The Myth of Preventive Medicine

[Marat]

There is a massive campaign today to save healthcare costs and improve healthcare outcomes by focusing on preventive medicine rather than just treating disease after it occurs, when care becomes more expensive and health becomes more difficult to restore. But the simple fact is that most of the truly serious diseases which cost the healthcare system the most money and which are most devastating to human health, well-being, and life cannot be prevented by any known means. Cystic fibrosis, lupus, type 1 diabetes and a host of autoimmune diseases, multiple sclerosis, muscular dystrophy, Tay-Sachs disease, muscular dystrophy, more than half of all cases of renal failure and heart disease, genetic cancers or cancers of unknown origin, and many neurological disorders are simply beyond the capacity of medical science to prevent. Other major diseases such as type 2 diabetes are very heavily genetically conditioned, so while their development can be delayed or moderated, they often cannot be entirely prevented. While it is sometimes argued that even though many serious illnesses cannot be prevented, at least preventive medicine can moderate their course by early intervention, but here too, the intensive management of these diseases can be very expensive and can also produce dangerous side-effects which are themselves effectively disease states, so not much is gained by preventive strategies. Ultimately the early and intensive management of unpreventable illnesses will fail in many cases to prevent chronic illnesses from becoming worse.

 

In many cases the effectiveness of interventions to prevent or manage disease is overestimated because the ability of the patients to comply with these interventions itself only measures their better initial health. Thus older people who can exercise are the ones who are already stronger and healthier, probably for genetic reasons, so this is why exercise correlates with health in older people, rather than exercise itself being the cause of their better health.

 

But given that the scientific evidence that preventive medicine is so important is lacking, why is it such a pervasive recommendation in healthcare policy discussions? One reason is that if preventive healthcare were really very effective, it would support the right-wing argument that the government should not spend much money on public healthcare, since disease is all the patient's fault anyway and could be avoided quite cheaply by just telling people how to behave. Another reason is that if patients could themselves prevent disease by doing what medicine told them to do, disease could be blamed on patients, thus relieving the medical profession of blame for the stagnation of medical progress in recent years, with polio being the last major disease to be conquered nearly 60 years ago.

[lemur]

Ever been to an emergency room? I try to avoid it but whenever I go, it is incredibly busy. Are all these people there because they have one of these unpreventable diseases you mention or are they there with something that was helped along by poor diet, insufficient exercise, too stressful lifestyle, etc.? The problem economically with preventive medicine is that if it really works, it would reduce medical revenues. Then, if health care workers wanted to continue making the same amount of money they would either have to charge more for the patients whose problems didn't get prevented OR lose revenue. Some people will argue that if preventive care really works then it's worth spending the same amount of money for it. Yet if revenue levels are maintained at the level that results in current economic pressures and lifestyles, I doubt that prevention would have much if any effect. Ultimately I think it is the stress and haphazard lifestyle activities caused by economic demands on people that result in unhealthy bodies, but the consumption and leisure opportunities produced by these bodies are what makes high-paying medical careers so interesting to go into. "Work hard, play hard, and when you get sick from it nuke the problem" seems to be the driving force behind both health problems and their expensive and therefore lucrative resolutions.

[skyhook]

There is the early detection thing. My country's health board have posters and advertise through the media to get people to do regular screening for common diseases, targeting those who reach a certain age like over 40. They go for blood test or checking the women's breast. Usually, it is hypertension, and blood glucose levels and eye test for Glaucoma for the more elderly ones. The doctors will highly recommend anyone who test abnormal to take some medicines like hypertension drugs...It is a preventive for diseases like stroke, and heart diseases.Some people have a distrust for some western medicines, it is compared to slow poison for some disbelievers.

 

There are some companies that are MLM companies, and they have some health products. These products are often marketed as preventive health supplements. I was really sceptical when they say one of their health products can reduce hypertension. It is probably fish oil..However, it seems to have an effect. ( Don't trust me on this, I can't back it up) I would like to prove that supplements are gimmicks, but sometimes it works, like making grey hairs turned black again. I'm a bit undecided. I don't take any supplements regularly. When I feel that my nose is getting inflammation again, I took a red cherry flavour drink from this MLM company to reduce the inflammation, and when I had a fever, this drink is able to suppress the fever. I'm quite impressed with its fever suppressing ability. You can skip panadol for the slight fevers. The cost of a pack of this drink is more than a pack of panadol or Paracetamol. Doctors like to presribe Paracetamol. Health supplements are more expensive or about the same cost as medicines from the clinics. My mum's hypertension can't be lowered on some days though, so I'm undecided how effective. If health supplements can do as well as doctor's medicines, there are doubts.

There are some people who believe the mass produced food ,vegetables ,fruits, etc...we eat today, are low in nutrition. and some cooking oils are unhealthy. I'm trying to grow some seedlings with a cheap NPK fertilizer and it seems the plants are lacking something! The leaves at the base turn yellow easily. I need more experiments. Some supplements may be useful for some people, like multi vitamins or vit C, and probably some B. It can probably prevent a flu if you live in densely populated cities.

Prevention is by looking from the ground up like the diet and living conditions, pollution. There is something the science can't prove whether some foodstuff are wholesome or not, as it seems not easy to check those ingredients.

The western world are rich, and money shouldn't be an issue, probably can reform the health policies. which some doctor say is not functional. They seem to be allocating resource to some very minor illness, though I can't name these. or it is due to tying up with insurance companies, which I don't hold in high regard.

Edited September 19, 2010 by skyhook

[lemur]

It is probably fish oil..However, it seems to have an effect.

I think you meant to say "snake oil." Fish oil is supposed to be really beneficial, containing omega-3 acids, whatever those are. Snake oil is the stereotypical term for a placebo sold by scam-artists.

 

 

 

[skyhook]

I think you meant to say "snake oil." Fish oil is supposed to be really beneficial, containing omega-3 acids, whatever those are. Snake oil is the stereotypical term for a placebo sold by scam-artists.

 

yes I'm refering to fish oil.

[Mr Skeptic]

Well, some preventative medicine is worth it and some isn't. There was a suggestion that we were overscanning for breast cancer in the younger patients, resulting in additional deaths. This is because the scans can find tumors that would have gone away after a while, but not for sure and the patient almost always opts for chemotherapy which is really really nasty. On the other hand, if you are at risk for heart attack taking an aspirin every day to thin your blood is almost free, and definitely pays for itself in reduced risk. Avoiding known carcinogens is also a good preventative measure. Cleaning wounds also worthwhile. Vitamin supplemented food. Regular checkups. Exercise. Washing hands. Cooking food thoroughly. Certain dietary modifications. Many many things that we do are worthwhile preventative measures, even if we don't think of them as medicine.

[CharonY]

Before we delve deeper in the matter what type of preventive medicine do we want to discuss here. The breast cancer example (also prostate for that matter) are cases of diagnostic scans and would not generally be included as preventive medicine.

Once we got that we can check whether studies have been conducted for any given preventive recommendation and then we can assess whether they are useful or not. The next question would then be (in case they are helpful) what population effects it has. Then we can discuss whether above mentioned non-preventable diseases are really of overwhelming concern so that preventing other diseases is simply not worth it (though we would have to define a metric as e.g. cost for it first).

 

Alternatively we can blame the medical profession as well as biomedical researchers and come up with better ideas.

[Marat]

Of course we generally do some things already which have the effect of preventive medicine, such as observing the rules of basic sanitation, eating a healthy diet, getting sufficient sunlight, etc. Any textbook of the history of medicine will tell you that the great advances in life expectancy and health from the early 19th century to today were achieved not by advances in medical technology but by improvements in basic public health measures such as better sanitation, diet, and swamp draining, which eliminated problems such as typhoid, typhus, cholera, ricketts, malaria, etc.

 

But my concern is with how much improvement in health and reduction of medical costs we can realistically expect to achieve by additional preventive medicine measures being proposed now, which so many politicians seem to assume will be enormous. I doubt that any gains will be significant, and for three reasons: First, the benefits of exercise, dietary interventions, and certain screening tests have been well known for the last 40 years, but since there is a limit as to how cooperative people are willing to be with such programs, there is no reason to expect that compliance with these recommendations will now suddenly improve. Second, the greatest burden on human health in the Western world today, both in suffering and cost, is in the chronic diseases listed in the OP which cannot be prevented. This is a most curious era in medical history, since as we are coming to know more and more about the importance of genetics in determining our health, we are also, paradoxically, insisting more and more stridently that preventive measures will make a huge contribution to health. Third, there is a massive cost both to the quality of life of patients and to the costs of the healthcare system in medical interventions to manage chronic illness and at least moderate if not prevent their worst sequelae. More intensive daily dialysis for renal patients, for example, improves outcomes, but it utterly destroys the quality of patients' lives and costs the healthcare system a massive amount of money. Intensive management of blood glucose in diabetics cuts the quality of patients' lives in half with repeated blood sugar testing, carbohydrate counting, and insulin injections every single day, and it triples the number of potentially catastrophic or even lethal hypoglycemic episodes. True, it also reduces long-term vascular and neurological lesions, but the monetary cost of the required pumps, continuous glucose monitors, diabetes educators' time, medical appointments, emergency room visits for hypoglycemic episodes, as well as the cost to the patients' quality of life is so great that it may well outweigh the benefits. Similar points could be made for the management strategies of many other diseases, which the preventive medicine movement rather simplistically evaluates solely in terms of their benefits rather than more realistically assesses in terms of their balance between costs and benefits.

[-Demosthenes-]

In the 3rd world millions of people die of vaccine treatable diseases and other diseases that would be treatable by inexpensive interventions or preventions. People die of tetanus, vitamin A deficiency, Zink deficiency, AIDS, all of which are at some level preventable or treatable by some means that is much less expensive than clinical intervention -- then sending an actual doctor or nurse to treat them, or even just setting up a clinic with cheaply paid local health workers. It's ridiculously cheaper to educate a group of people on how to prevent AIDS, and even supply some minimal means, than to supply antiviral medication for a lifetime. Many child deaths could be avoided if more mothers nursed their babies, or if they knew how to treat diarrhoeal diseases at home, basic nutrition, etc etc. In the 1st world Hypertension, Obesity, tobacco, and alcohol are related to a lot of deaths and a lot of clinical money spent that could have been spent on education on how to prevent these diseases. But even if you educate are many even going to prevent their own diseases?