Preventive Medicine Column
Dr. David L. Katz
Since an iron lung costs quite a few dollars, the prevention of polio cannot make sense. Right? If that one has you scratching your head, with a ‘say what?’ dangling from your lip- we are on the same page. Let’s populate it accordingly. Of course prevention can save dollars. But that will only be the case when what we refer to as “prevention” really makes sense.
Prevention enthusiasts– and I certainly do count myself among them- have long contended that preventive medicine has the potential to add years to life, add life to years, and save a lot of money into the bargain. Members of the other side- let’s call them the dubious, because no one is really a prevention ‘detractor’- have argued that the former points may be true, but the last is not.
Prevention, especially in the form of clinical preventive services such as cancer screening, costs money. And since part of the preventive medicine imperative is to find and fix disease early, prevention encourages healthy people to undergo medical testing to identify problems no one knew they had. Suddenly there is expense where there would have been none.
This case, and variations on it, has been made many times- including very recently in Reuters. The Reuters article cites a recent report by the Trust for America’s Health on transitioning the U.S. system from “sick care” to genuine “health” care, and a paper published in 2010 in the peer-reviewed journal, Health Affairs. The analysis in Health Affairs suggests that widespread use of preventive services could help us all save only 0.2% of personal health spending in the U.S.
The iron lung, with which this argument began, is a costly half-measure. It’s a form of prevention, yes; it prevents death in the early stages of poliomyelitis. But it’s not nearly as good as preventing polio outright, which of course is now the global norm, courtesy of immunization. Once polio is eradicated, assuming we can get there, its prevention becomes permanent and free. Were we to look at the iron lung and renounce further prevention efforts as financial folly, no such progress could occur.
Similarly, dialysis is expensive; preventing end-stage kidney disease brought on by hypertension or diabetes, or better still preventing hypertension and diabetes in the first place- are dramatically less so. Coronary bypass surgery is expensive; preventing coronary disease in the first place can be dramatically less so. Bariatric surgery and potential alternatives are expensive, while avoiding that weight gain in the first place could be dramatically less so.
And, similarly, screening for cancer in a population that gets it often enough to warrant screening is a fairly expensive half-measure. Better than nothing, certainly; but not nearly as good as going all the way. What would going all the way look like? Preventing so much cancer outright that screening for it is no longer warranted.
Is that possible? Almost certainly, yes. Studies spanning decades consistently indicate that fully 80% or more of all chronic disease, including cancer, can be eliminated outright with knowledge already at our disposal. Not treated more effectively. Not managed. Eliminated.
The method? Good use of feet, forks, and fingers. Being active, eating well, and not smoking. Lifestyle as medicine. That’s it.
We can avoid tobacco for free. We can be active for free- although we can also spend money on it if so inclined. And we have to eat one way or another. We can eat better without spending more money than we already do.
If we got down to the bedrock of true prevention- lifestyle as preventive medicine- we could add years to life, add life to years, and save a whole lot of money by putting to use the science and sense long at our disposal. Doing so will, of course, require changes in how we think about health, changes in our culture. But culture is what we make it, and we can change it for free.
Which brings us to the bottom line, figuratively and literally. We have the science we need to eliminate outright most of what ails us. Prevention could save us a whole lot of dollars if, when we used the term, we made a bit more sense.
Dr. David L. Katz; www.davidkatzmd.com