Preventive Medicine Column
Dr. David L. Katz
Those who don’t learn from the follies of history, we are famously told, are destined to repeat them. One of the oft-repeated follies is to ignore vulnerability, and wind up dealing with the consequences of that neglect.
The need for protective measures taken in New Orleans after Hurricane Katrina was well recognized before. Had such measures been taken in advance, the catastrophe would have been much diminished, if not averted. A similar case has been made about the calamitous effects of Hurricane Sandy along the Northeast coast.
It is a dilemma that bedevils the medical field, and particularly my specialty of Preventive Medicine, as well. It is, in a word, silly to treat hundreds of thousands of myocardial infarctions annually while knowing how to eliminate almost all of them. Silly, and, of course, tragic.
It is silly and tragic to treat type 2 diabetes, formerly known as “adult onset diabetes,” not only in ever more adults, but ever more children while knowing how to prevent the condition in 90% of adults, and eradicate it in children. After all, we invented type 2 diabetes in children– within the span of just the past generation.
Prevention produces far better outcomes and costs less than treatment. But like hurricane-proof shorelines and earthquake-proof buildings, it requires up-front investments for returns over time. We tend to be bad at that. But we need to get better, because lives are at stake.
As may be the fate of the nation. The Centers for Disease Control and Prevention is projecting that by mid-century, should current trends persist, 1 in 3 American adults could have diabetes. Devastating though it is, the toll of Hurricane Sandy is small in comparison to this brewing storm.
The first message in these winds is that current trends cannot persist, because the dollar and human cost of that are apt to be unbearable. We currently have roughly 27 million diagnosed diabetics in the U.S., and struggle to pay the health care bill. When 1 in 3 of us has diabetes, that will be well over 100 million. There is no bank account big enough to write that check.
The second message may matter even more. Guess who those adults will be, burdened with more diabetes than the world has ever known? Our children and grandchildren. They will be the adults in 2050, dealing with the crushing burden of chronic disease we bequeathed them.
The trouble with even temporary neglect of vulnerability is that the longer you wait, the worse your options. At the individual level, if you address vulnerability after the onset of diabetes, or after a first heart attack or stroke, your health will simply never again be as good as it could have been. Chronic disease can be managed, but the adage about not being able to unscramble an egg applies to health.
At the collective level, the more vulnerability converts to consequences, the more resources are diverted to deal with those consequences. Whatever search and rescue costs, we have no choice- the money must be spent. Whatever emergency angioplasty or coronary bypass costs, the money must be spent. The more often money is spent that way, the less likely allocations to prevention become– because the money is already gone.
Catastrophes are enormously expensive. Vulnerability to them is the quintessential case of a ‘pay now, or pay later’ scenario- in which the latter costs dwarf the former. Neglecting vulnerabilities we can fix is penny wise, pound foolish. The deficit grows.
The choice to take on vulnerability is never easy. Building a levee when the ground is dry may seem unnecessary, even frivolous. But of course, it’s the only time to build a levee that will reliably prevent catastrophe rather than one that might not be enough to mitigate it. Making a serious commitment to eating well and being active may not seem worth the effort or time before you are on your back staring at the roof of an ambulance- or riding next to your child doing so. But afterwards, the investment is larger and the return smaller.
We are vulnerable, and we know it. That knowledge is only power if we put it to use before the costs of that vulnerability come due. Forewarned is forearmed only if we take up the requisite arms against a sea of looming troubles, and by opposing, end them before ever they begin. Again.
Dr. David L. Katz; www.davidkatzmd.com