If Prevention is the Answer, What is the Question?

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Burden Lundgren
October 21, 2014

On the face of it, prevention seems to be a simple concept. Preventing a disease is better for the patient and less costly than treating it. But when we look at how prevention plays out over a population as well as for individuals, the concept turns out to be complex and often problematic.

First, prevention might be better labeled as “diversion” or “delaying.” In our unfettered optimism about medical research and technology, we forget a basic fact. The death rate for any population is 100 percent. In preventing death from one disease, we are opening the way for death from another condition or we may simply delay the onset of an illness (the heart attack that occurs at age 70 rather than age 50). That’s not a bad thing But let’s be clear about what we are doing.

Most people think of prevention as something that takes place in a doctor’s office. Clearly, the wide variety of interventions coming under the blanket of prevention means that it takes place at many levels and is undertaken by many people. If I take a long, brisk walk at a nearby park, I am practicing prevention. However, the civic authorities who built that park were engaged in prevention too.

No matter where it takes place, prevention comes with issues of medical uncertainty. Look at the changes in dietary recommendations over the last decades. Meat was good; then it was bad. Eggs were poison, now good. Fat was the devil; now it’s sugar. Tobacco is certainly the devil, but physicians used to serve as spokespersons in cigarette ads on television.

If we are confused about prevention, so are our doctors. Medical prevention guidelines sometimes seem to change with the wind. Two of the latest to do so are the guidelines for treatment with statins and anti-hypertensive medications, changes that upset years of practice and affect millions of people. Science today is not always science tomorrow.

And science is not the only dog in the fight. In a capitalist system, all the “bottom-line” stakeholders invested in anything from pharmaceuticals to weight loss programs have an interest in prevention guidelines that benefit their products, and they are not unskilled in exerting their considerable influence. The late Barbara Starfield, an expert in primary care, suggested that lowering of thresholds for “predisease” may be the greatest threat to effective prevention. For instance, while 97 percent of adults aged 50 and over have high cholesterol, high blood sugar and/or hypertension, only 8 percent of cardiovascular disease will develop in individuals with any combination of them. But the market drives treatment (or overtreatment) for all these factors for all patients.

Does prevention save money? Well, sometimes and maybe. If I take a walk in that park every day, it costs nothing and will likely result in better health and possibly longer life. But medical preventive measures are costly. There is close to universal agreement that certain measures save money, most notably immunizations and prenatal care.

But screening (which I will discuss more fully next month) involves expenditures for large populations most of whom will test negative, i.e., they didn’t need the screening in the first place. And what no one wants to discuss is that if we save money for a disease we prevent, we open the door to longer lives that incur even higher expenses. Smokers, for instance, have high health care costs, but their shorter lives limit the expenditures.

There is also what is known as the “prevention paradox,” the notion that the large benefits of prevention for a population are of little benefit for individuals. If thousands walk in that park every day, thousands of years will be added to their lives. For me alone, not so much. I am investing years of walking time to “earn” maybe an additional couple of additional years of life. But it would be possible to identify a higher-risk population that will reap a much greater benefit from that walk? It might be wiser to concentrate prevention interventions on them rather than those at average risk.

Prevention is not always benign. If you have watched television lately, you have seen advertisements for the new anticoagulants used to prevent strokes in people with irregular heartbeats. As one cardiologist remarked to me, stroke is forever. However, it is certainly well worth preventing.

For example, if your risk of stroke on the standard risk assessment scale is 1 percent/year without the condition and your risk triples with the condition that’s still a 97 percent chance of no stroke in a single year – although the risk grows over time. To prevent the stroke, you are given a medication that can cause intracranial or gastrointestinal bleeding and that cannot be reversed if you are in an accident. So you are taking a medication that is not risk-free every day for the rest of your life to prevent an event that will likely never occur.

Over 2 million people in the U.S. are candidates for this medication. Most of them won’t have strokes without it. But many certainly will. We just can’t predict which ones so everyone on the medication takes a risk to benefit some, harm others, be a costly nuisance to most and Christmas every day for the drug manufacturers.

One of the darker sides of prevention is that it creates the concept of voluntary illness – illnesses that may be largely preventable by individual behavior. HIV/AIDS is the most recent example. Gay men and drug users were blamed for the disease, while others were described as “innocent” victims. But it doesn’t end with HIV/AIDS. In the January 2012 issue of Health Affairs, Sara Sklaroff describes the complexity of her life dealing with type 2 diabetes (a disease with considerable genetic and environmental components) along with the frustration of being blamed for her condition not only by laypeople but also by health professionals.

So, next month: screening. Now I’m heading to the park for that walk – and maybe some cheesecake on the way home.

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Author: Burden Lundgren, MPH, Ph.D., RN practiced as a registered nurse specializing in acute and critical care. After leaving clinical practice, she worked as an analyst at the Centers for Medicare and Medicaid Services and later taught at Old Dominion University. She has served as a consultant to a number of nonprofit groups. Presently, she divides her time between Virginia and Pennsylvania and is working on two books – when her cocker spaniels let her.

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