Book Review

To Improve Health and Health Care 1997: The Robert Wood Johnson Foundation anthology

N Engl J Med 1998; 338:1320-1321April 30, 1998

Article

To Improve Health and Health Care 1997: The Robert Wood Johnson Foundation anthology
Edited by Stephen L. Isaacs and James R. Knickman. 268 pp. San Francisco, Jossey–Bass, 1997. $18.95. ISBN: 0-7879-0909-2

“It's better to give than to receive” is a common expression among some resource-starved academicians who look enviously upon colleagues who have joined the ranks of foundations and governmental granting agencies. This refreshingly self-critical and humble book suggests that giving is not as easy as it appears, at least if you have high expectations for an impact on major social problems, critically evaluate your accomplishments, and then share the results with the world at large.

The Robert Wood Johnson Foundation is arguably the most important health care philanthropy at present, and perhaps ever. With a booming stock market adding almost daily to its corpus, the foundation has large and growing outlays that totaled $267 million in 1996. This sum dwarfs the grants of all other health-related foundations and probably exceeds spending on health-services research and development by the entire federal government. The reach and ambition of the programs the foundation has pursued during its 25-year existence shine through in this slim book. What is most impressive and valuable about To Improve Health and Health Care 1997, however, is its careful recounting of programmatic performance — both the successes and the shortfalls. For those who take the time to read the book carefully, it provides a valuable lesson for proponents of social change. The bottom line: expect failure, be patient, and build incrementally on small successes.

Though a multiauthored work, the book has clearly been carefully edited by Stephen L. Isaacs, a lawyer and health-policy analyst, and James R. Knickman, vice president of research and evaluation at the Robert Wood Johnson Foundation and a former professor of health administration at New York University. The chapters display a nice balance of topical variety and stylistic consistency. Each examines a major program or programmatic thrust of the foundation, reports its history, evaluates its effect, and discusses lessons learned and how it might have been done better — or in some cases, why the problem may defy solution.

Though the authors — especially those from the Robert Wood Johnson Foundation — repeatedly point out the limitations of the foundation's resources, the programs themselves are far from timid. The first chapter, by Irene Wielawski, a health care journalist, describes the results of an evaluation of Reach Out, a $12 million, five-year program that funded 39 sites in 24 states. The purpose of the program was to encourage physicians in local communities to become involved in caring for uninsured patients and to support them in their efforts. The accounts of the fortunes of three particular sites provide an object lesson in the limits of altruism for solving basic social problems, such as gaps in health insurance in the United States. As Wielawski notes, “On the most basic level, project leaders have discovered that appeals to busy colleagues . . . to `do the right thing' don't go very far without an organizational structure to effectively channel contributions.”

Another chapter, by Beth A. Stevens, a senior program officer at the foundation, and Lawrence D. Brown, a professor of health policy and management at Columbia University, recounts a multifaceted project by the foundation to assist state governments in health care policy making. One element of the program was a $25.5 million effort that helped 15 state governments rethink and expand coverage for the uninsured. Begun in 1991, the project was reauthorized twice and will extend until the year 2001. In a penetrating and somewhat wistful analysis, Brown and Stevens note how difficult it has been for the foundation to affect state policy making in this highly politicized and unpredictable policy terrain. They bluntly conclude: “Foundations are condemned to falter in pursuit of health reform because their goals are high, the means available to them are limited, and health reform combines complicated policy problems with acute political conflicts . . . [the foundation] must often make do with leading to the waters of policy wisdom horses it cannot compel to drink.” They further recommend that in the future the foundation improve its ability to assess the political realities in states with which it hopes to form partnerships in the interests of health care reform.

Arguably, some of the most important and effective efforts by the foundation have involved research. A chapter by Joanne Lynn, a professor of health care sciences and medicine at George Washington University Medical Center, discusses the results of a $29 million research and demonstration program that attempted to alter the care of terminally ill patients in several major academic centers. Called the SUPPORT study, this well-known initiative failed in its primary objective — to make the care of this population more rational and humane — but succeeded unexpectedly in generating copious information about the illnesses and treatment of patients at the end of life.

Another fascinating chapter recounts the contributions of the National Health and Social Life Survey, which the Robert Wood Johnson Foundation supported in combination with several other foundations. This survey involved in-person interviews with 3432 adults about their sexual behavior and health problems. It contributed valuable new information on the epidemiology of sexually transmitted diseases and thereby helped to inform preventive efforts for such diseases generally and the acquired immunodeficiency syndrome in particular.

Though many chapters contain considerable information about and analysis of policy-relevant topics, the average reader is likely to find this book a relatively inefficient way to learn about the topics in question. This is really a book about the opportunities and limits of foundations generally, and therefore is likely to be of the greatest interest to the relatively small audience that has shepherded major philanthropic resources in health care or hopes to do so. For this very important group, To Improve Health and Health Care 1997 should probably be required reading.

David Blumenthal, M.D., M.P.P.
Massachusetts General Hospital, Boston, MA 02114