From the time we turn on the radio to hear the morning news until we turn off the television at night, we are bombarded by messages about new drugs, foods, exercise regimes, government programs, and other effects that supposedly will make our lives healthier and more fun. But reality and hype differ. Understanding innovations and their diffusion is now more important than ever; because of the spread of communication technologies and the globalization of the world economy, innovations will spread even more rapidly than in the past.
This issue of the Journal focuses on public health innovations, and on what makes one innovation diffuse more rapidly and be sustained longer than another: attributes of the innovation itself, the environmental context of the innovation, and characteristics of the innovators.
Every new idea has attributes that make it easier or more difficult to diffuse and sustain. People prefer to adopt magic-bullet technical solutions rather than change their behaviors. A pill that promises weight reduction in 3 weeks has much more appeal than a program of gradual change in diet and exercise. But as periodic headline-grabbing tragic deaths of star athletes who were trying to control weight or enhance performance show, we need to know much more about the implications of innovations for the public as a whole, for specific segments of the public, for government, and for business.
I am not suggesting that we become Luddites who oppose and delay every proposed wonder drug, treatment regime, and behavioral modification program. I am suggesting that we need to assess the effect of innovations in the same way we follow the ripples of a stone skimming across a lake. The initial impact of the stone does not necessarily tell us the size and number of peaks and troughs in succeeding ripples. We have learned, sometimes painfully, that innovations set in motion indirect effects upstream and downstream from the innovation that can have a greater effect than the innovation itself.
Innovations are successful in some places and times and failures in others. We need to know more about the spatial and temporal diffusion of major public health–influencing innovations because that information will tell us how innovators deal with the diversity of norms, values, laws, religions, ideologies, and political issues that can influence the adoption and long-term prognosis of a public health–related innovation.
The marketing ability of innovators, whether they work for government, business, or not-for-profits, seems to be growing exponentially, certainly far more rapidly than our ability to assess and monitor the impacts of innovations. The commercial marketing of alcohol, breakfast cereals, drugs, exercise equipment, food fads, various new forms of gambling, and other innovations is a daunting challenge to all of us. Meanwhile, public health practitioners trying to develop and market ameliorative programs and tools typically face a much more difficult path that requires them to go through legal, political, economic, and other hoops to identify the right ways to shape their innovations to legal, social, and other factors that influence government and not-for-profit based innovations.
In this issue, Blocker2 examines alcohol prohibition as an innovation, taking us through the moral context of the time and assessing the innovators. The author concludes that it is a mistake to assume that prohibition was a failed innovation. Gardner and Brandt3 examine the tobacco industry’s remarkably successful use of physicians to promote cigarettes. They assess why this innovation worked and how the tobacco companies recognized that the marketing of cigarettes through doctors was no longer credible. Looking a half century later, Lewis and Wackowski4 describe one of the tobacco industry’s latest innovations, using flavored cigarettes to target youths. Both tobacco articles are accompanied by photographs that demonstrate the tobacco industry’s attempts to stay ahead of public health practitioners in the critical struggle to attract or discourage new tobacco users.
Some innovations spread relatively quickly; others are much slower or fail to diffuse. Des Jarlais et al.5 compare the diffusion of the DARE program to reduce the use of illicit drugs with the much slower diffusion of needle exchanges. The authors observe that the DARE program diffused quickly, despite a lack of strong evidence of its salience, whereas needle exchange programs have not, despite strong scientific support for their effectiveness. The article highlights critical social and political environments that frame innovations and affect their diffusion. In a future issue of the Journal, Fajans et al.6 will examine the Strategic Approach to Strengthening Reproductive Health Policies and Programs, a World Health Organization initiative that assesses reproductive health policies and programs. Ongoing nurturing of the Strategic Approach is essential, especially in environments where programs like this one have no history and no organizational framework to anchor them.
Dannenberg et al.7 report the results of a conference aimed at improving and diffusing health impact assessment as a tool for local health planning. The authors recommend evaluation of the method, pilot studies, a database of health impacts, training of practitioners, and other steps that would produce a more effective health impact assessment process. Garland et al.8 assess the role of vitamin D in cancer prevention. They note that evidence points to a positive effect on lowering cancer risk, but they also recognize some of the contrary evidence that doubtless has retarded the acceptance of the vitamin for cancer prevention. Garland and colleagues underscore the uncertainty attached to hundreds of claims about old and new drugs.
During the last 3 decades, concern for environmental protection has produced many technical innovations in monitoring, surveillance, and pollution prevention. Rather than focus on the latest technical improvements, we feature 2 important policy innovations. Greenberg and Hollander9 examine the diffusion of the Environmental Protection Agency’s brownfield pilot program across more than 400 local governments in the United States. They argue that the program has been a successful federalist innovation as measured by its objectives and widespread geographical diffusion. Abrams et al.10 report on the apparent success of New York State’s antismoking campaigns in reducing exposure to environmental tobacco smoke in the workplace.
This issue of the Journal offers specific information about some key innovations related to public health. Equally important, it emphasizes the complexity of the political, economic, and social processes that are often more important than the science and engineering that produced the innovation.