Monday, January 23, 2006

Prevention – Let’s Give Ben Franklin A Belated Birthday Present

Founding Father Benjamin Franklin, whose 300 birthday we currently are celebrating, said “An ounce of prevention is worth a pound of cure” (Hmm –was that statistically means tested?). Yet 230 years later America still spends only @2% of its 1.9 trillion dollar Disease Care Industry bill on Prevention. Why in God’s name, I ask, if Father Ben was right so long ago? Let me try to explode (whoops "explore") some myths about Preventive Medicine- a field of medicine that I have attempted to practice my entire 30 year plus medical career. See 5th point on my ETIOLOGY post of 3 Jan

Prevention doesn’t work? - Otherwise highly regarded physicians have tried to convince me for decades that “most of their patients” can’t or won’t change their unhealthy behaviors? Well there is a growing body of scientific evidence that with proper support like health coaches and financial and other incentives people do indeed change unhealthy behaviors from smoking, to diet, to exercise etc. Significant advances in behavioral science like
stages of change
theories and tracking of expenditures made by American citizens - usually out of pocket- on preventative strategies from gym memberships to purchases of vitamins and food supplements is a very real testimony to change capacity.

Prevention doesn’t pay? – Alas- Definitely true in today’s Disease Care system. Incentives for payers rarely exist except at the margins. Assuming you are lucky enough to have health insurance have you ever tried to get reimbursement from your insurance company or payer for wellness programs for example?- Or perhaps for often cheaper and safer alternative medicines?- Or the vitamins and diet supplements you are spending @4 billion dollars a year on? How’ bout getting your doctor to spend time with you to talk about health- Sorry folks-not now- Doctors don’t get paid much for so called cognitive services. Docs have to do something to you in order to get paid like write you a script, order a procedure, or send you to a surgeon. Also the economic returns for the largest purchasers of disease care-namely corporations and the federal government’s don’t realize fast enough financial returns from prevention to satisfy their constituents like stockholders and powerful lobbyists for the disease care industry who rig the election of our politicians. Finally immoral/amoral anti-prevention health economists argue, even publicly that “we can’t afford prevention” since people might live longer? OUCH! That one always hurt me personally. Well, perhaps we have such a crisis in health care that prevention is now an economic imperative since we as a nation spend almost twice per capita what our major peers/competitors on the global market spend on health care and, to add insult to injury, get less!

Prevention makes patients feel blame, guilt, and/or abandonment? Well- I suppose in part asking patients to take some responsibility for their individual health behaviors is, to some, controversial? After all who wants to grow up? Conversely, however, without decent jobs or decent wages the poor or working poor often turn to unhealthy pleasures to cope with what an unfair society has thrown at them. Also much of prevention is NOT in fact the responsibility of the individual patient. There is institutional prevention such as clean air, water, soil and foods. There is providing all able Americans decent jobs with decent wages. And there are many diseases and conditions that have almost nothing to do with individual health behaviors and choices such as genetic conditions, environmental assaults to our bodies, and acts of fate or god such as natural catastrophes or accidents and crime often leaving little choice or control by its victims. And of course viruses and bacteria are indeed real and are indeed contagious- in some cases highly contagious.

Prevention is anti-technology? Well who ever said that 21st behavioral sciences were not based on technology? It may be different types of technology like sophisticated computer software but it still is nonetheless technology or increasingly sophisticated neuroscience which can unravel for example be the basis for perception, lifelong beliefs and attitudes and other cognitive processes ultimately leading to many health behaviors. And, while we are on the subject of technology, when in April of 2003 the human genome consortium (a private-public partnership) revealed it had unraveled the full sequence of the human genome(30-40 thousand separate human genes) I and others predicted its application to prevention would be far greater than its application to gene therapy misadventures. Now most prominent leaders in medical genetics seem to agree that detecting genetic traits in individuals for let’s say heart disease and cancer holds the best promise of the human genome project. That surely is technology in the service of prevention.

What can we do? In addition to adopting good personal health attitudes and behaviors I strongly recommend that you visit
Health Promotion Advocates
headed by my friend Dr. Michael O’Donnell (PhD) who are making slow yet steady progress on advancing legislation through the US Congress on the value of Health Promotion. You can help! Practicing physicians need to be given economic incentives to help patients change their health behaviors or talk to patients about home life, school or work. Also we all need to become involved in ensuring that much more of our disease care system money is re-allocated to prevention programs. The American Public Health Association has many ways you can become involved in issues on a wide range of prevention topic like childhood nutrition, smoking bans, environmental degradation and many others

Finally a word about my personal views on this topic of Prevention. Prevention and Disease Management (known as tertiary prevention) will no doubt dominate 21st century US Medicine- There simply is no choice on this one. Also, our planet earth is in deep trouble. We are all going down soon if we don’t reverse the poisoning of the bio-sphere to which all human health is inextricably linked. I also personally believe that there is growing evidence that lifelong prevention begins from conception to age 4 or 5. So that is where I would put my health care dollars. I would protect and promote the health of nation’s infants and very young children. That is where real prevention begins and perhaps ends? Feedback very welcome.

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