The Prevention Agenda: Missing the Forest for the Trees

Jan. 30, 2009— -- If only we could prevent disease, we would do so much for the health of the public. We would spare so many from suffering and from death before their time. As a bonus, we could forego the effort and expense of treating avoidable diseases.

Such is the dream of every person, physician and politician who has ever lived. And for every person, physician and politician living in the United States today, this dream is within our grasp. We have a science that points the way.

It is tragic that this science is not at the forefront of the nation's health agenda. Rather we are offered an approach to prevention that will not and cannot spare us from avoidable suffering or premature death. We are about to pay dearly for a public health mistake.

We live in a risky world. The sands under our financial institutions and international alliances are shifting more than ever. We have limited influence beyond our vote, and certainly no control. But we are told repeatedly and stridently that we can control our health risks by avoiding health-adverse behaviors and by attending to disease early on, before we have symptoms.

Some sage advice: We should never start smoking. We need to wear seatbelts when we drive and never drive inebriated or exhausted. We need to submit to rational immunization programs. And we need to practice safe sexual behavior.

This is all obvious. Some advice is not so straightforward. The need for a screening colonoscopy engenders debate that relates to the age at which one should submit and whether a repeat study is valuable. The need for a screening mammography is debated because the test performs very, very poorly. The need for screening PSA is also hotly debated not just because the test performs poorly, but one needs to closely consider whether the exceedingly slight reduction in risk of death from prostate cancer is worth the considerable likelihood of grief from the procedures necessary to reduce that risk.

But most of the advice requires a leap of faith over logic. We are told we need to do some things to reduce risks which present very little hazard to our well being and longevity. Furthermore, we are told we need reduce these small risks despite a science that says no meaningful benefit will result: We need to be lean and fit with normal blood pressures, blood lipids and blood sugars. We need to conform to the latest version of dietary advice. We need to walk stairs. We need to swallow pills to pummel surrogate risk factors such as blood cholesterol or blood sugar. We need to measure bone mineral density to treat osteoporosis early on. And our next episode of back, neck, knee or shoulder pain is the forerunner of catastrophe unless we fix something.

Truth be told, there is no important risk to being chunky, only to being obese (BMI>30). At most a high cholesterol level puts a year or two of longevity at risk; for nearly all of us it's a matter of months and there is no evidence that taking pills or eating differently will improve the odds.

Type II diabetes is easy to treat with pills that lower blood sugar, but such treatment does much more for the blood sugar than it does for you -- if it does anything good at all.

Treating mild hypertension is barely defensible except with the simplest of agents; restricting salt intake works as well.

Osteoporosis is as much a part of aging as graying, and its early treatment offers no meaningful advantage to the aged.

All the fancy technology to define the disease in coronary arteries leads to nothing that can be shown to save lives or spare one from symptoms. As for the next episode of musculoskeletal pain, the most scientifically supported advice is to get on with life; this too shall pass.

However, the public health agenda will have us all screened. The public health agenda will have us all wary, concerned and medicalized. The public health agenda will have more and more of us undergoing various forms of biopsies with no yield.

More and more of us will be swallowing drugs to lower blood pressure, lower cholesterol and lower blood sugar as well as keep the calcium in our bones. More and more of us will have some form of surgery on our coronary arteries. And more and more of us will bear the stigmata of surgical hubris about our knees, shoulders and backs. All this may be done more efficiently, perhaps more expertly, and perhaps at a reduced cost per person, but don't for one minute think you, the public, or the public coffers will be better off.

There is a major treatable risk factor that remains unspoken in all the prevention advice, marketing and background noise. The most important risks to longevity, and to quality of life, lurk in one's station in life.

Beware if you can not find a niche that affords some sense of satisfaction, an element of comfort, and hint of pride. Whether we measure this by socioeconomic status, by neighborhood, by education, by job satisfaction or by job security, if you are not comfortable in your skin it will cost you five to 10 years on this planet. You are at risk of dying from something, "all-cause mortality", well before your time. It doesn't matter if you are "thin" and have normal blood pressure, blood sugar and cholesterol. For you, 75 is old; for those who are comfortable in their skin, 85 is old.

Some of you who started life with few advantages and in a poor neighborhood have been able to move up in society. You have done much for your quality of life. You have also improved your longevity. But you will not catch up to those whose biology was not tainted by a passage through poverty.

Some of you who have spent most of your life nurtured by and nurturing the comfort and pride that come with a solid position in society now find yourself without job security, or even a job. In addition to all the turmoil in your life, you have acquired turmoil in your biology that is a kiss of earlier death.

We only have theories, many theories, as to the biology that determines all-cause mortality, the timing of the time of your death. But the public health message is clear. We will serve the health of the public far more by fostering effective educational programs and providing nurturing occupational opportunities than by any assault on fried foods or coronary arteries. A kinder and gentler America is a public health agenda.

Dr. Nortin Hadler is professor of medicine and microbiology/immunology at theUniversity of North Carolina at Chapel Hill, and an attending rheumatologist at University of North Carolina Hospitals. He is the author of "Worried Sick: A Prescription for Health in an Overtreated America," and "The Last Well Person."