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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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?

Addendum

:
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.