“What Prevents Prevention?”
Much of our built environment simultaneously enables and holds us in check. Playgrounds constructed today must meet certain standards that will, on the whole, minimize opportunities for injury even as they provide fun spaces for play. Roads crisscrossing our cities, counties and the country are designed to be both efficient in transmitting vehicular and pedestrian traffic as well as effective in precluding accidents. We must build our homes, offices and hospitals to codes whose very existence are to protect us from foreseeable dangers. Preventing harm, it can be said, shapes how we build civilization.
As a society we have reasoned that it is far better to pre-empt injuries than to attend to them after the fact. Why is it better? Some claim that avoiding trauma is better than experiencing it. Others hold that it’s a more sustainable use of resources to build a structure just once instead retrofitting it because it led to avoidable harms.
To be sure, many reasons exist why prevention is more efficient, effective, and ethical than reaction. But this leads to several questions: why has this attitude not similarly pervaded other arenas of our civilization, especially medicine? What prevents prevention?
Interest in prevention is not new, of course. It concerned George Armstrong, for example, who in the 1760s documented pediatric diseases and opened a hospital (dispensary) for children in London, the first of its kind in the world. Prevention was a significant goal for him:
But, in conducting the physical department of the Dispensary, I did not confine myself to the therapeutic, or curative part of physic only; I likewise extended my care to the prophylactic branch, or that which concerns the prevention of diseases, constantly endeavoring to hinder their being so frequent, or so violent, when they happen. (192)
Figuring out how to prevent people from becoming patients was, for Armstrong and others, more than a guiding principle. It was a goad.
By 1909, this goad prompted J. H. White, a surgeon at the US Public Health and Marine Hospital Service in New Orleans, to speak to the American Medical Association’s Section of Preventive Medicine and Public Health this way:
There is—there can be—no higher specialty in medicine than that for which this Section stands, and we must present this to the public in such unmistakable terms that the full recognition shall be accorded both to the sanitarian and to the profession as a whole, for neither can stand alone….It is sheer waste of ability and time for the members of this Section to tell each other what they already know….Our greatest function, it seems to me, lies in the fact that we are the connecting link between that great medical body which handles the vast majority of the diseases we would prevent and the general public, the victim of those diseases.
This being an undisputed fact, we should have in mind constantly the two duties which follow this fact as naturally as the day follows the night. We must impress on the public the vast import to them of preventive medicine; we must show them that health means wealth and happiness, to the first very frequently and to the last always a necessary adjuvant. (665)
On White’s account, preventive medicine’s ultimate value—and task—is in its ability to educate and motivate the public to embrace prevention as its medical paradigm. Insofar as wealth and happiness matter, prevention is in the public’s interest.
In some ways the public has embraced prevention. We see this in the broad participation in vaccine programs, improved private hygiene and insistence on better public sanitation. Prevention is also evident in environmental standards, for which White presciently called over a century ago. As he says, though medicine saves individual lives one at a time,
Is it not infinitely wiser to prevent the pollution by sewage of a stream supplying a city of a million than to fight that pollution in the bodies of 10,000 innocent victims of filth, or even to attempt the repurification of 100,000,000 gallons of that filth-laden water every day? Is it not better to prevent the pollution of our food, houses, vehicles and streets by tuberculosis than to spend millions on treatment and then see our loved one die by tens of thousands? (ibid.)
Preventing diseases by addressing causes is a far wiser use of human ingenuity and resources than reacting, piecemeal, to belated and painful conditions.
Though prevention may be wise, it surely is not simple. Just a few years ago Harvey Fineberg of the Institute of Medicine identified (Box 1) many factors confounding medicine’s adoption of prevention as a primary organizing principle.
Extant systems offer perverse incentives that make it difficult to embrace prevention as medicine’s overarching organizing principle. Even though it may be difficult to conceive of much less movement toward a system that privileges prevention, how and why does that difficulty justify not doing so? Just because something may be difficult to achieve does not mean that the status quo is superior or better ethically justifiable.
Fineburg offers a few ideas to spur healthcare toward a more preventive model (Box 2).
These suggestions are not impossible, just difficult. Their implementation is a matter of will.
So, questions remain: what hampers prevention in the American healthcare system? Why do those apparent obstacles or challenges continue to justify the status quo? And what are the reasons justifying prevention as the guiding principle in other domains of American existence, such as the built environment, but not in the realm that it perhaps matters most, in medicine?
Armstrong, George. 1783. An Account of the Diseases Most Incident to Children from Birth to the Age of Puberty. London: T. Cadell.
Fineberg, Harvey. 2013. “The Paradox of Prevention: Celebrated in Principle, Resisted in Practice.” The Journal of the American Medical Association. 310/1:85-90.
White, J. H. 1909. “The Scope of Preventive Medicine.” The Journal of the American Medical Association. 53/9:665-666.