foundation of decision making and the measure of success; and 6) enhancing and facilitating communication within the public health system (e.g., among all levels of the governmental public health infrastructure and between public health professionals and community members” (IOM, 2002).

This redirection of GPHAs over the past 25 years—in content, from clinical care to population health, and in role, from doing to leading—has been echoed in the development of programs for chronic disease prevention. The Centers for Disease Control and Prevention (CDC) has led the development of these programs through its National Center for Chronic Disease Prevention and Health Promotion, initiated in 1989 (Collins et al., 2009). CDC’s initial focus was on state-level programs aimed at preventing and controlling often-fatal chronic diseases. One of the first, and still largest, programs was a clinical prevention program, the National Breast and Cervical Cancer Early Detection Program, which promoted and paid for clinical screening for breast and cervical cancer for uninsured women (CDC, [e]). As of 2009, other fatal disease–oriented programs existing in all 50 states focused on diabetes and comprehensive cancer control (Collins et al., 2009). Less widespread programs focus on heart disease and stroke (Collins et al., 2009).

From the beginning, CDC has also focused on state-level programs to measure and reduce leading chronic disease risk behaviors, in particular tobacco use, physical inactivity, unhealthy eating, and obesity (Collins et al., 2009; McGinnis and Foege, 1993). As of 2009, CDC-funded programs existing in all 50 states included the Behavioral Risk Factor Surveillance System and tobacco control (Collins et al., 2009). More recently, CDC has also initiated state-level programs focused on chronic disabling diseases, and one of the largest of these, begun in 1999, focuses on arthritis. CDC initially funded smaller arthritis programs in many states, ultimately 36; however, in 2008, after an external review, CDC began funding fewer states, now 12, with a minimum of $500,000 per year (CDC, [b]). These state arthritis programs “work to increase awareness that something can be done for arthritis and promote self-management education and physical activity” (CDC, [b]).

An additional theme of the CDC programs in recent years has been a transition from state-level categorical programs aimed largely at communication and service provision to community-level integrated programs aimed more at policies and environments. This transition has accelerated with the recognition that many local GPHAs have had difficulty mounting chronic disease prevention (Frieden, 2004). The first such CDC program, Racial and Ethnic Approaches to Community Health (REACH), began in 1999 and has focused on community-level approaches to eliminating racial and ethnic disparities in chronic illnesses (CDC, [f]; Collins et al., 2009). Others that have followed include Steps, begun in 2003 and later



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