On Conceptions of Prevention (Medical Humanities Lexicon)

Several of the listserves I participate in have linked to Gilbert Welch's article in the NY Times asserting that prevention is not a cure-all.  Countering both presidential candidates' assertions that "preventive medicine" is needed to improve population health, Welch argues that this is a myth:

The term “preventive medicine” no longer means what it used to: keeping people well by promoting healthy habits, like exercising, eating a balanced diet and not smoking. To their credit, both candidates ardently support that approach.

But the medical model for prevention has become less about health promotion and more about early diagnosis. Both candidates appear to have bought into it: Mr. Obama encourages annual checkups and screening, Mr. McCain early testing and screening.

It boils down to encouraging the well to have themselves tested to make sure they are not sick. And that approach doesn’t save money; it costs money.

Readers of this blog may or may not be surprised to hear that I agree with Welch.  But this hardly undermines the case for prevention, because the kind of prevention I have been urging repeatedly on this blog is not "preventive medicine."  I explained my argument on the Spirit of 1848 listserv, which I repost here:

"I am somewhat partial to the argument that Barbara Starfield et al., among others, have raised regarding the transmogrification of prevention from its public health roots to a more acute care model, in the sense of "preventive medicine." Of course, there is nothing wrong with preventive medicine as far as it goes, but the SDOH evidence base makes quite clear that the merits of the prevention addressed therein revolve around a different concept of prevention, one that emphasizes social policy extremely early in the lifespan, and even well before the lifespan (i.e., prenatal care, housing for putative parents, etc).

One of the problems with the political discussion on prevention is that it almost exclusively focuses on the newer, more acute care model. This does not really effectively tie into the robust evidence on SDOH in context of the public health, social model of prevention that has much older roots and
is based on more compelling evidence, in my view. Thus Starfield et al. argue that we need a concept of prevention based on population health rather than the focus on the individual risk factors that dominate preventive medicine today.

In addition, the political discourse on prevention irritates me insofar as it spends virtually all of its time discussing cost, and very little discussing the SDOH evidence base demonstrating that, due to the prevention paradox, public health prevention may not save money, but we have every reason
to believe it will dramatically improve population health, ameliorate disparities, etc."

Thus, the call for prevention is entirely evidence-based, and desperately needed, but only if we haven't already assumed that prevention is a function of the acute care medical model.  The kind of prevention that, based on the evidence, we have every reason to believe is desperately needed, is a model rooted in public health and social policy, not one premised on screening.

(Because this post assesses conceptions of prevention relevant to the medical humanities, I'm going to file it as a Medical Humanities Lexicon entry.  I will try to update this post with some additional sources in the near future).

UPDATE 10.16.08: Those who chanced upon this post via Health Wonk Review might be interested in reading a brief response to Joe Paduda's assessment of this post.

Comments

[Patrick S. O'Donnell]

I think I understand what you're getting at here and agree with it. But how would one characterize, say, a decision not to smoke, drink (alchohol), attend carefully to one's diet (in my case, a vegetarian trying to cut back on dairy products, refined foods high in sugar, etc.), regularly exercise, and so forth? In other words, under what heading do we put individual attention to (personal responsibility for) "healthy habits" and lifestyle decisions. Are these not indicative of "preventive medicine" in the old-fashioned sense? The focus, in this instance, is still on individual risk factors, but that does not preclude a corresponding focus, at the collective level, on "SDOH in context of the public health...model of prevention," indeed, I can imagine the latter allowing for and reinforcing the former. Perhaps this goes without saying but I thought to ask anyway!

[Daniel S. Goldberg]

Patrick,

Those are good questions. Starfield et al's critique, which supports but is not identical to some of the arguments sketched above, is that the focus on individual risk factors is silly because population health operates as a system, which means that risk factors aggregate and influence each other, such that isolating any particular individual risk factor is counterproductive. As evidence, Starfield et al. demonstrate the tenuous connection between any individual risk factors for many chronic diseases and population health outcomes.

The argument is not, of course, that individual risk factors do not exist. It's that if we want to have an impact on public health via prevention, policy must focus on the aggregate risk factors which collectively seem to exert a much stronger influence on health than individual risk factors.

The focus on the individual risk factors is, of course, more consistent with an acute care medical model than a public health model, though -- and here comes disease causality again -- public health as currently practiced can fairly be criticized for relying on a similarly flawed notion of linear, static systems and causes.

In a larger sense, my argument, along with many SDOH commentators, is not that lifestyle does not matter in disease. We've known for over 300 years it matters tremendously. The insight is that social and economic conditions exert an enormous influence on the choices and lifestyles people have. Smoking may lead to disease; but why is it that smoking prevalence is much higher among populations with low SES?

Lifestyle is important, but it is totally insufficient to reduce that to a purely individual basis, which is a tremendous problem with much of what passes for contemporary health promotion, in my view.