GrantWatch. Loren Renz is director of research at the Foundation Center in New York City.

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1 GrantWatch I. ESSAY Private Foundations And The Crisis Of Alcohol And Drug Abuse by Loren Renz At the start of the 1980s, alcohol and drug abuse had attracted the attention of only a few private foundations. As America s grantmakers began to recognize the devastating toll of alcohol and drug abuse on the nation s health and on the future of its youth, a surge in funding began in the mid-1980s. Since then, foundations have taken a more active role in prevention, treatment, education, research, and public policy initiatives. In this essay, I document the growth of foundation support for efforts to combat substance abuse in the 1980s, and I highlight patterns of giving. Data are from a recently published study of foundation grants reported between 1983 and The study draws from a sample of over 450 philanthropic foundations, including the 100 largest foundations, ranked by total giving. 1 While these foundations represent only 2 percent of active grant-making foundations, their grants account for at least 40 percent of total dollars awarded annually by private and community foundations. Interpretation and evaluation of grants data were enhanced by information provided in annual repor ts and by a survey of grantmakers completed in early Trends In Private Foundation Giving During the period 1980 to 1987, when all foundation giving rose by 61 percent in inflation-adjusted dollars, support for substance abuse programs increased fourfold. As a share of overall foundation giving, alcohol and drug abuse funding more than doubled during the period, rising from 0.4 percent in 1980 to 1 percent in As a share of health giving, it climbed from 1 percent in 1980 to 4 percent in 1987, signaling both growing national alarm over public health issues and changes in funding priorities brought on by federal budget cuts by the Reagan administration. (In 1981, the federal government had slashed funding by 25 percent Loren Renz is director of research at the Foundation Center in New York City.

2 194 HEALTH AFFAIRS Summer 1990 for programs aiming to reduce demand for drugs.) When measured in current dollars, grants rose from $4 million in 1980 to over $26 million in Not only did grant dollars for substance abuse increase among the foundations sampled, but the number of funders rose by over 77 percent, from 107 in 1980 to 190 in From 1983 to 1987,337 foundations made 1,814 substance abuse grants totaling $87 million. Over this period, the number of these grants paid out annually nearly doubled from 258 to 490. Most of the 1,814 grants were small and benefited local treatment or public awareness programs. Over two-thirds of the grants were less than $25,000, and one-third ranged from $5,000 to $10,000. However, 151 grants exceeded $100,000; these concentrated on treatment programs, with emphasis on expanding local hospital services, long-term care, and special care for women and teenage substance abusers. Large grants also supported national media campaigns, such as the Chemical People project, pilot school-based prevention programs, and community-based prevention programs aimed at high-risk populations. Many of the twenty-three largest grants, $500,000 or more, supported capital projects of nationally recognized treatment recovery centers, leading in some cases to their transformation from residences to more innovative, multiservice agencies providing training, outpatient care, and model prevention programs. With increased recognition that alcohol and drug addictions coexist, few treatment or prevention programs were restricted to either alcohol or drug abuse. The share of undesignated substance abuse funding grew from 57 percent in 1983 to 77 percent in 1987, while the share of grants for alcoholism programs declined from over 30 percent to 12 percent. While 337 philanthropic foundations reported substance abuse grants between 1983 and 1987, a handful of funders led the field. As illustrated in Exhibit 1, thirty-five foundations awarded at least $500,000 each over five years 75 percent of all grant dollars ($65 million) and 40 percent of all foundation grants. Not surprisingly, independent foundations, which represent nearly two-thirds of the data sample, paid the largest share of grant dollars, $71.3 million. Independent foundations increased spending from $6.6 million in 1984 to $23 million in 1987, a sign of increased expenditures by the most active funders. Community foundations more than doubled annual grant dollars from $752,000 in 1983 to over $1.7 million in 1987, while funding by company-sponsored foundations peaked in 1984 at $2.1 million and dropped to $1.5 million by Influential funders. A key factor in the tripling of grant dollars between 1984 and 1987 was the brief entry of the Joan B. Kroc Foundation into the funding ranks. Under its Operation Cork program, it became the single largest grantmaker in the substance abuse field, award-

3 GRANTWATCH 195 Exhibit 1 Major Funders In Alcohol And Drug Abuse, Source: L. Renz et al., Alcohol and Drug Abuse Funding: An Analysis of Foundation Grants (New York: The Foundation Center, 1989). Based on a sample of 450 foundations from the Foundation Grants Index. Note: Dollars are in thousands. Figures may not add up due to rounding. a Represents number of grant payments made on single- and multiple-year grants. b Includes grants reported by four separate trusts, including $2.11 million by The Medical Trust. ing $16 million over three years, including nearly $13 million to the Hazelden Foundation in Minnesota to build multiservice facilities and develop new training and prevention programs. In 1987, the foundation completed its planned commitment to Operation Cork; it no longer funds substance abuse programs.

4 1 9 6 HEALTH AFFAIRS Summer 1990 Leading funders for alcohol and drug abuse programs include the Conrad N. Hilton Foundation, which has committed nearly $9 million to support testing of Project ALERT, a model school-based drug abuse prevention program designed by The RAND Corporation. The Henry J. Kaiser Family Foundation addresses substance abuse within its Health Promotion Program and primarily supports projects that are preventive, are community-based, and serve special populations, including Native Americans. In 1986, The Pew Charitable Trusts set aside $2 million for a five-year Prevention of Chemical Dependency Program and helped to organize Grantmakers Concerned About Alcohol and Other Drug Abuse, a funding network addressing alcohol and drug issues. The Metropolitan Life Foundation, the largest company-sponsored funder of substance abuse programs by dollar amount, in 1983 helped launch The Chemical People, a public television special to combat drug abuse. The J.M. Foundation has led the development of alcohol and drug abuse education programs for medical students and cofounded Grantmakers Concerned About Alcohol and Other Drug Abuse. The Christopher D. Smithers Foundation devotes its resources solely to alcoholism and is the only funder that has been continuously active in this area since The Gannett Foundation awarded ninety-seven grants from 1983 to Through its Communities Priorities Program (CPP), funding increased sevenfold, from over $88,000 in 1981 to $675,000 in Finally, The San Francisco Foundation has been an early and constant supporter of innovative community- and school-based prevention programs. New initiatives. Several philanthropic foundations recently have undertaken important funding initiatives. As the nation s largest health care philanthropy, The Robert Wood Johnson Foundation announced, in February 1989, the single largest commitment of private funds ever designated for substance abuse programs $26.4 million for its Fighting Back program. These funds will enable local communities to develop strategies using education, prevention, treatment, and aftercare to combat alcohol and drug abuse. Among other newly active private foundations, the S.H. Cowell Foundation has committed $1.5 million over three years for a community-based alcohol prevention program aimed primarily at the underserved. Many of the most visible grantmakers in the late 1980s were community foundations, pressed to respond to urgent drug problems in the areas they serve. The New York Community Trust was one of the first to establish a formal substance abuse program and now has a fund devoted solely to this purpose. The trust s program focuses on prevention and early intervention for children and youth. The Community Foundation of Greater Washington, D.C., is working with the local government and

5 GRANTWATCH 197 the private sector to combat the drug epidemic in the nation s capital. The Winston-Salem Foundation announced a major drug education and abuse prevention program, funded in part from a permanent endowment. The Community Foundation for Southeastern Michigan started a five-year regional leadership effort to decrease substance abuse in the Detroit area, based on a communitywide prevention approach. Target Areas For Grants Foundation grants in the alcohol and drug abuse field may be grouped into six major categories: prevention (school-based, community-based, and public awareness programs aimed at populations not classified as abusers); intervention (treatment and rehabilitation programs aimed at those abusing alcohol or drugs and providing services to their families); education for health professionals; biomedical research; social and behavioral research; and public policy (including legislation, advocacy, and civil rights). Exhibit 2 shows changes in annual distribution of grant dollars by program area. Prevention. Although prevention programs received only 36 percent of funding, compared with 48 percent for intervention programs (Exhibit 3), prevention is by far the fastest-growing area of foundation support in the substance abuse field. This can be attributed to the recent surge of support from a few influential funders such as the Kroc, Hilton, Exhibit 2 Yearly Distribution Of Foundation Grant Dollars For Alcohol And Drug Abuse, By Major Program Category, Source: L. Renz et al., Alcohol and Drug Abuse Funding: An Analysis of Foundation Grants (New York: The Foundation Center, 1989). Note: Total grant dollars were $87.1 million over this period. a Other includes social research, public policy, and biomedical research.

6 1 9 8 HEALTH AFFAIRS Summer 1990 Exhibit 3 Yearly Distribution Of Grants For Alcohol And Drug Abuse, By Program Category, Source: L. Renz et al., Alcohol and Drug Abuse Funding: An Analysis of Foundation Grants (New York: The Foundation Center, 1989). Note: Dollar figures in thousands. Figures may not add up due to rounding. Kaiser, Pew, and Metropolitan Life foundations. As a result, in 1987, prevention outpaced intervention programs for the first time; they each received $13.7 million and $9.9 million, respectively. From 1983 to 1987, the largest share of prevention funding nearly $16 million supported school-based programs. Because of the Hilton Foundation s involvement, this was the dominant area of evaluation research. Public education efforts, including media campaigns, received the largest number of grants by far (289). As in almost all other categories, prevention grants were aimed primarily at young people. In fact, more than one-third of all foundation substance abuse dollars nearly $30 million supported programs designed to help teens and children. Community-based approaches. In the late 1980s, as the drug plague emerged as the nation s number-one community problem, foundations began to favor community-based models of substance abuse prevention. From almost zero funding in 1983, the share of dollars dedicated to community-based programs jumped to 14 percent ($3.8 million) in Many grants in this emerging area support newly formed community. coalitions; many address multiple risk factors such as family violence,

7 GRANTWATCH 199 teen pregnancy, suicide, traffic injuries and fatalities, school dropout, and substance abuse. Intervention. Treatment and rehabilitation programs, categorized broadly as intervention, received nearly $42 million over five years, but by 1987, funding levels were declining. Among intervention strategies, residential programs received the largest share of grant dollars ($17.6 million), followed by medical treatment programs, including outpatient services, which received $14.8 million. Foundations responded generously to expansion efforts of nationally recognized recovery centers and local hospitals to establish chemical dependency units. Grants also financed services for juveniles, women with dependents, and other underserved groups. A much smaller share of funding, $9.5 million, went to communitybased counseling and referral agencies offering outpatient services, aftercare, emergency food and shelter, and support services for families of abusers. While these agencies, which often serve disadvantaged inner-city populations, received the largest number of grants (436), the dollar value of these grants was well below the average for other intervention grants. Total funding for community-based agencies was less than one-third of the amount awarded for medical treatment and residential programs combined, and only community foundations distributed their largest share of intervention dollars to this critical area. Additionally, funding priorities in intervention appeared to be shifting by While the share of support for residential programs and medical treatment services had declined sharply, the share of intervention dollars represented by outpatient counseling programs had increased. Education for health professionals. Foundations played a major role in educating physicians, nurses, and counselors about substance abuse. From 1983 to 1987, professional education received nearly 10 percent of grant dollars, or $8.4 million. However, while the number of grants increased fivefold mainly as a result of The J.M. Foundation s Medical Student Program in Alcohol and Other Drug Dependencies growth in annual funding peaked in 1986 at $3.9 million, due to onetime grants of $1 million or more awarded by the Kroc Foundation. By 1987, funding for professional education dropped to $1.7 million. Social and biomedical research. Social and behavioral research in the substance abuse field, though not well funded (only 2.6 percent of grant dollars, or $2.3 million), was concentrated in two areas: evaluation of industry-based alcoholism programs; and studies of special groups of substance abusers, particularly teenagers, children of alcoholics, women, and the elderly. Foundations devoted less than 1 percent of dollars ($625,000) to investigating the biomedical causes of addiction, an indicator of the low priority given to disease-specific research by foundations.

8 200 HEALTH AFFAIRS Summer 1990 This may be due to a perception that disease-specific research is one of the few areas of biomedical research that can attract sizable donations from individuals. As a result, private grantmakers are more likely to invest in more abstract research goals. 2 Public policy. Few foundations showed a consistent interest in funding advocacy or policy research. In fact, nearly half of the funds disbursed in this category came from the Ford Foundation to combat discrimination against ex-offenders and ex-addicts in employment and entitlement programs. Other policy issues included legislative efforts to reduce traffic accidents caused by drunk driving, protect the civil rights of workers against random drug testing, and curb the impact of alcoholic beverage advertising on young people. Forecasting Future Trends And Issues In Funding Based on a survey of fifty-five active grantmakers conducted in conjunction with the grants study, the following trend analysis indicates that until the drug epidemic is contained, more grantmakers will fund alcohol and drug abuse programs to protect their traditional program interests. 3 Program areas that are affected by drug and alcohol problems include infant health, youth development, mental illness, health promotion among at-risk populations, criminal justice, homelessness, and community services. Community foundations are the fastest-growing segment of supporters of alcohol and drug abuse programs and an emerging source of local leadership. Most surveyed funders predicted levels of support to remain constant or to increase, and the base of foundation support appears to be expanding. Despite new growth, the absence of the Kroc Foundation may reduce total annual grant dollars over the short term. However, funding will increase because of The Robert Wood Johnson Foundation s $26.4 million Fighting Back program. Primary prevention, especially school- and community-based programs directed at adolescents and their parents, is of paramount interest to grantmakers. Grant dollars will continue to support intervention, but with greater emphasis on community-based treatment, outpatient services, and nonmedical counseling programs. As in prevention, priority will be given to services for at-risk youth and children of alcoholics and drug addicts. Whether in prevention or treatment, funding strategies may be more selective. There is increasing interest in programs that address multiple risk behaviors, especially those of adolescents, and in a community task force approach to promote more effective service delivery. Based on the current guidelines of leading foundations, community-based models of

9 GRANTWATCH 201 prevention and intervention will undoubtedly dominate giving patterns in the years to come. Shifts in program emphasis may result in a decline of support for capital projects and media campaigns, two strategies favored in the early to mid-1980s. With the exception of programs for children and youth, and to a lesser extent women with dependents, few grantmakers target grant dollars to special groups of alcoholics or drug abusers. Despite heightened awareness of the interrelatedness of crime and acquired immunodeficiency syndrome (AIDS) among drug abusers, only five of the fifty-five foundations surveyed seek out substance abuse programs aimed at prisoners and ex-offenders, and only one has a policy of funding human immunodeficiency virus (HIV)/ AIDS programs geared to intravenous drug users. 4 These findings illustrate grantmakers preference for investing in primary prevention or early intervention efforts. Evaluation concerns. While program effectiveness is foremost in the minds of grantmakers and remains the single largest barrier to funding, few foundations expressed a willingness to support evaluation research. Evaluation projects require costly technical expertise and long-term support, which practitioners claim is simply not available. At issue are concerns about methods to measure effectiveness and who is responsible for evaluation. Amidst the current national outcry over drugs, the need for public/ private debate and cooperation regarding effective prevention and treatment is urgent. In a similar vein, although grantmakers generally agree on the need to educate lawmakers about alcohol and drug abuse issues and to strengthen public policy, few expect to support either research in the social causes of addiction or policy-related projects. This suggests an oversight in responsibility among influential funders and the need for rethinking long-term funding strategies. For grantmakers considering a more active role, opportunities abound, and the timing is right. NOTES 1. L. Renz et al., Alcohol and Drug Abuse Funding: An Analysis of Foundation Grants (New York: The Foundation Center, 1989); and Foundation Grants Index, Editions (New York: The Foundation Center, ). 2. Z.E. Boniface and R.W. Rimel, U.S. Funding for Biomedical Research (Philadelphia: The Pew Charitable Trusts,. 1987), Renz et al., Alcohol and Drug Abuse Funding. 4. According to the Foundation Center s 1988 survey of AIDS funding, of the $51 million paid out since 1982, $3.3 million (eighteen grants) went to programs serving drug addicts. This suggests that health funders not surveyed in the substance abuse study are funding this critical need. Support for AIDS prevention and treatment may increase the flow of grant dollars aiding intravenous drug users in the future.