Months after the grant that brought it to life ran out, Live Tobacco-Free Austin lives on.
Like many of the wellness programs started with $372.8 million in stimulus funding, Live Tobacco-Free Austin secured a new federal grant before the old one had run out and retained most of the staff hired to run the program.
Contrary to the billing of the $862 billion American Recovery and Reinvestment Act as a one-time infusion, the smoking and obesity programs branded Communities Putting Prevention to Work were never meant to be orphaned.
While hundreds of new hires were spending hundreds of millions in advance of a March 2012 spending deadline, advocates were busy embedding promises for billions more in something called the Prevention and Public Health Fund created with the passage of the Patient Protection and Affordable Care Act, Obamacare.
The fund is expected to spread $1 billion around to wellness programs this year and increasing every year after to $2 billion by 2016.
To augment that, the Centers for Disease Control and Prevention began the Community Transformation Grant program, pouring $103 million into wellness programs, several, including $1 million for Austin’s smoking program, started through Communities Putting Prevention to Work.
The Texas Department of State Health Services received a $10 million Transformation Grant for its wellness programs.
“You have a one-size-fits-all approach to multi-faceted problems,” Marlow says. “There is no such thing as a temporary solution, just more money for more solutions.”
In the early part of 2010, about a year after the stimulus bill was passed, the Austin/Travis County Health and Human Services Department filed two of what would be 263 applications for Putting Prevention to Work through the Centers for Disease Control.
The CDC made 44 awards, including $7.5 million for a smoking program for Austin, rejecting its application for an equal amount for an obesity program. The San Antonio Metropolitan Health District was the only other Texas agency to get a grant, $15.6 million to combat obesity.
Los Angeles County got the largest grants, for smoking and obesity programs, $32.1 million; New York City got $31.1 million; Seattle/King County got $25.5 million; and Philadelphia, $25.4 million.
Cassandra Deleon had been working for the Texas Department of Health and Human Services when she applied for and was hired, along with eight others, to manage the Austin smoking program.
The grant was the largest of its kind secured by Austin/Travis County, and Deleon says staff saw in it a tremendous opportunity to change the social norms around smoking.
There was one problem. For years tobacco was a potent political issue in Austin, but with the passage of what was, in 2005, one of the strongest local anti-smoking ordinances in the country a kind of exhaustion set in.
Austin spent about $1 million incorporating tobacco use data into the medical records of its hospital and clinic partners, Deleon says.The program set up the Live Tobacco-Free Austin website. The Ash Trailer – a vintage Airstream covered entirely with ash trays – was designed for public service appearances, she says.
Most of the funding, about $3 million, went into a radio, television and billboard campaign touting the benefits of living tobacco-free.
Deleon says she is pleased with how they deployed the grant money. The community transformation grant is testimony to the commitment to fight smoking, she says.
But this kind of program, she says, resists efforts to correlate spending with fewer people using tobacco. “We’re in the process of collecting data and, of course, were hoping for a reduction in tobacco use across the board,” Deleon says. “It’s more like that what we’ll be able to track is awareness of our live tobacco-free message.”
This is an example of the diminishing return on the money spent getting people to give up tobacco, Marlow says. After billions in federal, state and local subsidies, hundreds of thousands of tobacco-related deaths, punitive ordinances and prohibitive taxes on cigarettes, more than 45 million adults choose to continue to smoke, according to CDC figures.
“After all that’s been done, people who smoke know it’s unhealthy,” Marlow says. “Continuing to tell them that is not giving them any new information. But that isn’t going to stop the paternalists from spending money on what is no longer effective.”
There is evidence that smoking cessation programs will have to fight for funding with obesity, the new darling of federal wellness. The CDC made $230 million in obesity grants, compared to $142.8 million for smoking through the Communities Putting Prevention to Work program.
San Antonio, which has found itself on several of those much anticipated lists of the nation’s fattest cities, was an ideal candidate for its obesity grant, by far the largest single grant ever awarded to the Health Department, Christine Rutherford-Stuart, assistant director for the Community Health Division, says.
Unlike Austin, San Antonio’s bid for a Community Transformation grant was turned down. After an extension runs out and the $15.6 million is spent, the last of 13 people hired through the stimulus will be let go, Rutherford-Stuart says.
Assuming the one-time windfall wouldn’t come again, San Antonio spent nearly half of its money on bike and walking lanes and outdoor fitness equipment for parks and libraries, infrastructure that could be maintained in the future by other municipal departments, she says.
A full quarter of the funding went to physical activity programs. Among them is Siclovia, an annual bicycling event modeled after a popular rally in Bogotá,Columbia. More than 15,000 people participated in the first Siclovia, 40,000 last year and 60,000 people are expected on Oct. 7, Rutherford-Stuart says.
Another 20 percent of the grant went into nutrition and health plans, including the installation of salad bars in 108 public and charter schools in the city.
Rutherford-Stuart says the YMCA, its partner for Siclovia, has agreed to continue funding the event in coming years. The Health Department is relying on partnerships to continue exercise, fitness and nutrition programs in the absence of the stimulus money, she says,
Having put all of this in place, Rutherford-Stuart says her department will be hard pressed to find proof of actual improvement in public health. Through questionnaires the department hopes it might be able to track changes in behavior.
“We’re happy for the opportunity to use the grant money, but it will be a huge challenge going forward.,” she says. “It took decades to get where we are in San Antonio and in this country with obesity. It’s going to take decades to alleviate the problem.”
Data from the CDC suggests what has been done at the federal level since the turn of this century has not worked. The current obesity rate of 35 percent – meaning nearly 110 million Americans are obese – is the nation’s highest ever.
In 2000, no state had an obesity rate greater than 25 percent. Today, two dozen have rates between 25 and 30 percent and a dozen top 30 percent, the CDC says. In 2000, 27 states could claim obesity rates of less than 20 percent. In 2010, none could make the claim.
The federal response to this failure is to redouble its efforts and its funding, making it clear to what were once pilot Communities Putting Prevention to Work programs that money will be made available to do further battle with fatty foods.
After exhausting its stimulus grant, Los Angeles County got another $9.8 million from the Community Transformation fund. San Diego County spent its $16.1million stimulus grant on obesity and got another $3 million in transformational funds. Philadelphia, too, got another $1.5 million after spending $15 million on obesity and $10.4 million on smoking.
Amanda Dudley, spokesman for the CDC’s National Center for Chronic Disease Prevention and Health Promotion, says the CDC has no intention of continuing the Communities Putting Prevention to Work as a national program.
The agency, however, refers to the grant money available through the Affordable Care Act as CPPW Phase Two funding.
And although one of the primary goals of all stimulus programs was to create or retain jobs, Dudley was unable to say how many of those jobs CPPW created or retained or offer a generalized assessment of the impact the program had on government hiring.
Trying to count the jobs, she said, would be misleading because of the way Recovery.gov, the stimulus website tracking spending and job creation, collected the data.
Having also failed to negotiate Recovery.gov, Texas Watchdog contacted the recipients of the 10 largest CPPW smoking and obesity grants. Los Angeles County flatly declined to answer questions. Philadelphia officials said they were still analyzing what they had done with their grants. Four agencies did not respond to our inquiry.
What is clear from the four that responded – the Miami-Dade County Health Department, San Diego Health & Human Services Agency, the Seattle – King County Department of Public Healthand theSouthern Nevada Health District – was a commitment to continue on as long as the funding continued to come in.
Although almost all of its grant had been spent by July of this year, San Diego County hung onto all 13.7 full time equivalent positions, spokesman Michael Workman says.
A package of Community Transformation, Supplemental Nutrition Assistance Program Education and other grants and some county money has kept 6.7 jobs alive in a program that has been renamed Healthy Works.
“The program is considered a cornerstone of the County of San Diego’s Live Well, San Diego!, a 10-year initiative to improve the lives of San Diegans through healthy, safe, and thriving communities,” Workman says.
The other seven CPPW employees were re-assigned to other jobs on the county payroll, Workman says.
By Seattle-King County’s calculation, its grant paid the salaries for 134 jobs in the Public Health Department and with the community partners who participated in the obesity and smoking programs, spokeswoman Kathryn Ross says.
Roughly two-thirds of the Public Health employees brought on with CPPW money are staying, Ross says, through a combination of federal grants, some foundation funds and the reallocation of money in the department budget.
A good share of the work will involve developing a plan to make the one-time grant program sustainable, she says.
Of the 12 people hired by the Miami-Dade County Health Department funding had been found to hold onto more employees, although spokeswoman Rosa Oses-Prealoni says they are hoping to find more funding to keep several others.
The work will continue through other entities funded at least in part through federal, state and local taxes, Miami-Dade County, the Miami-Dade County School Board, the City of Miami, and the City of North Miami and the Consortium for a Healthier Miami-Dade.
Only in the Southern Nevada Health District, which kept its hiring to one person, was there an effort to make sure the CPPW money was spent on programs carried out largely by people already on staff, according to spokeswoman Jennifer Sizemore.
Regardless of the inability to account for or measure the effectiveness of these federal programs, which Marlow insists is dubious, the perception of crisis, in smoking and in obesity, creates an inertia difficult to halt.
“It’s a bottomless pit,” Marlow says, “and it will never stop.”
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