Category Archives: Prevention

“Imagining the Future to Enhance Prevention Today”

The American College of Preventive Medicine’s annual meeting was held the last week of February in Atlanta, GA.  I’m copying below the article I wrote for the American Journal of Preventive Medicine (in the March, 2015 issue:; volume 48(3):A5–A9) about the theme of the conference.  Note that the small numbers sometimes in the midst of a sentence refer to the references at the end of the article.


“Imagining the Future to Enhance Prevention Today”

Halley S. Faust, MD, MPH, MA, FACPM

President, American College of Preventive Medicine

“Just the facts, ma’am,” Joe Friday would intone using his signature phrase on the radio and TV series, Dragnet.  This is what we believe we practice: evidence-based preventive medicine (EBM) based on “just the facts.” The American College of Preventive Medicine’s (ACPM’s) mission states that we “improve the health of individuals and populations through evidence-based health promotion, disease prevention, and system-based approaches to improving health and health care.”1

In EBM and science as a whole, we seem to be striving for the concept that Goldenberg2 defines as objectivity:  “an epistemic virtue … that stands for an aperspectival ‘view from nowhere,’ certainty, and freedom from bias, values, interpretation, and prejudice. Even if objectivity cannot be achieved, it is perceived to be an ideal worth striving for.”

Though there are controversies surrounding EBM regarding its definition,3 the philosophical base,4,5  definitions of underlying objectivity,2 causal inferences,6 value of magnitude of the effect of proven interventions,7 and balance between evidence and experience in recommending clinical interventions,8 all seem to agree that the evidence is clearly where we need to start.

Ultimately, we want to know if an intervention likely will enhance well-being for an individual or a population.  To simply suggest clinical or population-based interventions without examining the effectiveness, safety, and costs of health-promoting or disease-preventing interventions, and without knowing what works and what doesn’t, would be irresponsible.

Yet, even assuming we could agree on what the evidence implies for clinical or population interventions, evidence alone usually does not lead to health-promoting behaviors in individuals,9 or prioritization of health-promoting policies by policymakers.10 Nor is health care always on top of the list for voters.11 We even have trouble convincing our own healthcare workers (HCWs):  During the 2012–2013 influenza season, the influenza vaccination coverage was only 75.2% for all HCWs, and only 81% among hospital-based HCWs.12

And, as we may often lament, lack of evidence in “alternative” medicine does not prevent individuals from partaking in unproven clinical interventions or prevent policymakers from passing unwise or half-baked laws or regulations.

Why do people or policymakers avoid health-promoting behaviors or pursue unproven, and perhaps even potentially dangerous, behaviors that they believe to be beneficial?

One of many reasons is because we as prevention specialists believe that “just the facts, ma’am” is enough.  In our zeal to be accurate with data, we often ignore methods that would be more effective than simply presenting the facts. We fail to incorporate into our practices lessons learned from non-medical disciplines that could help us persuade patients to increase prevention’s priority in their personal lives, or in policymakers’ work in resource allocation and regulation development.

Why Do We Prioritize Treatment Over Prevention?

In the U.S., we spend about 8.5% of the healthcare dollar on prevention.13  Most of us in prevention still believe that this is a lot less than we should spend. Dee Edington, the Katherine Boucot Sturgis plenary speaker at the ACPM annual meeting in 2009, claimed that 20% of the healthcare dollar on prevention would be a better allocation. Miller and colleagues,14 in a brilliant paper that has received little recognition in the preventive medicine community, found that the marginal benefits of prevention and treatment for cardiovascular disease (CVD) would be reached at 37% spent on known effective prevention and 63% on effective treatment, requiring a reallocation of 9% of spending from their current spending estimate of 28% of the CVD dollar on prevention.

Why this seeming over-prioritization of treatment, or neglect of prevention? As the philosopher David Hume15 wrote, “Reason is, and ought only to be the slave of the passions.” Although we may believe that this is (or ought to be) backwards, the reality is that modern studies in the social sciences, neurosciences, and policy decisionmaking disciplines ratify Hume’s description of human nature. As stated in a recent Wall Street Journal article, “Most of us assume that when we try to solve problems, we’re drawing on the logical parts of our brains. But, in fact, great strategists seem to draw on the emotional and intuitive parts of their brain much more.”16

An appeal to the rational mind is not nearly as motivating as an appeal to the passions.17,18   It is very difficult to ignite the passions for any kind of changes of habit or policy when we are not responding to immediate needs—when we don’t have evidence in front of us of vivid suffering.

In a prior publication, I argued that the priority of treatment over prevention, or alleviating harm over preventing harm, is “a function of our compassion, which is animated by spatial and temporal vividness.”19  This claim is based on what Slovic et al.20 describe as the affect heuristic:

Representations of objects and events in people’s minds are tagged to varying degrees with affect. In the process of making a judgment or decision, people consult or refer to an “affect pool” containing all the positive and negative tags consciously or unconsciously associated with the representations.… Using an overall, readily available affective impression can be far easier—more efficient—than weighing the pros and cons or retrieving from memory many relevant examples, especially when the required judgment or decision is complex or mental resources are limited.

The affect heuristic can be evoked in many ways.

Think of the infant Jessica McClure, who fell down a well in 1987. Millions of dollars of previously unallocated resources were mobilized to save her.21 This is an example of Jonsen’s22 well-known rule of rescue.  [Jonsen22 explores this rule as a deontological imperative when we also need to be considering utilitarian consequences. He asks, “Should the rule of rescue set a limit to rational calculation of the efficacy of technology?  Should we force ourselves to expunge the rule of rescue from our collective moral conscience?”]

Think of James Foley and Steven Sotloff—their beheadings by Islamic State for Iraq and Syria (ISIS) in vivid video evoked outrage in the American public, mobilizing Congress to pass the bill giving authority for the Obama Administration to arm Syrian rebels. The Associated Press’s take on this?

We only respond if there’s video.… Time and again, we are informed of outrages … but only grow outraged and force action when video or audio or images emerge.… “Seeing things provides more information and puts a human face on whatever the situation is, and helps people relate on a much more personal level to what’s going on.”23

Video gives us vividness, an essential ingredient to mobilizing resources.

Think of the way Americans give to charity. As recently discussed on a National Public Radio Planet Money podcast,24  90% of all money is given within 90 days of a disaster—a clear-cut event that is a “galvanizing moment” that focuses world attention by evoking affect tags. Slowly moving, deadly disasters like the Ebola outbreak go on without a clear, defining moment in the mind of the general public. Further, prevention requires giving to currently normal individuals or populations.  Prevention occurs before suffering or disaster.

When vividness of suffering is not evident, affect tags are not evoked and the affect heuristic is not in play. Yet, we know there will be unnecessary suffering in the future because patients and policymakers are not taking health-promoting action today. How can we find ways to evoke affect tags associated with future suffering so patients and policymakers will take action today?

Somehow, we need to capture the imagination—get people vividly to imagine the reality of the future. This is our challenge.  This is the theme of the American College of Preventive Medicine’s annual meeting to be held in Atlanta, Preventive Medicine 2015 (PM2015), February 25–28.

Making the Future Vivid Through Imagination

How might we stoke the imagination to enhance prevention today?

There are many ways we can stoke the imagination.  These methods have been used by non-scientific disciplines for ages working with the needs and desires of individuals. Data, information interpretation, and EBM are still important, of course. Proposing courses of action without evidence that they are meaningful would be irresponsible, and PM2015 will continue its strong emphasis on scientifically based information skill building and dissemination. At the same time, we will explore ways that we can harness the imagination through non-science, yet evidence-based, tools by looking at ways that elicit the affect heuristic imaginatively.

To do this, we will tap experts from outside of traditional preventive medicine in some of the following disciplines:

1. Sound business techniques. Companies use marketing and sales methods to encourage needs fulfillment through purchasing of goods and services. They use persuasion techniques that convince the consumer or customer that their product or service is just what customers need to fulfill desires that they may not even know they had. Of course, from the preventive medicine perspective, sometimes these techniques result in encouragement of poor health habits— excessive calories intake, smoking, stress-producing anxieties, inappropriate use of medications, sedentary lifestyles, among others. And from an ethical perspective, we need to ensure against coercion or manipulation.  However, these techniques can also be used to encourage health-promoting behaviors—to evoke images of future happiness and well-being because of actions we take today.

Increasingly, businesses are using behavioral economics to motivate employees and customers as well.  They are using “nudges” to “alter people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives.”2527

2. Spiritual/religious heuristics. “Effective ethical arguments and policy making are not made in sealed chambers of rationality—in the real world they reach people imbued with traditions and cultures.  Traditions inform our ethical premises and reasoning, and certainly impact on health policy decision making.”28  Theological reasoning is directly relevant to both imagining and analyzing our personal actions and how we believe we should treat communities. How do we assess the question of “do not stand idly by thy neighbor” with the resource-competing “build a parapet around your roof?” How do we account for (and work with) the influence of religious leaders in times of calm to strengthen relationships so we can get them to deliver health-promoting messages?29,30

3. Experimental psychology and health behavior.  There are a number of behavioral “models” of why we behave the way we do in health care31 and broader pursuits.32  Psychologists and sociologists have been studying these areas for many years, yet we rarely have these specialists present in preventive medicine meetings.  This may be very relevant to how we treat risk factors through lifestyle medicine,33,34 and how consumers consider the value of first dollar prevention coverage that could backfire.35 For example, Segar and Richardson36 recently opined on how autonomy and intrinsic experiences such as pleasure motivate regular walking better than emphases on healthy outcomes:

…affect drives people’s daily decisions, and regular walking is determined by whether people consistently decide to walk…messages featuring affective benefits consistently resulted in higher participation than the health-related ones…larger delayed rewards for walking, like preventing illness, will not be as motivating as smaller, immediate rewards, like experiencing pleasure (i.e., delay discounting).

Segar and Richardson suggest that we eliminate health as the driving motivator for physical activity, and emphasize the core needs such as the inherent pleasure and meaning it brings to our lives.

Further, how individuals understand and react to risk is a complex and critical topic for how we can promote healthy lifestyles,36 appropriate use of prevention screening methods,37 and policies.38

Food psychologists are helping us understand how doing exercise or taking risk-reducing medications can cause health-adverse compensatory responses in people by their feeling they have been given license to consume more calories or eat less-healthy foods.34,39

4. The arts. In music, “the emotions accompanying expectations are intended to reinforce accurate predictions, promote appropriate event-readiness, and increase the likelihood of future positive outcomes.”40  Music is a way of evoking the “imagination response,” which is a way of imagining “different possible outcomes and vicariously experienc[ing] some of the feelings that would be expected for each outcome… provid[ing] an important mechanism for motivating an individual to take courses of action that increase the likelihood of a positive outcome.”41

Music is known to help us express basic emotions.41  Paradoxically, even sad music is known to induce pleasant emotions.42 Music can alter customer purchasing patterns in restaurants,43 and influence consumer choices during wine purchases.44  Music is used to evoke emotions in advertising, film-making, military campaigns, and even to manipulate our emotions.  It’s also used to soothe us; since the dawn of civilization, mothers “have used soft singing to soothe their babies to sleep, or to distract them from something that has made them cry.”45

We all have unlived lives that enhance our lived ones.46  Sometimes literature can evoke imaginative responses to fictional circumstances, or relate personal experience to health-promoting behaviors. Eula Biss47 uses personal narrative to illustrate how metaphors in medicine, risk, health, and motherhood inform our understanding of immunization and willingness to take acceptable medical preventive actions to protect our children. Among many useful insights, Biss suggests that many alternative practitioners may be successfully convincing mothers to use “alternative” therapies (and avoid vaccinations) because they avoid war metaphors commonly evoked in clinical medicine.

Films evoke responses as well. For example, watching films can cause short-term action desires on smokers.48

In other words, using non-prevention traditional disciplines may help us in our difficult work of eliciting affect heuristics in a positive way to enhance the effectiveness of our clinical and policy work.

It’s not uncommon for preventive medicine specialists to eschew these types of techniques for high-minded reasons. We may be turned off by the assumption that advertising and marketing are manipulative tools. We may be turned off by religion or the idea that religious precepts are not as important as secular human rights statements or codes of ethics. We may feel that emotional appeals are somehow unfair. And we are right to be cautious that persuasion does not veer into coercion or manipulation.  We always want to be aware that our actions are ethical; at the same time, being too “virtucratic” diminishes our effectiveness as clinicians or policy advocates.49

As Epstein49 reminds us related to the 2014 midterm elections, “Political arguments at the level of ideology are seldom won. As Jonathan Swift wrote, ‘it is useless to attempt to reason a man out of a thing he wasn’t reasoned into.’”

The way we behave related to health, our imagination, and the future often has more to do with our passions, our affect tags, and our imagination than “just the facts, ma’am.” Come to Preventive Medicine 2015 in Atlanta and find out more about how you can better influence and persuade your patients and policymakers by stoking the imagination of the future for better health today.


1. ACPM. Who we are. American College of Preventive Medicine 2014.

2. Goldenberg MJ. Iconoclast or creed? Objectivism, pragmatism, and the hierarchy of evidence. Perspect Biol Med. 2009;52(2):168–187,

3. Luce BR, Drummond M, Jonsson B, et al. EBM, HTA, and CER: Clearing the Confusion. Milbank Q.  2010;88(2):256–276,

4. Karanicolas PJ, Kunz R, Guyatt GH. Point: evidence-based medicine has a sound scientific base. Chest. 2008;133(5):1067–1071,

5. Upshur R. Making the grade: assuring trustworthiness in evidence. Perspect Biol Med. 2009;52(2):264–275,

6. Faust HS. A cause without an effect? Primary prevention and causation. J Med Philos. 2013;38(5):539–558,

7. Greenhalgh T, Howrick J, Maskrey N. Evidence-based medicine: a movement in crisis? BMJ. 2014;348:g3725,

8. Williams BA. Perils of evidence-based medicine. Perspect Biol Med. 2010;53(1):106–120,

9. Montori VM, Brito J, Murad M. The optimal practice of evidence-based medicine: incorporating patient preferences in practice guidelines.  JAMA. 2013;310(23):2503–2504,

10. Haas M, Ashton T, Blum K, et al. Drugs, sex, money and power: an HPV vaccine case study. Health Policy. 2009;92(2–3):288–295,

11. Polling Report I. Problems and priorities. 2014

12. Black CL, Yue X, Ball SW, et al. Influenza vaccination coverage among health care personnel—United States, 2013–14 influenza season.  MMWR Morb Mortal Wkly Rep. 2014;63(37):805–811.

13. Miller G, Roehrig C, Hughes-Cromwick P, Turner A. What is currently spent on prevention as compared to treatment? In: Faust HS, Menzel PT, eds. Prevention vs. Treatment: What’s the Right Balance?. New York: Oxford University Press, 2012:37–55.

14. Miller G, Daly M, Roehrig C. Tradeoffs in cardiovascular disease prevention, treatment, and research. Health Care Manag Sci. 2013;16(2):87–100

15. Hume D. A Treatise of Human Nature. New York: Oxford University Press, 1740.

16. Blastland M, Spiegelhalter D. Risk is never a strict numbers game. Wall Street Journal. 2014.

17. Kahneman D. Thinking, Fast and Slow. New York: Farrar, Straus and Giroux, 2011.

18. Kahneman D, Slovic P, Tversky A. Judgment Under Uncertainty:

Heuristics and Biases. New York: Cambridge University Press, 1982.

19. Faust HS. Our Alleviation Bias: Why Do We Value Alleviating Harm More than Preventing Harm? In: Faust HS, Menzel PT, eds. Prevention vs. Treatment: What’s the Right Balance? New York: Oxford University Press, 2012:139–175.

20. Slovic P, Finucane M, Peters E, MacGregor DG. The affect heuristic. Eur J Operational Res. 2007;177(3):1333–1352,

21. Small DA, Loewenstein G. Helping a victim or helping the victim:  altruism and identifiability. J Risk Uncertain. 2003;26(1):5–16,

22. Jonsen AR. Bentham in a box: technology assessment and health care allocation. Law Med Health Care. 1986;14(3–4):172–174.

23. Washington J. Where’s the tape? America cares when there’s video.  Santa Fe New Mexican. September 14, 2014.

24. Chase Z, Smith R. Planet Money. In: Chase Z, Smith R, eds. Why Raising Money for Ebola Is Hard. New York: National Public Radio, 2014.

25. Thaler RH, Sunstein CR. Nudge—Improving Decisions About Health, Wealth, and Happiness. New York: Penguin Books, 2009.

26. Rice T. The behavioral economics of health and health care. Annu Rev Public Health. 2013;34:431–447,

27. Rogers T, Milkman KL, Volpp KG. Commitment devices—using initiatives to change behavior. JAMA. 2014;311(20):2065–2066,

28. Faust HS, Menzel PT, eds. Prevention vs. Treatment: What’s the Right Balance? New York: Oxford University Press; 2012.

29. Faust HS, Bensimon CM, Upshur REG. The role of faith-based organizations in the ethical aspects of pandemic flu planning—lessons learned from the Toronto SARS experience. Public Health Ethics. 2009;2(1):105–112,

30. Roberts LF, VanRooyen MJ. Ensuring public health neutrality. N Engl J Med. 2013;368(12):1073–1075,

31. Glanz K, Rimer BK, Viswanath K, eds. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San Francisco, CA:  Jossey-Bass; 2008.

32. Schwartz B, Ward A, Monterosso J, Lyubomirsky S, White K, Lehman DR. Maximizing versus satisficing: happiness is a matter of choice. J Pers Soc Psychol. 2002;83(5):1178–1197,

33. Bolton LE, Cohen JB, Bloom PN. Does marketing products as remedies create “get out of jail free cards”? J Consum Res. 2006;33(1):71–81,

34. Sugiyama T, Tsugawa Y, Tseng C, Kobayashi Y, Shapiro MF.Different time trends of caloric and fat intake between statin users and nonusers among us adults: gluttony in the time of statins? JAMA Intern Med. 2014;174(7):  1038–1045,

35. Dixon RB, Hertelendy AJ. Interrelation of preventive care benefits and shared costs under the Affordable Care Act (ACA). Int J Health Policy Manag. 2014;3(3):145–148,

36. Segar M, Richardson C. Prescribing pleasure and meaning: cultivating walking motivation and maintenance. Am J Prev Med. 2014;47(6): 838–841,

37. Rosenbaum L. Invisible risks, emotional choices—mammography and medical decision making. N Engl J Med. 2014;371(16): 1549–1552,

38. Miller M, Solomon G. Environmental risk communication for the clinician. Pediatrics. 2003;112:211–217.

39. Werle COC, Wansink B, Payne CR. Is it fun or exercise? The framing of physical activity biases subsequent snacking. Marketing Lett. 2014,

40. Huron D. Sweet Anticipation: Music and the Psychology of Expectation. Cambridge, MA: MIT Press, 2006.

41. Juslin PN. What does music express? Basic emotions and beyond. Front Psychol. 2013;4:596,

42. Kawakami A, Furukawa K, Katahira K, Okanoya K. Sad music induces pleasant emotion. Front Psychol. 2013;4:311,

43. North AC, Shilcock A, Hargreaves DJ. The effect of musical style on restaurant customers’ spending. Environ Behav. 2003;35(5):712–718,

44. North AC, Hargreaves DJ, McKendrick J. In-store music affects product choice. Nature. 1997;390(6656):132,

45. Levitin DJ. This is Your Brain on Music—The Science of a Human Obsession. New York: Penguin Group, 2006.

46. Phillips A. Missing Out: In Praise of the Unlived Life. London: Hamish Hamilton, 2012.

47. Biss E. On Immunity, an Inoculation. Minneapolis, MN: Graywolf Press, 2014.

48. Wagner DD, Cin SD, Sargent JD, Kelley WM, Heatherton TF.  Spontaneous action representation in smokers when watching movie characters smoke. J Neurosci. 2011;31(3):894–898,

49. Epstein J. After the midterms, virtucrats still rule. Wall Street Journal. November 4, 2014.

[Note that this was a non-peer reviewed contribution from the American College of Preventive Medicine, which is one of the sponsoring societies of the American Journal of Preventive Medicine.  No financial disclosures were reported by the author of this paper.]


Bill Stewart’s Egregious Errors about the Hamas-Israel Conflict

Bill Stewart’s August 9 column (“Toward Israel: A Double Standard?”) includes many distortions and factual errors. In some cases he seems to have accepted Palestinian propaganda uncritically.  I sent this into the Santa Fe New Mexican as a rebuttal but they have, apparently, chosen not to include it in their Sunday opinion pages:

Limited space permits an examination of only some of the many errors in Stewart’s column:

1.  The most recent war was caused by the murder of three Israeli teens.

The death of the teens was not why Israel attacked Hamas in Gaza. If Hamas had not started its indiscriminate rocket attacks Israel would have investigated the teens’ murders as they did of the Palestinian teen’s murderers and brought the responsible parties to justice.

Hamas went to war against Israel (yes, Hamas started it) for a different reason, however. As Dennis Ross, a much more current actor in the Middle East than Stewart, pointed out in his Washington Post article of August 8, “it was Hamas’ political isolation and increasingly desperate financial situation. The group was broke after Egypt closed the smuggling tunnels into Gaza, Iran cut off funding because of Hamas’ opposition to Syria’s Bashar Al-Assad, and Qatar was unable to send money through the Rafah border crossing, which Egypt controls.”

It’s not uncommon for the media to perpetuate myths associated with cause and effect in the Arab dispute with Israel – that Ariel Sharon caused the second intifada in 2000 is another example.

2.  Hamas was freely elected, and therefore “cannot be ignored.”

A single free election does not make for a democratic government. It does not provide the liberties on which a Western democracy is based. It does not automatically mean a rational, reasonable actor willing to negotiate. Indeed Hamas has been unwilling to compromise or negotiate with Israel in any way. Its charter and continued avowed purpose is to eliminate Israel and all Jews. (Yes, all Jews – read its charter. It wants to commit genocide.)

Since Hamas was elected it has acted as a ruthless regime, enforcing arbitrary executions, threatening the press from reporting the truth, lacking any transparency with its constituency, forcing out Christians, persecuting gays and lesbians, and severely curtailing women’s rights.

3.  Israel’s defense has successfully protected its people, therefore the Israeli response has been disproportionate.

Stewart swats away the threat of the 3500 rockets Hamas shot at Israel as being a non-threat because of Hamas rocket-building incompetence and Israel’s effective Iron Dome system. He cites the unfortunate death toll of Palestinians in Gaza as an ipso facto indication of disproportion.

This is clear nonsense. No nation sits back and lets an aggressor continue to assault its citizens indiscriminately. Israel has a sovereign duty to eliminate the source of the threat. If the enemy has placed its citizens in harms way, then it is the enemy’s fault if there are large casualties of its own residents. For Stewart to ignore all of the actions Israel took to reduce such casualties is irresponsible journalism, analysis, and understanding of the concept of “disproportion” in international law.

If Hamas had established bomb shelters, if Hamas had encouraged their citizens to heed the multiple warnings from the Israelis before they counter-attacked, if Hamas (or the UN for that matter) had established safe havens for non-combatants in unoccupied areas (yes, there are such areas in the Gaza Strip) instead of right in the middle of where rockets are fired and military command-and-control posts are established, the Palestinian death toll would have been considerably lower.   What reasonable civil authority puts its citizens in greater jeopardy rather than protecting them?

The Israeli military, in the past proven to have more credibility in documenting casualties than Palestinian and UN sources, estimates that 500-800 of the Palestinian dead were Hamas combatants, a similar ratio from other Hamas-Israel disputes, and a lower ratio of civilian-to-combatant deaths than any conflicts in modern history.

4.  Israel’s settlements in the disputed areas are illegal. 

The ad infinitum repetition of this mantra does not make it true.  First, of course, there are no Israeli settlements or soldiers in the Gaza Strip. They left in 2005.

Second, given the history related to international proclamations, treaties, legal precedent, and wars, international legal experts like Eugene Rostow (US undersecretary of state for political affairs during and after the 1967 Six-Day war), Judge Schwebel (former president of the International Criminal Justice Court), and Julius Stone (renowned international expert from Australia) affirm that Israel’s claims on the territories are stronger than any other entity, and that the settlements are not illegal.

5.  There is not yet a secure peace between the Palestinians and Israel; Israel has been “appallingly unfair” to the Palestinians.

The Israelis were not the occupants of the disputed territory from 1948-1967, yet nothing was done to establish a state for the people now called Palestinians – the Arabs proclaimed their intent to drive Israel into the sea – or to re-settle the refugees. The Palestinians have been kept in refugee camps in Lebanon, Jordan, and Syria. Except in Jordan, Palestinians have been prohibited from voting, holding certain jobs, owning land, and having other full rights accorded other citizens.

There were no long fences dividing Israel from Gaza or the West Bank until the Palestinians took up terrorist ways, forcing the Israelis to defend themselves with checkpoints and fences. The Israelis offered long-term peace treaties in a two-state solution at least twice in the past 14 years, only to have been rejected by the Palestinians and most of the rest of the Arab world.

The Gaza strip was not embargoed before Hamas came to power and began its 2005-6 cross-border attacks on areas that had allowed Gazans to move goods into and out of Gaza. It was Hamas’ actions that caused the siege of the Gaza Strip, not Israel’s desire to do so. Further, it is not just Israel that now embargoes Gaza, but Egypt as well – Egypt experienced the hegemonic terrorist activities of Hamas in the Sinai Peninsula, and has tightened the border as strongly as Israel.

After the 2012 Hamas-Israel war Israel increased building supplies going into the Gaza Strip, including an estimated 600,000 tons of cement. Instead of being used for hospitals, schools, bomb shelters, and other infrastructure, the cement went to building an underground network of tunnels for secret movements that were to be used for an assault on southern Israeli towns and villages on Rosh Hashanah this year. Captured documents show Hamas’ intention to kill thousands of Israelis.

6.  Peaceful resolution was possible in Ireland, why not here?

Maybe this isn’t so much a factual issue as simply a naïve one – or just Stewart’s rhetorical hyperbole trying to sound profound without any underlying substance.

Stewart’s question, “Are the Jews and the Arabs any different” than the Irish and British, fails to reflect an understanding of cultures, geographies, security needs, neighborhoods, histories, and credible broad-based threats. What did he learn in his years at the State Department and as an international journalist?

Maybe it’s been much too long since he’s been out in the field? Or maybe he just has a double standard when it comes to Israel?


Empathy and Prevention – a reply to Paul Bloom

In the May 20, 2013 issue of the New Yorker Paul Bloom argues convincingly that policy should include more rational argument and less empathy. Empathy leads us to spend a million dollars to get a single little girl out of a well, and yet have to scrap over pennies for building a fence that keeps the girl out of the well in the first place. Empathy leads us to commit an outsized amount of research funds to a deadly disease that affects only a few people, while ignoring or underfunding research that would prevent diseases in the first place. Empathy leads us to worry about the effects of mitigation of global warming because of anecdotes about people who might be put out of business with greater regulatory efforts to reduce carbon emissions, while not being able to envision and prevent the effects on future generations (now a cliche).

Bloom is right about all of this. But he is wrong about his conclusion. He writes (his final paragraph):

Such are the paradoxes of empathy. The power of this faculty has something to do with its ability to bring our moral concern into a laser pointer of focussed attention. If a planet of billions is to survive, however, we’ll need to take into consideration the welfare of people not yet harmed—and, even more, of people not yet born. They have no names, faces, or stories to grip our conscience or stir our fellow-feeling. Their prospects call, rather, for deliberation and calculation. Our hearts will always go out to the baby in the well; it’s a measure of our humanity. But empathy will have to yield to reason if humanity is to have a future.

To state that “empathy will have to yield to reason” is to think only rationally. Yet policy is made because of both reason and anecdote, analysis and empathy. Empathy is a form of expression of moral accounts. And values are critical to policy decision-making. To claim that empathy has to yield to reason is to contradict how we think, deliberate, and act. Instead of his weak conclusion that is so contradictory, we need to take empathy into account during policy-making. How might we do this?

First, by finding our own anecdotes. We need to find human images and stories related to prevention issues that invoke empathic responses. We need to use “Mad Men” tactics to persuade policy-makers of the value of preventive actions not just with cost-benefit and cost-effectiveness analyses, but also with narrative and emotion-evoking explanations. In the policy world we generally have been bereft of such approaches. We even can be antagonistic to them; we believe that the facts and science will do our arguments for us. But as Bloom so poignantly shows us, facts don’t hold a candle to the little girl in the well.

Second, by acknowledging the need to include empathy in our studies – how do our reactions to information and circumstances influence our willingness to be influential with policy analysis and decision-making? After all, policy analysis is just that – taking data of various sorts and trying to figure out the impact of various actions to fix a problem. Two analysts can look at the same set of data and arrive at different conclusions and courses of action because values and empathic responses are so critical to the analytic method. Our greater or lesser sense of the effects and empathic responses to those effects may strongly color our conclusions and action recommendations.

So while Bloom analyzes the problem correctly, he concludes with the wrong action statement. Empathy doesn’t have to yield to reason, analysis has to take both empathy and reason (among many other things) into account on an equal footing. And more importantly how we sell our recommended courses of action needs to play on the empathic response he so wisely discusses in his article.

BTW, often the concepts of empathy and compassion are confused. Bloom defines empathy correctly in his article, but then sometimes uses it as if it were compassion, which incorporates a component of compulsion to action. If the reader is interested in a more definitive discussion of the “spectrum of beneficence” and how empathy plays in the clinical encounter model, take a look at my 2009 article, “Kindness, not Compassion, in Health Care,” Cambridge Quarterly of Healthcare Ethics, 18, 287–299 DOI: 10.1017/S0963180109090458.

One Health: the Balance between Animal and Human Health

Animals and humans interact in many more ways than we think about in domestic suburbia.  Sure, we know that animal farmers are constantly in contact with their produce, and we are happy to pet our domestic cats and dogs.  Sure we recognize that some wild animals get rabies or, here in the desert of New Mexico, occasionally someone comes down with plague because of flea bites from infected indigenous rodents (our first case of this year was just last week).  And we’ve all heard of bird flu.

Yet there are many more ways that animals and humans interact that can compromise the health of individuals or populations.  In an excellent summary article, “Links among Human Health, Animal Health, and Ecosystem Health” Peter Rabinowitz and Lisa Conti from the Yale School of Medicine discuss how small-scale animal agriculture, human migration patterns and travel, animal worker practices, housing and land use development, changes in indigenous wildlife species, toxic hazards like the mercury poisoning in Minimata, Japan, and climate change impact animal and human health synergistically.

In 2007 the American College of Preventive Medicine (ACPM) Policy Committee, of which I was a member and former Chair, passed a resolution introduced by the late Ron Davis urging the American Medical Association to “support an initiative designed to promote collaboration between human and veterinary medicine…encourage joint efforts in clinical care through the assessment, treatment, and prevention of cross-species disease transmission…AMA support cross-species disease surveillance and control efforts in public health…support joint efforts in the development and evaluation of new diagnostic methods, medicines, and vaccines for the prevention and control of diseases across species…[and] engage in a dialogue with the American Veterinary Medical Association to discuss strategies for enhancing collaboration between the medical and veterinary medical professions in medical education, clinical care, public health, and biomedical research.”

The AMA passed this resolution and has been a leader in encouraging the consideration of these issues.  The American College of Preventive Medicine has recently participated in a One Health capitol hill briefing and renewed its endorsement of the One Health initiative.  However, the greatest push to understand and deal with animal-human medical interactions has come from the veterinary community.  The medical community has been relatively quiescent on the issue unless an epidemic occurs.  When one looks at the One Health Commission there are only two MD individual members of the Board of Directors, and only one MD on the Council of Advisers.  (There are twelve on the honorary advisory board of the One Health Initiative.)

Who are the MD leaders concerned about this issue?  Mostly they are epidemiologists, infectious disease specialists, or ag-related occupational medicine specialists.  Two out of three of these specialists are under the medical specialty of preventive medicine.  There aren’t very many of us trained in preventive medicine.  The Institute of Medicine in 2007 estimated there are about 10,000 in the US and that we’d need another 10,000 over the next few years.  To quote from a report from ACPM:

  • Between 1999 and 2006, the number of residents enrolled in preventive medicine training programs declined nearly 20%, and in 2007-08 less than half of the approved number of residency positions were filled.
  • The number of preventive medicine residency programs decreased from 90 in 1999 to 71 in 2008-2009.

These trends have not abated.  The demand for such residencies has not decreased – it has always been high according to preventive medicine residency directors.  The problem is funding – preventive medicine is the one specialty not consistently mostly supported by the federal government.  Hence for those residency programs in existence, most can only find funding to fill half of their slots (and many approved residencies’ doors aren’t even open).

For human medicine to be fully engaged in the One Health initiative we need more human medicine physicians to be engaged in preventive medicine, which means more federal funding for residencies.  But as with prevention in general, western society tends to provide less than what is needed in the balance with treatment.


A picture of Middle East difficulty

Why haven’t the Israelis and Palestinians made peace yet? A window into the difficulty can be seen in two articles in the Wall Street Journal today (August 20, 2013).

The first article details why the Saudis and UAE are siding with the Egyptian military: they see their nations’ interests as being free of the type of Islamism being espoused by the Islamic brotherhood. [Ignore the irony here for a moment – think Wahhabism.] As the WSJ states, “the Saudis and UAE want to deal a blow to the Muslim Brotherhood and undercut the influence of the regional rivals that back them: Turkey and Qatar.” Saudis and UAE have pledged $12 billion in aid to Egypt, more than counterbalancing any cutoff the US might make of our $1.5 billion.

In a parallel article “EU is to Debate Aid to Cairo” EU members are wringing their hands about what to do. They are increasingly reducing arms exports to Egypt and debating other aid that they would reduce. To give some sense of the relative lack of leverage this means, “Germany had approved weapons sales valued at [$17.6 million] in the first half of 2013…” Again, a drop in bucket.

But more importantly, the approach to dealing with the issue is what is striking. The Saudis and UAE’ers, who live in the region and understand the cultures and mentalities of the players better than Westerners do, are saying a strong hand is necessary inside of Egypt before democracy can be respected. The Westerners, who have our consistent ambivalent “let’s make nice and compromise for the good of everyone” approach and have not been particularly successful in our approaches to foreign cultures (think Africa, Asia, the Middle East) over the centuries, believe the specter of democracy is more important, even if a type of theocracy results.

Israel, the only nation that straddles the Middle Eastern and Western cultures, wants a stable Sinai peninsula and western border with Egypt. It senses that a stable government is vital, and that isn’t likely to happen until General Sisi can install law and order: “‘Only after stability is restored, only after law and order is enforced, only then can you start to talk about launching a process that leads to more democratic processes,’ sad the senior Israeli official.” Though at the same time Israel is wary of an Islamic backlash throughout the region.

So the Obama administration dickers (that has been its approach in most foreign policy for 5 years now) without a clear strategy. And, as a senior Arab official says in the first WSJ article, “‘I don’t think that Washington is really in the conversation’ on Egypt in a significant way.” Seems to be true on Syria as well.

Why is Kerry pushing the Israeli-Palestinian line right now? Perhaps it has to do with the same naïveté driving our wrong-headed approach to Egypt and Syria?

Addendum on August 21: See the article by Walter Russell Mead that is more articulate about this problem in the American Interest just brought to my attention, “Bambi Meets Godzilla in the Middle East.”

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.

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.

Nice Review of Prevent vs. Treat by Linda Hill

As an admittedly boastful statement, I am pleased with Linda Hill’s review of Menzel’s and my Prevention vs. Treatment:  What’s the Right Balance? in the June, 2012 edition of the American Journal of Preventive Medicine.  The concluding paragraph reads:

Impressively, the author of each chapter is aware of the material discussed in the other chapters and is able to put his or her own discussion in the larger context. This must have required tight coordination among authors including sharing of drafts, as well as superb editing. This is a thoughtful and very well written text, contributing in a meaningful way to the fıeld.

While I am proud of the statements by Linda, my real reason for posting this review information is to call attention to the AJPM search for a new editor-in-chief (EIC). The AJPM has done remarkably under the current editorial staff, lead by Kevin Patrick, the EIC,  and his managing editor, Charlotte Seidman.  Both have decided to retire from their AJPM responsibilities at the end of 2013 after almost 20 years – a remarkable tenure for any journal editor.  The journal’s Board of Governors (of which I am one) is now searching for their successors.  The call for applications or nominations for the EIC can be found here.  If you know of anyone capable and interested in this position, please don’t hesitate to contact the Journal secretary or treasurer (listed on the website link above), or me.  Thanks.

USPSTF on PSA Testing for Prostate Cancer

The US Preventive Services Task Force published their final recommendation update on PSA screening to detect early prostate cancer.  The USPSTF is the most unbiased and science-based organization in the US.  It is free from bias, and scrupulously maintains a strict conflict of interest policy.  It’s members do not have a financial interest in the outcome of the analyses done, like the American Urological Association might have for PSA testing, nor do they have a conflict of commitment – a worldview that catching cancer early is a prime overwhelming driving force, like the American Cancer Society has had in the past.  (I think the ACS has been much more nuanced and reasoned in their responses in the past few years as compared with the past.)  The AUA has announced that it is “outraged and believes that the Task Force is doing men a great disservice by disparaging what is now the only widely available test for prostate cancer, a potentially devastating disease.”  I think the AUA is wrong, and that the USPSTF’s recommendation is more balanced and reasoned than the AUA states.

Basically the USPSTF claims that there are reasons not to screen for prostate cancer using current techniques, especially the PSA test.  The summary:

The U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years. 
Grade: I Statement

The USPSTF recommends against screening for prostate cancer in men age 75 years or older.
Grade: D Recommendation

Paul Menzel and I have written about a number of factors which should be involved in recommendations and/or resource allocation associated with prevention screening, and I won’t repeat those items in this blog.  I will mention, however, that Diana Petitti’s chapter 5 of our book, Prevention vs. Treatment:  What’s the Right Balance? looks at some of those issues as well from a former USPSTF member’s insider view.

One Infant Dies from Whooping Cough; Unvaccinated and Political Officials Responsible

A 2-month-old infant died from whooping cough (pertussis) yesterday in New Mexico. It’s unclear how the child was exposed to the disease. It had been vaccinated with its first dose of vaccine, usually given at 2, 4, and 6 months, and then later in childhood several times as well. Recently the Advisory Committee on Immunization Practices has recommended that adults be re-vaccinated for pertussis when they get their tetanus and diphtheria booster shots as well.

Pertussis vaccine is very effective, but immunity wanes after 4-20 years (depending on age of the individual, number of booster shots, etc.). Herd immunity for pertussis requires a high vaccination rate – in the 92-94% range. Since vaccine efficacy is somewhere between 85% and 95% (depending on the study you read), if herd immunity is not reached even those vaccinated (but not with effective immunity) are vulnerable.

Before vaccines were available, for example “from 1926 to 1930, there were 36,013 pertussis-related deaths in the United States. The average death rates from 1940 to 1948 per 100,000 population per year were 64 in children less than 1 year old, 6.4 in those 1–4 years of age, and 0.2 in those 5–14 years of age. More than 90% of the reported pertussis cases occurred in children less than 10 years of age, with about 10% of those in children less than 1 year of age.” (Cherry, 2007) Since vaccination has become available, death rates have dropped to less than 1 per 100,000 population.

The tragedy here is not solely the one New Mexico infant’s life (which I don’t mean to minimize with this commentary). The tragedy is that these deaths are preventable. Now, I’m not one to attribute blame for many things – I find it doesn’t do much good to concentrate on who did something, but more to look at why it happened and how we can correct the situation, including preventing deaths in the future. But in this case it seems clear to me that we have blame to apportion in two arenas: 1. those who don’t vaccinate their children or get their own vaccinations, and 2. our politicians who skimp on public health resources.

1. The unvaccinated are responsible for the death of this infant.
Parents who are irrationally fearful of getting their children vaccinated reduce the population vaccination rates and therefore herd immunity is not obtained. Similarly, adults who don’t get their booster shots are as culpable.

Because immunity is not 100% obtained by 100% of the population being vaccinated, some individuals will be vulnerable to getting pertusis. The only way to prevent those vaccine failures from getting the disease is for the population to reach its herd immunity, requiring at least 94% of the population being vaccinated. Those who don’t get vaccinated (aside from those who have justifiable medical reasons like compromised immune systems from cancer or immune deficiencies) are reducing the probability of herd immunity. They are, in essence, freeloaders – thinking they can avoid the disease while abdicating their responsibility to prevent it for themselves or others.

2. Our state and local politicians (and federal to some extent) are responsible for the death of this infant.
Local and state health departments have been devastated with the reduction in financing during this recession. They have lost 15-25% of their personnel, had to reduce or eliminate 33% of their programs, and have had significant morale problems. They are asked to perform almost all of the functions they were doing before 2008 with many fewer resources. This impacts vaccination rates and surveillance capabilities.

It’s always difficult to point the finger at one fiscal cut and say “that caused this infant’s death.” That’s because people don’t attribute the same kind of cause and effect from indistinct dollars (even if guided to certain programs) and unidentified lives in the community. But there are plenty of philosophical reasons to claim that there is no difference between identified and unidentified lives when it comes to health care expenditures. (Harvard’s Program in Ethics and Health had a 2-day conference on this topic last month.)

But politicians who self-righteously defend program cuts while simultaneously decrying the ineffectiveness of our health care system or public health system are as culpable as freeloading parents who don’t get their children vaccinated, or adults who aren’t re-vaccinated. And now they want to do it again: cutting the Prevention and Public Health Trust Fund to reduce interest rates on college loans.

What about you – are you up-to-date on your booster shot for tetanus, diphtheria, and pertusis? If you are over 60 have you gotten your shingles and pneumococcal vaccines?


A couple of days after I first posted this item it came to light that the state of Washington declared a pertussis epidemic on April 3rd. Over 1280 cases have been reported as of May 11. The governor of WA “announced the state is putting $90,000 into a public awareness campaign and diverting some federal money to pay for 27,000 doses of vaccine.” Where was the governor in preventing the epidemic in the first place? This gets back to the old question: “Prevention vs. Treatment: What’s the right balance?” Unfortunately, this is another example of prevention not getting its due when it could have been more effective – before the epidemic occurred.

Second addendum:
See the NY Times article today about this outbreak. Here’s the particularly relevant paragraph:

Here in Skagit County, about an hour’s drive north of Seattle — the hardest-hit corner of the state, based on pertussis cases per capita — the local Public Health Department has half the staff it did in 2008. Preventive care programs, intended to keep people healthy, are mostly gone.

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