Another review of Prevention vs. Treatment: What’s the Right Balance?

Bhaven Sampat has written a review of our text in Global Public Health 8(2):236-9, 2013. His summary judgment is:

Having expressed some minor complaints, I emphasise that I like the book and recommend it. I have long been interested in teaching a course on cost-effectiveness analysis that goes beyond technique and engages some of the political and ethical issues behind the scenes. This volume would be a good introduction to these themes in the context of prevention and treatment. The first three chapters would also provide a very good short introduction to the prevention versus treatment debates for policymakers and others interested in a general overview of these issues.

The first three chapters include the introduction (Faust and Menzel), economics (Altarum Institute – Miller, Roehrig, Hughes-Cromwick, and Turner), and cost-savings/effectiveness (Russell). We’re pleased he liked these chapters and they tend to be the most quoted of the chapters on policy-related blogs.

Let’s look at his “minor complaints.”

First, he doesn’t think the third section of the text, on how religious perspectives look at the balance, are valuable. “Though these chapters provide a useful introduction to medical ethics issues from different traditions, I do not think they connect well with the other chapters or speak to the balance question.” Given that other reviewers have praised the connectedness of the chapters, I’d like to better understand what he means by that portion of his comment. But more importantly, his “speak to the balance question” comment is puzzling. Each chapter in the third section specifically looks at how each religion represented considers how to balance prevention and treatment. The problem is that, except for Seventh Day Adventism (SDA), they all come out on the side of treatment without actually making the comparison in their religious texts or commentaries, except as gleaned from isolated statements.

This was surprising to Paul and me as well – none of Protestantism, Catholicism, or Judaism explicitly address the balance between treatment and prevention. This is the interesting finding from this section. When pushed, the authors of these chapters, who originally all stated there is no preference stated, eventually intuited that indeed treatment is commanded to take precedence in most instances (except in the “community elders” argument of Judaism). And even when Roy Branson’s chapter on SDA went a little deeper he found it easy to conclude that while prevention was still very important historically and theologically, there could be some concern that the SDA treatment system, which today is one of the largest in the US, is overwhelming in its use of resources, worrying that it could crowd out the prevention orientation.

Perhaps Sampat thought that they don’t address the balance question because indeed within the traditions they don’t explicitly address it, and he confused that with not asking or addressing the question within the chapters?

To the second minor complaint I plead guilty: I approached the book originally with the strong bias that prevention is underfunded and we don’t devote sufficient attention to it in policymaking or in the clinic. The latter is demonstrable with the under-use of prevention resources, even those considered cost-saving and cost-effective. This bias was stated explictly in the introduction, wherein Paul and I illustrate this underfunding and under-attention emphasis in various settings and the US’ clear bias toward treatment and away from prevention. This has been my stance throughout my career and I still believe it correct. And here is how I believe, from a policy perspective, this conclusion is dispositive: everyone talks about how treatment care costs too much – and by “health care” they usually mean “treatment” care. And everyone talks about how we don’t do enough in prevention. Yet we continue to pay for treatment care (almost at any cost) even when we know that additional dollars to prevention could help (but not cure) under-utilization of prevention. I address this in chapter 6 of our text, where I point out that funding alone (e.g. first dollar funding of prevention by the Affordable Care Act) won’t fix the access and other issues associated with successful prevention for individuals and communities.

Having said this, Sampat would be surprised to find how much my own view and public stances on prevention have changed since beginning the book. Now instead of speaking in full defense of prevention I add nuances of concern and reality. I even have one talk, “The Moral Problem of Prevention,” where I explicitly point out these concerns and why prevention might not take the theoretical moral high road which it used to take.

I agree also with Sampat’s concern that we didn’t spend more time on both the politics of prevention (mostly just covered in Diana Petitti’s chapter) and how the values-attitudes mix impacts both policy and individual decision-making. I call for more imagination in effecting the “affect heuristic” in prevention – we need to figure out how we can evoke better future suffering because of a lack of prevention in order to have decision-makers understand better their effects when they don’t fund prevention. Indeed the theme of the American College of Preventive Medicine’s 2015 meeting will be just that – Imagination in Preventive Medicine, from a policy and delivery perspective.

Generally those who practice prevention both in the public health and private clinical spheres have not been very good at marketing health to their stakeholders. Certainly marketing techniques like those used for unhealthy products and services have evolved into fine arts – glossy well-designed corporate annual reports, while many public health programs still use the equivalent of xeroxed, hand-folded brochures. We need to find efficient, effective ways to deliver better messages, motivate people in different directions, and change tastes (literally).

Perhaps Paul Menzel and I will produce volume 2, which would address some of Sampat’s minor complaints. Maybe he’d like to explore the political context more? We would have liked to have addressed some of his complaints in our first volume, but frankly were concerned about going over 400 pages for practical publication purposes.

At the same time, we thank him for his comments and review.

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Backcountry skier rescue vs. prevention

There are frequent examples in the media of how we are willing to spend much more on treatment/alleviation of harm when prevention is possible with less suffering.

An article in the Wall Street Journal today, “Ski Resorts Open Unbeaten Paths” describes the opening of backcountry skiing as sanctioned by the US Forest Service and the various ski resorts such as Tahoe-area Squaw Valley, Sugar Bowl, and Heavenly, Grand Targhee (Idaho – the article states Wyoming), Telluride (CO), and Jackson Hole.  The Telluride Sheriff says he has to do 20 backcountry rescues a year now, up from 5.

Our friend, Dan Gregorie, is quoted in the article.  Dan lost his 24 year-old daughter, Jessica, a lovely young lady, at a Tahoe ski resort in 2006 when she slipped walking over a non-backcountry bridge area on a ridge between two ski areas.  She was carrying her skis and going carefully.  Dan has devoted his life since then to encouraging policy change by forming the California Ski and Snowboard Safety Organization (CSSSO).

There may be certain ways backcountry skiers can be even better prepared:  first, they should be licensed or registered in some way to assure proper education of survival and precautions to be taken (avalanche beacons, expandable support in avalanches, proper communication devices, etc.) when going out-of-bounds. Second, the ski resorts, if making backcountry more accessible, should provide hazardous trail warning signs past the boundaries and protections where necessary, and ski patrols to assure prompt assistance if something does go wrong. Finally, backcountry skiers should be taxed for going “out-of-bounds” so that funds can be used to pay for the public rescues like the Telluride Sheriff’s department needs to do periodically.

The resorts want liability exemptions for accidents or deaths.  Yet, as the CSSSO has documented, they don’t adhere consistently to the safety recommendations and engineering designs that would make ski slopes safer.  The backcountry skiers want freedom of access, but the opportunity costs for their deaths (see the tale of experienced, well-equipped backcountry skiers who died in the Cascade Mountains) and injuries are high.