Every state is now doing something to address the issue. There are costly high-profile "Wait to Have Sex" television commercials. There are community and statewide radio and outdoor advertising campaigns. Dozens of curriculums and educational programs have been developed and tested; there are information-based programs covering the mechanics of sex and the consequences of pregnancy. There are programs that deal with peer pressure, decision-making and communication skills. Some programs teach abstinence, period. Others teach abstinence, but. A new focus lately, in dollars and time, has been solely on the male involvement factor in teen pregnancy.

The crucial question of course: "Is any of this working?"
The inability to quickly satisfy the politics of the moment with a statistically credible "cure" threatens many programs that may be valuable in the long run. That question and the lack of an answer have also made teen pregnancy prevention something of a battle ground, testing to what extent we can use social marketing techniques to change behaviors, especially the behavior of teens.

What We Know

There is little evidence that any abstinence or postponing sexual involvement curriculum delays the onset of increased sexual activity — in part because many programs have not been sufficiently evaluated. And everything we know about advertising suggests that classical Madison Avenue techniques are aren't the best choice to help us change the behavior of teens, especially their sexual behavior.

What advertising campaign could possibly overpower the pervasive effects of the media, peer pressure, a lack of family structure and the proverbial raging of hormones? Hormones alone are enough to daunt the staunchest advertising advocate. Chemical onslaughts at adolescence are strong enough to cause some young men to literally swagger. Aside from the more obvious physical changes and sexual urges, testosterone alone is responsible for foul moods, excessive aggressiveness, irritability, an unhealthy sense of omnipotence and even the desire to be alone. To change behaviors, we have to overcome not only media and peer pressure, but compelling and persistent forces of nature. A tall order for advertising, even if we knew what we were doing. And when it comes to targeting teens, we do not.

The Partnership for a Drug Free America has spent over $50 million a year in donated fees and services, and over $350 million a year in media time and space to support some of the industry's most stunning creative efforts. The image of eggs frying in a pan and the accompanying "this is your brain, this is your brain on drugs" voice-over is one of the most memorable advertising messages of all time. Yet despite many years of great advertising and at least adequate exposure, we see no evidence that any impact on drug use by teens has been made. In fact, in many cases and for many reasons, drug use among teens has, at times, gone up during the campaign's most intense efforts.

Anti-tobacco marketing has not done much better. We have graphically illustrated the effects of tobacco on the lungs, mouth and heart in classrooms starting in the third grade. Every cigarette advertisement, as well as every pack of cigarettes, carries a clear and simple message that cigarettes lead to an early death. Yet more and more teens now smoke. California spent $26 million in one recent advertising campaign to discourage smoking. We have no clear evidence that the highly provocative campaign was effective with teens. Despite the very justifiable cry against tobacco companies for targeting teens in their advertising, one reason cigarette smoking among teens may be on the rise, is simply the fact that we're so aggressively trying to discourage it.

Like the wars against tobacco and drugs, fighting the war against teen pregnancy has succeeded so far in demonstrating only our limitations. We cannot make people do what they don't want to do. We can't make them listen because we know more or because the facts support our story. This is especially true with teens.

There probably is no rational marketing approach to teen pregnancy prevention worth pursuing. Advertising has the impossible task of conveying potential future benefits to a population which by and large has no concept for the very word "future." What's more, when it comes to reaching teenagers, we are dealing with behaviors over which logic may be a last resort. Anyone who is a parent knows this.

And as much as the media has attempted to shed some light on their little corner of the world, their's is a world unto itself. The lives most teens lead with others, in cars and hangouts, on street corners, at parties, on dates, is not a world we know or can do very much about.

There is no "cure" to the teen pregnancy problem, so we should stop looking for one. There is no single enemy, so there is no antidote or inoculation. And it is unlikely that any amount of evaluation will reveal one anytime soon. The problem is systemic. The science of marketing will have no more success than the science of medicine has had treating other social problems as if they were a disease. And it certainly doesn't appear to help matters when the science of government steps in.

The Unpredictability of Change

Change has its own agenda. When it comes to social marketing, we are not as in charge as the success of product advertising might lead us to believe.

Drug habits change depending on availability and cost, but they are also affected by the destructive fashion of the times. There seems to be a continental mood to drug taking. We have done nothing in a hundred years of drugs and alcohol awareness, rules or enforcement to change it.

Violence is another area seemingly out of our control. Today there is an almost mysterious drop in crime rates at a time when crime is an increasingly unfortunate fact of life. Statistics for violent crimes, such as murder and armed robbery, are way down in big cities like Los Angeles and New York. This turn for the better has been variously attributed to more prisons, more police, better enforcement and even the weather. Many make claims, but no one can tell us for sure why there is this sudden drop in violent crime.

Ironically, America's teen birth rate among 18 and 19 year olds dropped dramatically and unexpectedly in 1993, reversing sharp increases from the 1980's and disrupting a pattern that has redefined the American Family. This drop is not attributable to abortions or changes in welfare policy. It occurred before teen pregnancy awareness campaigns could have had an impact. We suspect that increased use of condoms has played a role, but no one can sufficiently explain a change in teen sex behavior apparently unprompted by the pressure of advertising, policy change, media outreach or classroom curriculum.

All this suggests there is a pattern, a wave or a cycle to behavior change. This pattern takes place like a weather front in a box. There is change happening within cultures, in our homes, on street corners and in pockets in our cities we know nothing about. Surveying, studying, basic and exotic research, perhaps not even living in these places can tell us in the short run what we need to know to predict or foster change, before a new breeze blows and the variables themselves change.

Things seems to happen when they're ready to happen, though we each play a part and there are a billion invisible hands. It is the drip, drip, drip of things, the nibbling away from the inside that causes the ground to give way. The Berlin Wall fell, literally over night. But, ultimately it was brought down by the weight of its own improper self over time.

This is not to say there is no role for advertising or social marketing, or media awareness to play in helping change teen behaviors. There is. But it is not to address teens directly. This is not to say research and evaluation is not important. It is perhaps our only way of navigating and the basis on which funding decisions are made. It's just that we can't wait for the results to be final; that day may never come. And it is not to say we shouldn't try things, even everything. It is likely, in fact, that in its own way, just about everything works and contributes to the drip, drip, drip. Enough hints in the popular media about the acceptability of not having sex, enough enforcement of statutory rape laws, more demystification of sex, more open discussions, more modeling of restraint by a friend here and there...all these factors contribute to changing the sexual behavior of teens. The issue is one of time and money. We can't afford the dollars "every thing" would take. And we especially can't afford the dollars a truly effective advertising campaign would take.

In the end, change will come from the top — when those who create entertainment and other media messages accept responsibility for their enormous power and influence. And from the bottom where mentoring, parenting, healthy alternatives and befriending set examples, describe limits, demonstrate rewards, and bond people heart-to-heart.

Here are four things we can start to do now to get us pointed in the right direction:

1) Change Our Culture. The culture of Public Health springs directly from the mind of science and a world of specialized knowledge. And though it is an especially pliant branch of medical science, Public Health still has its roots in medicine and the take-it-apart-to-fix-it world.

This analytical world of Public Health is now facing big problems beyond its grasp. The effect has been paralyzing. As a result, Public Health practitioners focus on that part of the marketing process closest to their own biomedical model, primarily planning, research and analysis. Breaking the problem down and looking at it from different angles, sharing information and going to meetings have given us only an illusion of some kind of control.

We need to become task driven, not meeting or analysis driven. We need a Public Health culture that rewards risk and encourages productive failures. We need an operational structure capable of step-by-step implementation. We need to recruit from our ranks those who are disciplined in organizing others to produce a product. More than PageMaker masters, we need production artists and graphic designers, event-stagers, community organizers and rabble-rousers. We need more people to help others stage a fun run, an immunization day, develop a poster contest, a write-in campaign to the media, create an anti-tobacco rally at a high school, or hold an End the Violence candlelight vigil.

Public Health is a crucial part of the solution. It is an already existing institution with offices and clinics and good-hearted people whose tradition is that of activists in the pursuit of the common good, whose whole reason for being is population health. But we need to begin to change the way it thinks, what it does, the way MPH programs train practitioners, and what we value as public health professionals.

2) Use Communication to Create Community. As much as we talk about the word "community," community is less and less a neighborhood and more and more some kind of shared electronic experience, usually television. We need to create communities in the here and now. An activated Public Health culture can do this in many ways, but primarily by getting teens and others working together and involved in some kind of self-affirming creative process.

People respect others when they respect themselves. Self-respect comes from accomplishing things. One of the things we can give young people with our media and outreach dollars is something to accomplish. That something can be creating communication tools.

Creating media messages is no longer just a corporate affair, the province of multinational media giants. Technology has made message creation everyone's business. Creating videos, radio programs, films, magazines and music is relatively inexpensive and accessible to most teens in most communities, with a little help from knowledgeable adults. What's more, the creation of entertainment and information messages in itself creates community. It creates focus and sharing. It is no accident that those in the film business refer to themselves as the film "community."

We are doing this now; we need to do more. News 101 is an organization in nine states that teams up teenage video crews with local TV stations to create and present teen-relevant news stories on the evening news. "Zines" are inexpensive teen-produced, computer-generated publications that can be geared toward positive messages. In New Mexico, our "Not Yet" teen-written magazine gives teens the opportunity to communicate with one another in a language they both recognize and accept. In Harlem, "New York City Uptown On-line" bills itself as the first world wide web-site to represent an inner city neighborhood as a comprehensive on-line community. Prodigy Services, Inc., has donated space to host the site to help make communication tools and technology available to minorities.

3) Create More Mentoring and Foster Care Programs. People behave one way or another because that behavior satisfies a basic need for acceptance and approval. Acceptance and approval can only be given by people at hand, not by media stars. This, of course, is what families are for. While traditional families are an endangered breed, we can help build new ones in the form of foster care and mentoring programs. This kind of building takes hands-on activity; it is a "doing," not only a planning function. It is something an activated Public Health culture can help accomplish.

It can do this in many ways, but mainly by identifying and inspiring leaders. People are the engine of change. The New York Times tells the story of Brenda Krause Eheart. She helped turn parts of the old Chanute Air Force base in Central Illinois into a 63-duplex foster care community for difficult-to-place children. Brenda recruited middle-aged and elderly men and women to serve as parents and "Honorary Grandparents."

These "Grandparents" receive subsidized rent in return for community work, like craft instruction and maintenance work. But the main value all these people serve is to become a part of someone's life. This new foster care community costs about $15,000 per child/per year, about $45,000 less per child/per year than the state of Illinois would pay for group homes for these children. And a downright bargain when it comes to purchasing neighborly support, cooperation and caring. Officials from a half a dozen states are now looking into the program. Will each of them have a Public Health culture that can find and inspire a Brenda Krause Eheart?

Mentoring programs are more doable in the short run, but they to take imagination, gumption and heart. They also take recruiting, organizing, station wagon-driving, lemonade-making, baseball-playing, listening, talking and time-spending. And they take marketing. Asking for people, not behavior change, is where we can put our media dollars to work. Advertising can help us recruit both mentors and participants.

4) Leverage Advertising. One of the problems with advertising "don't" messages to teens is that it gives them one more thing to rebel against. It does not work. So our advertising, by and large, should not be targeting teens. Perhaps it should be targeting pre-teens. But for sure it should be targeting adults. We should not only be recruiting them to our foster care communities and mentoring programs, we should be asking them to help us make teen pregnancy a shared problem. Advertising can put various solutions on the table for discussion. For this kind of advertising to work, it must raise the kinds of potentially polarizing issues that bureaucracy by its very nature struggles to avoid. So, this should be the work of foundations and corporate partnerships, not government or state health departments.

One of the things a corporation can do that neither government nor foundations can is make a behavior the norm when marketing a product. The product at issue here is condoms. Nothing we can do about teen pregnancy could make a bigger difference than making condom use the norm among teens. This is what advertising does best. Advertising alone, for example, made orange juice a part of the American breakfast. Advertising gives products value and cache, especially for teens. Teens like Nike and Reebok. When a product is advertised, it becomes a part of our, and their, public reality.

In the End

In the end, we are all influence peddlers and carriers of change. We all interact with others, serve as role models for someone or have the power (by virtue of what we say or do) to change someone's attitude or at least affect their day. And those in marketing, media and health; those who manage budgets, set direction, oversee organizations, create words or images or see them reproduced, magnified and directed everywhere at once, have a unique opportunity to foster change.

But neither advertising, nor planning, nor evaluation, nor analysis, nor endless meetings in search of a "cure" will not solve the teen pregnancy problem. Creating a new cultural orientation for those who would help, and new organizational structures and partnerships, will give us the most leverage, in the long run, from which to change the world.