The Invention of Prevention
Written by Editor   
Sunday, January 14, 2018 01:37 PM

Concern has mounted for 40 years over the inexorable rise of U.S. health care costs despite mediocre health outcomes compared to other advanced countries. Particularly since 2000, healthcare movers and shakers have convinced Americans that the solution is prevention -- if the health care system focuses on maintaining consumers' health, then they will avoid illnesses that require expensive treatments, and costs will decline. In this way, we will finally "bend the cost curve." After all, who wants a “sickness system"?

Adults can stay healthy, it is said, by getting routine check-ups and recommended cancer screenings and flu shots. Also, changing their “behaviors," as counseled by health care providers at regular visits: eating less (and better), exercising more, and eschewing fast food, tobacco, alcohol, and opiates.

In fairness, all of medicine can be considered "prevention." Primary prevention means preventing the onset of disease. In secondary prevention, we manage chronic diseases like hypertension, high cholesterol, or uncomplicated diabetes, to prevent complications like heart attacks. Tertiary prevention consists of measures to improve recovery and limit disability from those complications.

What people mean by “wellness” is primary prevention.  The trouble is, the medical system is really not the best tool for primary prevention; it is neither efficient nor particularly effective. It is also very expensive. 

The most effective way to improve the health of a population is to improve the so-called “social determinants of health" -- education, income, employment, environment, social supports, etc.

Why isn’t the medical system more useful for primary prevention?  It is hard to make a healthy adult healthier.  We bring in cars for routine maintenance. However, cars are mechanical and mechanical things are expected to fail over time.

People are different. Their structures are infinitely more complex, generally do not fail simply from the passage of time, and are not easily replaced. Injury or disease, on the other hand, can damage bodies and minds.

There are a few important, treatable diseases which are common, but clinically silent, for which providers should screen at regular intervals: hypertension, high cholesterol, and Type 2 diabetes. Although we currently screen for four kinds of cancers — breast (mammograms), cervical (Pap smears), prostate (PSA), and colorectal cancer (usually colonoscopy) -- on the theory that if we catch them early we can cure them more easily, all except colonoscopy have become controversial.

There is growing evidence that we screen too often, which drives up cost without identifying any additional clinically significant cancers; also, that excessive screening leads to treatment of small cancers which might never have progressed, so not just increasing cost from unnecessary services, but also causing discomfort, even injury, from unnecessary treatment. Surgery, chemotherapy, and radiation are not benign. 

Finally, there is no evidence of reduced morbidity or mortality from routine physical exams or diagnostic tests (apart from the above) on healthy, low-risk adults. Unnecessary exams not only increase costs, but can hurt patients.

Then there is the problem of the incidental finding, as our test results grow more detailed. Reports all too often report “the colon is OK, but we see something in the liver, not sure what it is, consider liver scan.” So I order the liver scan. The lesion in the liver turns out to be a non-problem, but the radiologist sees something in one lung. And so it goes. This happens all the time. The more tests one does, the more often it happens.

Finally, even visits for minor acute problems can cause harm, to the patient or to even the population. Acute upper respiratory tract illness is still the most common reason people visit primary care providers. For decades, doctors treated these conditions with powerful antibiotics. However, we learned years ago that most of these illnesses are viral and self-limited. Antibiotics (which treat bacteria only) are ineffective.

The result of millions of useless prescriptions is a high level of resistance to important antibiotics today, in individuals who have taken many as well as the population at large. And the drugs themselves often have unpleasant side effects.  Regarding the medical system, the best way for a healthy adult to stay healthy is to stay away from it.

The most effective way to improve population health is to attend to the social determinants of health -- lots of good jobs at good wages, education, decent housing, a safe, attractive environment, good social supports. Researchers dispute the relative importance of the different determinants, but everyone agrees that the medical system contributes no more than 10% to population health.

For any skeptics, we have a shocking example right in front of us.  Sir Angus Deaton and Anne Case have demonstrated that early mortality for one specific group — non-Hispanic whites ages 45-54 with no more than a high school degree — is rising, particularly from drug overdoses, alcohol and suicide, as well as a slowdown in progress against heart disease and cancer.  The authors label these "deaths of despair," and attribute them to an increasingly difficult, declining labor market for this group, leading to "measurable deterioration in economic and social well-being". The recent rapid spread of illegal opioids, of course, has only made the situation worse.

Our medical system can treat disease. The individual can contribute to disease avoidance, society as a whole can work to prevent it.